COVID-19 was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. The initial response to the pandemic included the cessation of routine services including elective orthopaedic surgery. There was apprehension among both surgeons and patients about restarting elective surgical services. The high mortality rate in perioperative patients who contract COVID-19 was of particular concern. The aim of this study was to identify the perioperative viral transmission rate in orthopaedic patients at our institution following the restart of elective surgery between August 2020 and November 2020 after the first wave of Covid in the UK.

All patients who had their elective Orthopaedic surgeries at our institution from 1st August 2020 to 30th November 2020 were checked whether they were Covid positive or experienced COVID symptoms within 2 weeks after the operation. All patients were advised a 14-day period of comprehensive social distancing, 3 days of self-isolation and had a negative COVID-19 test within 72 hours of surgery and underwent surgery at a COVID free site. The patients were contacted and the hospital database was searched to identify those patients who were Covid positive or had Covid symptoms after the surgery. Baseline patient characteristics were recorded including age, gender, procedure, the subspeciality and admission type. Patients who underwent emergency procedures and trauma operations were excluded.

Out of the 499 patients, 315 were contacted over telephone and hospital database was searched for the rest of the patients. We found that none of the patients were positive for COVID or had symptoms of COVID within two weeks of surgery. 5 patients were COVID positive with symptoms few months after the procedure and all of them recovered. There were 144 inpatient admissions and 353 day cases.

The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. Findings of our study confirms that COVID-free elective pathway is an efficient process, and this could be implemented in future elective Orthopaedic surgeries during COVID times. Elective surgery can be safely resumed using dedicated pathways and procedures -Surgeons, hospital staff and patients should remain vigilant.

Introduction

Traditional treatment of idiopathic flatfoot in the adult population include calcaneal neck lengthening or fusions. These surgical methods result in abnormal function with significant complication rates. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft, calcaneal osteotomy and medial head of gastrocnemius recession if appropriate.

Introduction

Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban.

Introduction

Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty but do not recommend one particular pharmacotherapy over another.

Introduction

Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation.

The treatment of undisplaced femoral neck fracture in the elderly population is still controversial. We analysed the outcome of cancellous screw fixation for undisplaced femoral neck fracture in patients over 70 years.

Introduction: Diagnosis of syndesmotic injuries is primarily based upon the assessment of ankle radiographs. Earlier studies examining normal radiographs are limited by small sample size and methodological issues.

Materials and Methods: One thousand four hundred and fifteen consecutive patients with ankle radiographs were reviewed. 1023 patients were excluded as a result of a history of ankle/hindfoot pain, trauma, or surgery; or radiographic evidence of ankle/hindfoot pathology. 392 patients (218 females, 174 males) with normal ankle radiographs were included. 83 of 392 patients had bilateral normal radiographs. All radiographs were reviewed independently by a fellowship-trained foot and ankle surgeon and a fellowship-trained musculoskeletal radiologist. Tibiofibular overlap and tibiofibular clear space were measured on anteroposterior (AP) and mortise radiographs. These four measurements were analyzed.

Results: Mean AP overlap was 8.3 mm (±2.5). Mean mortise overlap was 3.5 mm (±2.1), 7.7% patients had < 1 mm overlap and 4.9% of patients had < 0 mm overlap. Mean AP clear space was 4.6 mm (±1.1), 7.1% patients had > 6 mm clear space. Mean mortise clear space was 4.3 mm (±1.0), 4.3% patients had > 6 mm clear space. All measurements were significantly different between females and males (p < 0.001). Mortise clear space is the most accurate measure when obtaining contralateral radiographs. Intraobserver and interobserver reliabilities of all measurements were high (intra-class correlation coefficient range 0.820–0.983).

Discussion and Conclusion: Our data unequivocally demonstrates that basing treatment of syndesmotic injuries on previously reported radiographic criteria can lead to unnecessary operative intervention or failure to treat. Lack of overlap on the mortise view can represent a normal variant, which has not been definitively reported in prior investigations. Our data forms the basis for new radiographic criteria to evaluate syndesmotic disruption.

Introduction: Management of surgical failures of 1st MTP joint is complex. We present a series of 9 patients treated with bone block arthrodesis of the 1st MTP joint.

Materials and Methods: 9 patients who underwent bone block arthrodesis of the hallux MTP joint over a three year period were retrospectively identified. Most of the patients had failed fusions and kellers arthroplasty. All 9 patients had pain and deformity of the hallux, 8 patients had limitation of mobility and 6 patients had gait and shoe wear problems. All patients underwent 1st MTP arthrodesis with interpositional tricortical bone blocks, to restore 1st ray length, with additional cancellous bone graft used in three patients. The construct was held with K-wires which were buried under the skin. 3 patients were put in plaster postoperatively.

Results: The average age of the patients was 59 years with average follow up of 15 months. The hallux MTP score postoperatively was 78 out of the possible 90. The 1st MTP joint angle improved from 29.17 to 15.33. All the nine patients were satisfied (four rated it excellent and five rated it good) with their outcome, of which six would readily undergo similar operation and three would undergo the operation if there was no other option. Postoperative complications were mostly metalware related with 8 patients having shoe wear problems for which they underwent K-wire removal (usually under a local anaesthetic in the clinic). 4 patients had minor paraesthesia, 3 patients had superficial infection treated with antibiotics and 1 patient had persistent non-union (but was pain free).

Conclusion: The results with bone block arthrodesis are satisfactory and have added advantage of restoring the length of the 1st ray.

The treatment of undisplaced femoral neck fracture in the elderly population is still controversial. We analyzed the outcome of cancellous screw fixation for undisplaced femoral neck fracture in patients over 70 years.

Materials and methods: From 1998 to 2003, ninety-seven patients with undisplaced femoral neck fracture, aged over 70 and treated with cancellous screw fixation were retrospectively identified. Full clinical data was available for 79 of the 97 patients identified. All patients had in-situ fracture fixation.

Results: Of the 79 patients, M:F was 22:57, average age was 81.3 years. The average inpatient stay was 13.2 days. The mean follow up was 12 months (1m–78m). 24 patients had Garden type I and 55 type II fractures.

26 (32.9%) patients did not return to their pre-morbid mobility status, 5 (6.3%) of which did not return to their preadmission dwelling (2 went to residential home and 3 went to nursing home).

We had documented radiographic details in 46 patients: 41 patients had a healed fracture on radiographs (89.1%), 4 patients had AVN, 4 patients had non-union and 1 patient had AVN with non-union. The failure rate was 19.6%. 15 patients had evidence of screw back out with healed fracture.

12 out of the 46 complained of pain postoperatively of which 9 (19.6%) patients had re-operation: 6 (13%) underwent revision surgery and 3 (6.5%) required screw removal.

30-day mortality was 3.7%. 1-year mortality was 23.2% of which 16 died within the first 6 months (19.5%).

Conclusion: This study shows that in our unit, cancellous screw fixation of undisplaced femoral neck fractures in patients over the age 70 has a good outcome with 19.6% re-operation rate. Radiographic failure rate is 19.6%. One third of the patients did not return to their preadmission mobility level/dwelling.

Introduction: There has been a renewed interest in metal-on-metal bearing for total hip replacement with the benefit of a larger head size and decreased incidence of dislocation. In the revision hip scenario cementation of a polyethylene liner, for a previously compromised liner fixation mechanism into a preexisting well-fixed shell or a cage, has become an accepted method to decrease the morbidity of the procedure. Perhaps Bir-mingham cementless cups could be used as cemented devices in primary and revision hip surgery where a cementless cup is not possible.

Aim: To study the pull-out strength of cemented Bir-mingham sockets in an experimental model.

Materials and Methods: Eight Birmingham cups were cemented into wooden blocks after they were reamed to the appropriate size allowing for a 3mm cement mantle, multiple holes drilled into the reamed sockets and cement vacuum-mixed. Cable was then threaded through the holes on the rim of the cup and the wooden block was then mounted on a metal plate and secured. Linear tension was then gradually applied on the cup through the cable.

Results: The pull-out strength of the cemented Birming-ham cups was higher than the failure of the cable. The tensile load to failure for the cables ranged from 3642.6 N to 4960 N with an average load of 4286.9 N.

Conclusion: The average tensile load of 4286.9 is very high compared to previous studies with cemented poly-ethylene and metal liners. This finding is very promising and might support clinical application in complex primary and revision total hip replacement.

Introduction Resurfacing hip arthroplasty is becoming an increasingly popular option in the management of hip arthritis in younger individuals. Large series from units pioneering the technique have yielded encouraging results, but smaller units have reported alarming complication rates in recent years. We report a single-surgeon series performed from within the ambit of a multicentre trial.

Method Data on 49 cases in 46 patients (28 males, 18 females, age 34–68, mean 50.6) were collected. Harris Hip scores were obtained preoperatively and at follow-up (6, 12, 24, 36 and 48 months, mean 16.2). Radiological assessment included evaluation of component position and possible migration. Technical difficulties with implant insertion were recorded.

Results Postoperative hip scores improved dramatically in 47 cases. 3 patients have thigh pain. In one case rotational displacement of the cup occurred over 3 months. This is asymptomatic. In 2 cases there was minor femoral neck notching during surgery, without complications. One femoral component was inserted in slight varus. There was incomplete seating of the acetabulum in 4 cases, without complications. Lateral guide pin protrusion occurred into the tissues during surgery in 2 cases, and this pin is no longer used. Painless clicking, possibly due to impingement, has been noted in 4 cases. There was 1 death, due to total mesenteric infarction. There have been no femoral neck fractures and no revisions in these cases, all performed via the anterolateral approach.

Discussion Resurfacing arthroplasty is more technically demanding than total hip replacement. All cases in this series were entered in a multicentre analysis, the benefits have including regular contact with other surgeons. The procedure is conservative on the femoral side at least, and conversion to hip replacement in the event of future femoral component loosening or neck fracture should be easy, although the results of articulation between a new stemmed device and an old (worn) cup are not known. The results of this single-surgeon series from a DGH, performed within the ambit of a large multi-centre analysis, have been encouraging.