Tibial plateau fractures classically present in a bimodal distribution associated with high energy mechanisms in the younger population and fragility fractures in the elderly populations as a result they are well suited for looking at the effect major trauma centre status. Military trauma surgeons in training should be exposed to as much young high-energy trauma as possible to equip them for operations. Retrospective review of all tibial plateaus presenting to RVI 20 months before MTC status and 20 months following this. 61 patients pre, 66 post. Schatzker grade 1–4 were similar pre and post change. Post change there was an increase in Schatzker 5 (62%) and 6 (27%). High energy injuries were most common in younger males, cause was falls followed by RTAs. MTC status has meant an increase in high energy tibial plateaus (Schatzker 5–6) These were predominantly seen in younger males with high-energy mechanisms. As this is likely to be replicated across all injuries, we would recommend military trauma surgeons have a significant period of time training in major trauma centres to ensure adequate exposure to young high energy trauma.
Some military personnel are having Femoral Acetabular Impingement (FAI) surgery. The use of the alpha angle (AA) to help assess the diagnosis is common. Currently there are no standardised values available across a asymptomatic pre-arthritic population. Retrospective analysis of 200 consecutive individuals (400 hip joints) with ages 20 to 50, who had a CT performed between 1 Apr 2011 and 29 Nov 2011 due to abdominal pathology. The AA of Notzli was measured on the axial view. The mean AA value was 53.5 (95%CI 1.30) for Right hips and 53.4 (95% CI 1.31) for the left. In age 20–30 Right 52.6 (95%CI 3.5) the Left 52.0 (95%CI 2.9), 31–40 Right 53.9 (95%CI 2.5) Left 53.4 (95%CI 3.1), 41–50 Right 53.8 (95% CI 1.9) Left 53.2 (95% CI 1.8). Mean male Right 52.9 (95% CI 1.5) Left 53.2 (95%CI 1.9) Female Right 52.5 (95% CI 1.5) Left 49.9 (95% CI 1.6). 144/400 (37%) of patients had angle >55 degrees. Previous literature suggests an AA >55 degrees is diagnostic of FAI, we suggest that the AA is highly variable across age and sex and that >1/3rd of asymptomatic patients will have an AA that was previously regarded as abnormal.
Rugby union is the second commonest cause of sporting fracture in the UK. Yet little is known about patient outcome following such fractures. All rugby union fractures sustained during 2007–2008 in the Lothian were prospectively recorded. Patients were contacted by telephone in February 2012 to ascertain their progress in returning to rugby. There were 145 fractures in 143 patients, including 122 upper limb and 25 lower limb fractures. 117 fractures (81%) were followed at mean 50 months (range 44–56 months). 87% returned to rugby post injury, with 85% returning to rugby at the same level or higher. 77% returned by three months and 91% by six months. In upper limb fractures 86% returned by six months and 94% by six months. In lower limb fractures 42% returned by three months and 79% by six months. 32% had ongoing fracture related problems. 9% had impaired rugby ability secondary to fractures. Most patients sustaining a fracture playing rugby union will return to rugby at a similar level. While one third of them will have persisting symptoms post-injury, for the majority this will not impair their rugby ability.
Alcohol remains a significant cause of disease in the UK population. Yet the effect of alcohol on fractures remains conflicting. We present a prospective analysis of self-reported alcohol consumption and the epidemiology of fractures sustained. 1950 patients over 13 years of age were prospectively interviewed after sustaining a fracture with basic epidemiological data, fracture data and average alcohol consumption recorded. 1621 (83%) of interviewees provided information on alcohol consumption. 10% admitted to drinking in excess of Scottish Health guidelines. 18.1% of males drunk to excess, compared to 4.7% of females (p<0.001). The five most frequent fractures were distal radius (20%), metacarpals (12%), ankle fractures (12%), neck of femur (10%), phallanges (10%). 48% of fractures were falls from standing height. Excess drinkers were more likely to sustain an AO grade C fractures than safe drinkers (18.1% compared to 11.2%, p<0.05). Excess drinkers sustained more open fractures than safe drinkers (5% compared to 1%, p<0.001). Excess drinkers were on average 5.66 years younger than safe drinkers at the time of injury (44.57 years compared to 50.23 years, p<0.05). People reporting alcohol excess who have sustained a fracture are more likely to be younger and suffer more severe fractures than those drinking within current guidelines. Opportune targetting of patients consuming excess alcohol should be targetted at problem drinkers sustaining a fracture.
The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome. We used our arthroplasty database which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (< 55 years) were identified. A control group of patients ≥ 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period. (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10 year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004). Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.
Current literature comparing the effect on body mass index (BMI) on the outcome of total hip replacements (THR) is inconclusive. To describe the effect of BMI on THR over the first five years. We prospectively recruited 1,617 patients undergoing primary THR for osteoarthritis and followed them up at 5 years, recording, dislocations, revisions, deep and superficial infections, Harris Hip scores (HHS) and SF-36. A multivariate analysis was performed to identify if BMI is an independent predictor of adverse outcome. 148 (9%) patients had a BMI >35. 6.8% of patients with a BMI >35 had a dislocation by 5 year post op compared with 3.2%BMI 30–34.9, 2% BMI 25–29.9 and 1.5% BMI<25 (p=0.03) Superficial infections 14.2% BMI >35, 4.4% BMI <25. In SF 36 scores only Mental Health and change in health had no significant differences with an increase in BMI having a statistically significant decrease in all other SF scores. HHS had a mean improvement of 45.1 at five years with an expected loss of 0.302 HHS points (95% CI0.440–0.163) per 1 point BMI increase. There was no significant difference in deep infections, mortality <3 months, revision rates or length of stay. The most significant risk in increasing BMI is the dislocation rate, possibly representing increased technical difficulty in larger patients. Whilst increasing BMI has a reduced HHS and SF16 score, the overall benefit is still positive.
The risk of venous thrombo-embolism (VTE) is high in orthopedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post operative bleeding and transfusion requirements. We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out questionnaires to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then OD for 14 or 35 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was Deep Vein Thrombus or Pulmonary Embolism confirmed by Doppler or CTPA. Minor bleed was categorized as dressing soakage or reported wound leakage, major bleed as hematoma requiring revision within 30 days. 509 patients underwent TKR: 200 (39%) received Rivaroxaban only (Group 1), 296 (58%) also received tranexamic acid (Group 2). 13 (3%) patients had no data available. Five patients had a VTE: 4 (2%) in Group 1, 1 (0.3%) in Group 2 [P<0.05]. 39 patients had a minor bleed: 17 (8.5%) in Group 1, 22 (7.4%) in Group 2 [P=0.5]. 2 patients had major bleeds: 1(0.5%) in Group 1 and 1(0.33%) in Group 2 [P=0.69]. There were 30 blood transfusions: 21 (10.5%) in Group 1, 9 (3%) in Group 2 [P<0.0001]. We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results, whilst they show a trend towards decreased minor and major bleeding rates, are not significant and require larger studies looking at wound bleeding and leakage.
We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group. Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8–10 years post surgery. The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason. 203 patients were found to be < 55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study. A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28–55 years (median 51). Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval. Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years. TKR should not be withheld from patients on the basis of age.
Previous Anterior Cruciate Ligament (ACL) reconstruction is currently a bar from entry to the Royal Marines and Royal Navy, whilst the British Army allows recruits to join if asymptomatic 18 months post ACL reconstruction. However current Royal Marines policy is to rehabilitate recruits who sustain an ACL disruption in training. We retrospectively analysed the rehabilitation times and pass out rate of Royal Marines who had an ACL disruption during recruit training over an 8 year period. 12 recruits sustained an ACL disruption during recruit training in the study period, giving an incidence of around 1.5/1000 recruits. 9 Patients underwent ACL repairs in training, with 1 patient leaving and rejoining post repair and later successfully passed out. 2 patients were treated conservatively. Of the 12 ACL sustained in training 8/12 (67%) passed out. None of the patients treated conservatively passed out. The mean time out of training for successful recruits was 51.6 weeks (95% CI 13.1) mean rehabilitation time post ACL reconstruction for successful recruits was 36.7 weeks (95% CI 12.5). Mean time to discharge for unsuccessful recruits 63.2 weeks (95% CI 42.4). In the operative group 1/10 left due to failure to return to training and 1/10 left through unrelated reasons. Current costing for recruit training is £1800 per week per recruit. ACL injuries are not common in Royal Marine Training, and reconstruction is not a bar to completing Royal Marine basic training. We estimate that it costs around £100,000 per-injured recruit, to maintain a policy of rehabilitating ACL injured recruits in Royal Marines training. Further research into the long-term employability or Royal Marines sustaining an ACL injury in training is required.
The DuPuy Sigma total knee arthroplasty (TKA) is a modification of the well-established Press Fit Condylar (PFC) TKA and is used extensively in the UK and worldwide. This study reports the first 10-year clinical and radiological follow-up data for the Sigma PFC. A total of 235 consecutive Sigma TKAs were performed in 203 patients between October 1998 and October 1999, in our unit. Patients were seen at a specialist nurse-led clinic 1 week before admission and at 6 months, 18 months, 3 years, 5 years and 7-10 years after surgery. Data was recorded prospectively at each clinic visit. Of 235 knees, 171 (147 patients) were alive at 10 years. Twelve were lost to follow up. Eight knees (3.4%) were revised; four for infection and four underwent isolated change of polyethylene insert. Ten-year survival with an end point of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society score was 62 at 8-10 years compared with 31 out of 100 pre-operatively. Our results show that the PFC Sigma knee arthroplasty performs well over the first 10 years post-implantation.
The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome. We used our arthroplasty database, which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) was identified. A control group of patients ≥ 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10-year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004). We conclude that Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.
Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs. We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively. 61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights). By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy.
The risk of venous thrombo-embolism (VTE) is high in orthopaedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post-operative bleeding and transfusion requirements. We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out a questionnaire to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then once a day for 14 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was confirmed by Doppler or CTPA as Deep Vein Thrombus or Pulmonary Embolism. Minor bleed was categorised as dressing soakage or reported wound leakage, major bleed as haematoma requiring revision within 30 days. 509 patients underwent TKR: 200(39%) only received Rivaroxaban (Group 1), 296(58%) also received tranexamic acid (Group 2). 13(3%) of patients had no data available. 5 patients had a VTE: 4 (2%) Group 1, 1 (0.3%) Group 2 (P<0.05). 39 patients had a minor bleed: 17 (8.5%) Group 1, 22 (7.4%) Group 2 (P=0.5). 2 patients had major bleeds: 1 (0.5%) Group 1, 1 (0.33%) Group 2 (P=0.69). Blood transfusions 21: (10.5%)Group 1, 9 (3%) Group 2 (P<0.0001). We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results whilst they show a trend towards decrease bleeding rates in both the minor and major bleeds are not significant, requiring larger studies looking at wound bleeding and leakage.
