Aims

This study aimed to assess the carbon footprint associated with total hip arthroplasty (THA) in a UK hospital setting, considering various components within the operating theatre. The primary objective was to identify actionable areas for reducing carbon emissions and promoting sustainable orthopaedic practices.

The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years.

We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care.

Periprosthetic joint infections (PJIs) and osteosynthesis-associated infections (OSIs) present significant challenges in trauma and orthopaedic surgery, substantially impacting patient morbidity, mortality, and economic burden. This concern is heightened in patients with pre-existing comorbidities, such as diabetes mellitus, which are not always modifiable at presentation. A novel intraoperative strategy to prevent these infections is the use of Defensive Antibacterial Coating (DAC), a bio-absorbable antibiotic-containing hydrogel applied to implant surfaces at implantation, acting as a physical barrier to prevent infection.

The purpose of this study is to assess the use of a commercially available hydrogel (DAC), highlighting its characteristics that make it suitable for managing PJIs and OSIs in orthopaedics and traumatology. Twenty-five patients who underwent complex orthopaedic procedures with intraoperative application of DAC between March 2022 and April 2023 at a single hospital site were included. Post-operative assessment encompassed clinical, laboratory, and radiographic examinations.

In this study, 25 patients were included, with a mean age of 70 ± 14.77 years and an average ASA grade of 2.46 ± 0.78. The cohort presented an average Charleston Comorbidity score of 5.45 ± 2.24. The procedures included 8 periprosthetic fractures, 8 foot and ankle surgeries, 5 upper limb surgeries, and 4 elective hip and knee surgeries. Follow-up assessments at 6 weeks and 6 months revealed no evidence of PJI or OSI in any patients, nor were any treatments for PJI or OSI required during the interim period.

DAC demonstrated efficacy in preventing infections in high-risk patients undergoing complex orthopaedic procedures. Our findings warrant further investigation into the use of DAC in complex hosts with randomized control trials.

Aims

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians’ management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for this purpose to guide clinicians in order to treat PFI. There are also concerns about validity of the Dejour classification (DJC), which is the most widely used classification for TD, having only a fair reliability score.

The Oswestry-Bristol classification (OBC) is a recently proposed system of classification of TD and the authors report a fair-to-good interobserver agreement and good-to-excellent intra-observer agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

6 assessors (4 consultants and 2 registrars) independently evaluated 100 magnetic resonance axial images of the patella-femoral joint for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after 4 weeks. The inter and intra-observer reliability scores were calculated using Cohen's kappa and Cronbach's alpha.

Both classifications showed good to excellent interobserver reliability with high alpha scores. The OBC classification showed a substantial intra-observer agreement (mean kappa 0.628)[p<0.005] whereas the DJC showed a moderate agreement (mean kappa 0.572) [p<0.005]. There was no significant difference in the kappa values when comparing the assessments by consultants to those by registrars, in either classification systems.

This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on magnetic resonance axial images of the patella-femoral joint, with the simple to use OBC having a higher intra-observer reliability score compared to the DJC.

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

Aims

To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures.

Introduction: A Rose calcaneal osteotomy and Cobb procedure for treatment of acquired pes planus is gaining in popularity as a result of the advantages of anatomical reconstruction and reduced graft site morbidity. Although, its ability to provide long term dynamic function and effect on patient’s symptoms remains to be seen.

Materials and Methods: Twenty-two patients with stage two and three Posterior tibialis tendon dysfunction underwent surgical reconstruction with a Cobb procedure and Rose calcaneal osteotomy between 2003 and 2008. The average age was 59 years (range: 20–80 years). There were 18 females and four males.

Results: We evaluated the dynamic function of the Tibialis posterior muscle tendon function by ultra-sonograms postoperatively at mean follow-up time of 36 months. Eighty three per cent of patients achieved a single heel raise. Seventy-three percent of the patients showed an intact and mobile tibialis posterior tendon on supination and pronation movements. There was no difference in the satisfaction of patients with a tenodesis or non tenodesis.

Conclusion: Our results suggest that Cobb procedure does provide dynamic Tibialis posterior function in majority of patients.

We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself.

We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan.

Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment.

Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.

Introduction: Large numbers of studies have been conducted to help the decision making of appropriate management of an ankle fracture.

Aim: To assess intra-observer and inter-observer agreement of treatment for ankle fracture based on plain radiographs.

Materials and Methods: Fifty patients with ankle fracture were randomly selected. Antero-posterior and lateral view ankle radiographs were blinded by the first author and then reviewed by five orthopaedic surgeons with varying clinical experience. The observers were asked for their opinion about how they would like to treat the fracture? They were provided with additional basic information of patient age, sex, mechanism of injury and associated comorbidities. This exercise was repeated again after four weeks. The kappa coefficient and observed agreement values were used for statistical analysis.

Results: The kappa values on both occasions were 0.41(SE: 0.084, 95% Confidence interval: 0.248–0.576, P< 0.00001) and 0.29(SE: 0.099, 95% confidence interval: 0.098 TO 0.487, P< 0.00001). These results show only fair inter-observer agreement.

The kappa values for intra-observer agreement were from 0.34 to 0.69 (P< 0.001) for different observers. The observed agreement for these observers was from 70% to 94%. Only two most senior observers had good agreement.

Conclusion: These results show that there is only fair inter-observer agreement of the treatment for ankle fracture based on plain radiographs and only senior clinicians were consistent about their preferred mode of treatment on both occasions. There is a need of clear guidelines and better understanding of biomechanics of Ankle Fractures to minimize the ‘grey’ zone of when to intervene.