Background

Smartphones are now a ubiquitous presence within the modern healthcare setting. Uses such as internet, database software and storage of medical textbooks, all contribute to the clinical value of the devices. Within orthopaedics, transmission of digital images via smartphones is now routinely used to obtain instant second opinions of trauma radiographs. However questions remain as to whether smartphone image quality is sufficient for primary diagnosis and secondary consultation

Aims

Hip fractures pose a significant burden on the healthcare system. Hyperglycaemia and a state of Type 2 diabetes exists post operatively. Being normoglycaemic has well documented benefits. Pre operative carbohydrate loading has been shown to have two good effects. It decrease hyperglycaemia post operatively and allows the patient to undergo less strict fasting protocols. Insulin resistance to date has not been examined in these patients and this was determined using a validated formula (HOMA/IR).

Background

Malnutrition has been suggested to increase the risk of falls in frail elderly. It has been hypothesised that elderly, orthopaedic trauma patients may be malnourished. We conducted an observational study to identify if this was the case.

Introduction

Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral centre in Ireland.

Introduction

Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral Centre in Ireland.

Objective

To report clinical results of patients who underwent closed reduction and percutaneous iliosacral screw fixation for Tile Type C fractures.

Introduction

It is recommended that the ankle be held in dorsiflexion at the time of placement of syndesmosis screw. We assessed the validity of this recommendation.

Introduction: This study was performed to review the changing patterns of trauma admissions in Ireland over 5 years (1999–2005).

Materials and Methods: A review of prospectively collected admission data of trauma patients admitted to the Adelaide & Meath Hospital (AMNCH). Dublin, Ireland, during 2005. Data obtained from Hospital In Patient Enquiry (HIPE) system. A comparison is made similar data from 1999. Demographic data, mode of presentations, type of injuries, time of injury and place of injury were recorded. Injury severity was defined using the Injury Severity Score (ISS).

Results: 23% increase in number of admission in 5 years period. Mean age of admission reduced from 35 (1999) to 32 (2005). 67% of admission occurred outside normal office hours (9am–5pm). Commonest mode of injury was road traffic accident (RTA) in 1999 and sports related injury in 2005. Work related trauma increases by 40% and assault increases by 35% from 1999 to 2005. High energy trauma cases reduce by 50% but open fracture cases double in 5 years. Mean overall ISS score was 56. 7(1999) decreased to 45.9 (2006).

Conclusion: These changes cause significant impact on the health system. Increase in facilities for management of trauma is essential as this trend is more likely to continue.

Introduction: Proximal humeral fractures are common in the elderly osteoporotic population. Surgical management of such fractures with traditional internal fixation techniques is often challenging due to poor bone quality. Fixation with intramedullary devices theoretically offers better fixation, but with increased risk of shoulder pain and decreased range of motion. We undertook a study to compare outcome following fixation of such fractures with either an intramedullary nail (Polarus), standard Clover Leaf plate (AO), or Philos Locking plate (AO).

Method: All patients admitted for surgical management of a proximal humeral fracture were entered into the study. 10 patients were treated using a Philos plate (Group 1), 5 with a Clover Leaf plate (Group 2), and 10 with a Polarus nail (Group 3). Post-operative assessment included radiological evaluation, clinical assessment of range of motion compared to the non-injured arm, assessment of pain severity (visual analogue scale), and functional assessment (DASH score). Non-parametric statistical techniques were used to analyse results.

Results: There was no significant difference in age or sex distribution between the three groups. (Mean ages: Group 1: 54.6 yrs, Group 2: 45.2 yrs, Group 3: 59.7 yrs) Mean patient follow-up was 22 months (range 5–52 months).

All patients in Group 1 and 2 went on to satisfactory radiological and clinical union. A higher complication rate was noted in the Polarus nail group, with 3 patients requiring removal of metal due to soft tissue or subacromial impingement. In addition one patient developed a non-union and required Philos plate fixation.

All groups demonstrated a significant decrease in shoulder range of motion following injury, however this was less marked in Group 1 (Philos plate). In addition, patients in group 1 (Philos plate) demonstrated a more rapid recovery in terms of severity of pain, functional impairment and range of motion in the early postoperative phase. However, no significant long-term difference was noted in terms of post-operative pain or functional deficit between group 1 and 2. The poor outcome in group 3 was associated with a high incidence of shoulder pain and secondary procedures.

Conclusion: Intramedullary fixation of proximal humeral fractures resulted in a high level of complications requiring secondary procedures in many cases. Our study supports the safety and efficacy of plate fixation techniques in the operative management of proximal humeral fractures.

Introduction: With a worldwide aging population, and an expected doubling in numbers of people older than 65 between 1990 and 2020, we are in the midst of a predicted increase in osteoporosis and resultant fractures. The International Osteoporosis Foundation recently surveyed consultant orthopaedic surgeons in mainland Europe and New Zealand to determine how patients with osteoporotic fractures were managed. Their conclusion was that treatment patterns were varied, and the findings supported the need to improve fragility fracture services to reduce the risk of recurrent fractures.

Aim: The aim of our study was to see how Irish practices and opinions related to the IOF survey, in anticipation of a formal protocol being established in our unit.

Methods: A modification of the International Osteoporosis Foundation survey used in 2002 was sent to 85 Consultant Orthopaedic Surgeons listed in the Irish Medical Directory. The questionnaire evaluated the surgeon’s education and knowledge of osteoporosis management, as well as estimated numbers of patients being treated with osteoporosis and the investigations available to their service. Treatment and referral patterns were also established. All responses were anonymous.

Results: The Irish response rate to the survey of nearly 50% was higher than that of our European colleagues, and showed that only 25% of surgeons felt they received sufficient training in the area of osteoporosis, but only a minority were not confident managing the disease. One-quarter of those surveyed would treat a patient with a fragility fracture for osteoporosis themselves, while over half would refer the patient on to a General Practitioner for further management. 50% of Irish Consultants would first order bone mineral densitometry, and nearly three-quarters believe the General Practitioner is the most appropriate professional to follow up these patients. Significantly, 15% of Orthopaedic surgeons did not have any access to densitometry. The most popular treatment modality is a combination of calcium and vitamin D supplementation in conjunction with Alendronate.

Conclusion: There is currently a lack of standarisation in the management and follow up of patients with osteoporosis. While the disease and its treatment is an internationally important topical issue, our study showed that at a national level there is a lack of consistency between the need for specialised services and implementation of treatment algorithms, due in part to lack of investigative facilities and organised management teams.

Introduction Magnetic resonance imaging (MRI) is important in non-invasive evaluation of osseous and soft-tissue structures in the post-traumatic knee. However, it is sometimes impossible to determine if a focus of high signal intensity in the meniscus is confined to the substance, or extends to involve the joint surface. This is a critical differentiation as the latter represents menisci tears that can be found and treated arthroscopically, whereas the former represents degradation, intra-substance tears or normal variants not amenable to arthroscopic intervention.

The aim of this study was to investigate occurrence of altered signal intensity in the posterior horn of the medial meniscus and correlate with arthroscopic findings.

Materials and Methods 64 patients with suspected post-traumatic internal derangement of the knee who underwent MRI prior to arthroscopy were evaluated. All patients initially had MR imaging of the symptomatic knee using a standard protocol in a Siemens Symphony 1.5 Tesle Magnetom. MR images were then interpreted and reported by 2 radiologists experienced in MR and skeletal radiology. Meniscal tears were graded according to the system validated by Lotysch. A Grade 3 signal was considered unequivocal evidence of a meniscal tear. Equivocal tears (Grade 2/3 signal) were diagnosed if it was unclear if there was a small portion of normal intact meniscal tissue between a linear high signal in the meniscus and the articular surface abutting the meniscus.

Arthroscopy was subsequently performed by senior surgeons aware of the MR findings within 2 weeks of imaging.

Patients were re-assessed clinically and evaluated functionally at a mean follow-up time of 5 months. Radiographic, arthroscopic and clinical results were then correlated and evaluated.

Results There were 48 males and 16 females in the group, with a mean age of 28.2 years.. Tears of the posterior horn of the medial meniscus were reported on MRI unequivocally (Grade 3 signal) in 18 patients and equivocally (Grade 2/3 signal) in 10 patients. Subsequent arthroscopic correlation revealed 16 tears (89%) in the unequivocal group and only one tear (10%) in the equivocal group.

Discusion The finding that only 10% of patients with an equivocal tear in the posterior horn of the medial meniscus on MRI were subsequently found to have a tear on arthroscopy would suggest that early arthroscopic intervention is not warranted in these cases. We suggest that unless symptoms persist over the course of 3 to 6 months, or if a more compelling symptom complex develops, only then should arthroscopic evaluation be considered.

Conclusion Equivocal tears on MRI of the posterior horn of the medial meniscus have a low rate of arthroscopically detected tears and a trial of conservative therapy may be prudent in such cases.

Currently, data on the complication rates of primary total hip arthroplasty (THA) in Ireland is not available. We surveyed all consultant members of the Irish Orthopaedic Association (IOA) to determine the self reported complication rates of primary THA and analysed national audit data from the Economic and Social Research Institute (ESRI) for 2002. We received an 83% response rate to our survey. 58 surgeons reported data on 5,424 primary THAs for the year 2003. The mean dislocation rate was 1.02% and those using a posterior approach reported a significantly higher dislocation rate (p< 0.05). Deep infection rates were 0.44% and 29% of these were MRSA infections. There was no significant benefit reported from the use of body exhaust operative attire. The mean rate of venous thrombo-embolism (VTE) was 3.5%. There was no statistical difference reported in VTE rates when prophylaxis was commenced pre or post operatively, neither was there any significant benefit reported from using VTE prophylaxis for an extended period beyond the length of inpatient stay, nor from patients wearing graduated compression elastic stockings. ESRI national audit rates for dislocation were 25.7%, and rates of deep infection and VTE were 0.87% and < 0.1% respectively in 2002. Deficiencies in available ESRI data and questionable reliability of self reported rates, underline the necessity for a national Hip Register database in Ireland. The accurate recording of objective data on primary THA could provide an evidence base to improve surgical THA practices and patient outcomes and provide significant healthcare savings.

Introduction: Articular fractures, especially in weight-bearing joints of the lower extremity, require anatomical reduction for good long-term function. If anatomic reduction is achieved 90% of patients have good results. Accurate anatomical reduction of acetabular fractures is made difficult y the complicated anatomy of the acetabulum and pelvis. Plain films and computerised tomography are very useful in the assessment, classification and planning for surgery of these fractures, but conventional imaging only provides two dimensional images of these fractures. While interpretation of traditional imaging techniques becomes better with experience novel techniques may assist in the understanding of these complex injuries. This project presents the use of three dimensional life size models which can be rapidly manufactured from CT scans to facilitate fracture classification and operative planning.

Patients and Methods: Standard 4 mm CT cuts were reformatted to 2 mm and saved as DICOM files for a series of 15 consecutive patients with complex acetabular fractures (not including isolated posterior wall injuries). These were imported into Mimic (Materialise) data conditioning software, which allowed manipulation and thresholding of images so that a three-dimensional computer model could be built. The data was exported to the Selective Laser Sintering (SLS) system and a life size three-dimensional model constructed. Three consultant orthopaedic surgeons and three senior trainees were asked to classify, using the system of Letournel, each fracture using 1) conventional radiographs (AP pelvis, Judet views and CT scans). 2) Using a model. As no absolute of fracture type was available the Kappa statistic was used to evaluate inter and intraobserver agreement. This compared an observed level of agreement with the level of agreement that would be expected by chance alone.

Results: Interobserver agreement was not absolute using either conventional radiographs or the sintered model. For the consultants the kappa statistic using conventional radiographs was 0.61 while the kappa value using the model was 0.76 (p=< 0.05). For the trainees the kappa was 0.42, using conventional radiographs and 0.71 using the model (p=< 0.01)>

Discussion: The complex three-dimensional anatomy of the pelvis and acetabulum make assessment and classification of fractures of these structures notoriously difficult. The value of accurate fracture classification is well recognised particularly in the treatment of intra-articular injuries. The use of this real life model of a fractured pelvis has been shown in this study to significantly reduce the degree of interobserver variability in the classification of these injuries. This effect is particularly evident for less experienced surgeons.

Conclusion: The technique is available and relatively inexpensive. These models may be of great benefit for preoperative planning, classification and assessment of prognosis in acetabular fractures. Its use should prove invaluable as a tool to aid clinical practice.

Limb length discrepancy (LLD) is a complication of total hip arthroplasty (THR). We reviewed the x-rays of patients who underwent THR in our unit to establish the incidence and magnitude of LLD, and try to identify reasons why a length discrepancy arose. Patients with abnormalities of the opposite hip (previous THR, significant osteoarthritis) were excluded, to allow comparison with a normal contralateral side.

100 consecutive patients who fulfilled these criteria were included. There were 38 male and 62 female patients. The implants used were Charnley (89 cases), Elite (4 cases), and Exeter (7 cases). The following measurements were made on pre-and post-operative films on the hospital PACS system: centre of lesser trochanter to ischial tuberosity; tip of greater trochanter to centre of femoral head; centre of head to base of teardrop. The distance from the osteotomy in the femoral neck to the centre of the lesser trochanter was also measured. The interval from the greater trochanter to the closest margin of the pelvis, and the interval from the lesser trochanter to the base of the teardrop (compared to the normal side) were recorded as indices on adduction. Surgery was performed via a direct lateral (Hardinge) approach (95 cases) or through transtrochanteric approach (5 cases).

There was a radiographic difference between limbs of > 1cm in 43 cases; in 9 of these, the operated limb was longer, and in 34 cases it was shortened. In those cases where the operated side was lengthened, the cause was on the acetabular side in 2 patients, and on the femoral side in 25 cases, and on the femoral side in 9 cases. The shortened limb was noted to be adducted relative to the opposite side in 29 patients. There was difference noted in the incidence of discrepancy between different implants. The transtrochanteric approach was associated with significantly (p< 0.01) less length discrepancy.

Our findings suggest that shortening is much more common than lengthening following THR, and that incorrect positioning of the acetabulum is the more likely cause. Persistence of an adduction contracture may also contribute to an apparent shortening postoperatively. The transtrochanteric approach appeared to make LLD less likely. Surgeons should be aware of these findings when performing THR. The clinical effect of differing degrees of LLD is till debatable.

A series of 19 patients with severe rheumatoid arthritis had replacement of both hips and both knees. They are reviewed after a mean follow-up of 27 months. The preferred programme is to replace hips before knees. Pain was relieved in all the patients and function was improved in all but two. Severe rheumatoid disease and prolonged immobilisation before the operations were not contra-indications to a successful outcome, but the presence or the development of cervical myelopathy combined with gross upper limb deformity militated against a good result.