Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients.

A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge.

The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05).

Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.

Objective

To evaluate the clinical and functional outcomes obtained by combination of high-flexion Freedom® Total Knee System (TKS) and mini-subvastus approach in total knee replacement patients.

Background

Conservative treatment of acute AT ruptures with functional rehabilitation has demonstrated superior results with equal reported re-rupture rates but without the added complications of surgical treatment.

There is no consensus on the duration and method of treatment using functional rehabilitation regimes.

The purpose of this paper is to define our treatment regime, the Leicester Achilles Management Protocol (LAMP), supported with patient reported outcomes and objective measures of assessment.

Background

Patients presenting to fracture clinic who have had initial management of a fracture performed by Accident and Emergency (A+E) often require further intervention to correct unacceptable position. This usually takes the form of booking a patient for a general anaesthetic to have manipulation under anaesthesia (MUA) or open surgery.

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity.

Aim:

The Lenke Classification for adolescent idiopathic scoliosis (AIS) classifies curves as nonstructural if they reduce to less than 25° on bending radiographs. We aimed to establish whether there is a significant difference in curves assessed as structural/ nonstructural when comparing bending radiographs to forced traction radiographs.

Background

The majority of studies assessing minimal clinical important difference in outcome do so for management of chronic low back pain. Those that identify MCID following spinal surgical intervention fail to differentiate between the different pathologies and treatments or use variable methods and anchors in the calculation.

Introduction

In all traumatic injury there is a clear relationship between the structural tissue damage and resultant disability after recovery. There are no publications that compare significant thoracolumbar osseous injury to non specific soft tissue injury.

Background

Fractures of the odontoid peg are one of the commonest cervical spinal injuries in the elderly population. In this population there is a higher risk of morbidity and mortality as a result of the injury. The magnitude of the mortality risk has not been quantified in the literature.

Introduction

Despite the lack of robust evidence, numerous different track and trigger warning systems have been implemented. The MEWS (Modified Early Warning Score system) is one such example, and has not been validated in an emergency traumasetting. A considerable proportion of trauma admissions are elderly patients with co-morbidities. Early recognition of physiological deterioration and prompt action could therefore be lifesaving.

Background

The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined.

We present a series of 18 consecutive cases of primary reverse total shoulder arthroplasty for irreparable proximal humerus fractures in patients over 70. Failure of tuberosity union and poor cuff function leads to unsatisfactory results in over half the patients with hemiarthroplasty. Reverse total shoulder arthroplasty does not depend upon a functional rotator cuff and requires little formal rehabilitation.

Patients over 70 with irreparable proximal humerus fractures treated with a reverse total shoulder arthroplasty were included in this study. Only primary arthroplasties were included. Reverse arthroplasties for failed hemiarthroplasties were excluded.

All arthroplasties were performed using either a deltoid split direct lateral (superior) approach or the antero-lateral MacKenzie approach. The SMR reverse total shoulder prothesis was implanted in all cases using a press-fit glenoid base plate and glenosphere, and press-fit or cemented humerus stem. Tuberosity repair was attempted in 10 cases. The supraspinatus was excised from the greater tuberosity.

Patients were allowed self-mobilisation after two weeks in a sling. Patients were recruited and followed up per ethics approved protocol.

Outcome measures used were range of motion, dislocation and revision rates radiological signs of loosening and glenoid notching, DASH and Constant scores. Results were compared to another series of cases of reverse shoulder arthroplasty for sequelae of trauma and failed hemiarthroplasties, as well as a series of primary hemiarthroplasties.

At an average follow-up of 30 months (minimum 12 months) all patients were satisfied with their results. Average forward elevation was 132 deg. and abduction 108 deg. There was not deterioration of movement at 12 or 24 months. No patient had ongoing pain. The average constant score was 62.

There was no evidence of humeral stem loosening apart from one case of early subsidence in a press fit stem. Eleven cases showed glenoid notching, four Nerot grade 1, six Nerot grade 2 and one Nerot grade 3. All notching had stabilised after 12 months. There were no cases of dislocation. No case needed revision, or awaits revision. All cases were pain-free at last review.

Overall results for this group of primary reverse arthroplasties for fractures was much better than for reverse arthroplasties for sequelae of trauma. The results were also better than for primary hemiarthroplasties. Irreparable three and four part fractures of the proximal humerus pose management challenges in the elderly. The reverse total shoulder arthroplasty is very attractive option for elderly patients with irreparable proximal humerus fractures. They require little rehabilitation and can give reproducibly good functional results, which do not deteriorate with time.

Increased use of locking volar plates for distal radius fractures led to a number of reports in literature of flexor tendon injuries from impingement and attrition against hardware. Repair of the pronator quadratus is critical in preventing tendon injury. We present a pronator quadratus sparing approach to the distal radius.

The senior author has used a pronator quadratus sparing lateral pillar approach for for the past five years. A lateral incision is used over the radial styloid. The first dorsal compartment is released and APL and EPB tendons retracted. The underlying brachio-radialis tendon and insertion fascia is split and the palmar portion elevated off the distal radius with the pronator quadratus as a single contiguous sheet. The distal edge of the pronator quadratus is elevated from the wrist capsule by sharp dissection. The radial artery is protected by the retracted tissue.

Repair of the brachio-radialis tendon and insertion fascia is much more robust than that of the pronator quadratus covering the entire plate. Since 2004, the senior author has used the pronator quadratus sparing approach for volar plating of the distal radius, in 183 cases.

At last follow-up there were no instances of flexor tendon injury, which was considered to be one of the outcome measures and end-points. There was no impingement in the first dorsal compartment, except in two cases of lateral pillar hardware impingement from additional lateral pillar plate fixation through the same approach. Nine cases had minor persistent superficial radial nerve parasthesia. One case had a superficial wound infection requiring drainage. The repaired pronator quadratus formed a barrier protecting the plate. The infection was aggressively treated and the plate left in situ for three months till fracture union. Cultures from the retrieved plate showed no organisms.

Another implant had two of the locking screws back out. The pronator quadratus fascia was tented with an underlying haematoma. The fascia however only showed minimum screw penetration and no flexor tendon injury. Average wrist dorsiflexion was 72 deg and palmar flexion 65 deg.

Average pronation was 81 deg and average supination 69 deg. Supination range was slow to recover in younger patients. One explanation could be the tight pronator quadratus repair. Average PRWE and DASH scores were 19.

The quadratus sparing approach to the volar distal radius is easy to perform and protects the flexor tendons at the wrist. Cases demonstrated that an intact pronator quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation.

Humerus non-unions are difficult to treat, especially those with infected non-unions, bone loss, deformity, previous multiple surgeries and/or broken hardware. This paper presents our experience with the use of the Ilizarov frame with humerus non- unions.

Eight consecutive humerus non-unions were treated using the Ilizarov frame. Only loose or infected hardware was removed. The Ilizarov frame was applied using safe zones principles of Ilizarov, Catagni and Paley.

Aspetic non-unions were treated with deformity correction, sequential compression and distraction, bone grafting and intramedullary stabilisation for diaphyseal nonunions. Infected diaphyseal non-unions were treated intra-medullary reaming with or without excision of infected necrotic bone segment, followed by insertion of antibiotic cement rod and compression.

Elbow spanning frames were avoided for supracondylar non-unions. Fine wire fixation of the distal fragment was preferred instead. Free elbow movement was allowed.

There were two infected (diaphyseal) and six aseptic non-unions (four diaphyseal and two supracondylar) treated with this technique. Broken hardware was left in-situ in five cases.

The average time from the index injury was 14 months, with each case having had an average of 3.2 procedures, prior to the application of the Ilizarov frame.

Union was obtained in all cases. The average humerus shortening was 1.5 cm. There was no residual angular or rotational deformity. Infection was eliminated in both the infected non-unions.

Primary bone grafting was used in all aseptic nonunions. Additional bone grafting was needed as a secondary procedure in four cases prior to frame removal. T he average time spent in the frame was 4.5 months. The Ilizarov method is a useful option for the management of complex humerus non-unions. Patients learn to tolerate the fixator and can achieve functional shoulder and elbow range with the fixator.

Purpose of study: We aimed to compare the efficacy and effect of Ender nail and unreamed interlock nail in the management of Type I, II and IIIA fractures.

Methods: 33 cases of open tibial shaft fractures in 32 patients were included in this prospective study. 17 tibial fractures were fixed with Ender nails introduced by antegrade approach and 16 tibial fractures were fixed with statically locked Interlocking nails. The mean follow-up period was 17.8 (6 to 32) months. The mean injury-surgery interval was 5.6 (1 to 16) days.

Results: In the Ender nail group, the average union time for open fracture was 19.5 weeks and 18.3 weeks for Type-I fracture. In the Interlock nail group, the average union time for open fracture was 24.8 weeks and 23.8 weeks for Type-I fracture. Mann-Whitney test revealed significant difference between the two groups for the data described above. Treatment with either nails showed no significant difference in union time for Type-II and type-IIIA fractures. Ankle movement restriction was noted more in interlock nail group (p = 0.04). Anterior knee pain, chronic osteomyelitis and breakage of distal screw were observed in interlock nail group. No complication was seen in Ender nail group.

Conclusion: Ender nailing is a safe and effective choice for treatment of open tibial shaft fractures due to faster fracture union rate and fewer complications. Ender nail is a good implant in treatment of open tibial shaft fractures especially in regions with limited access to specialized, sophisticated and expensive facilities.

Introduction: Carpal scaphoid fractures can be treated non-operatively in a cast, but the duration of treatment can take up to 12 weeks, with non-union rates of 15%. The hypothesis of this study was: percutaneous fixation of acute scaphoid fractures results in better union rates, faster time to union, and better function.

Method: In a prospective study, 48 consecutive acute and subacute scaphoid fractures were treated with percutaneous Acutrak screws. These patients were compared to a case-matched control group treated non-operatively in a cast. Herbert-Fisher type A (‘crack’) and B4 (fracture-dislocations) fractures were excluded from the study. The implant is a cannulated headless titanium screw with conical design and continuous differential pitch for inter-fragmentary compression. The screw was introduced retrograde according to a technique devised by the senior author (MP). In addition to the standard postero-anterior and lateral views, prone and supine oblique views were used to achieve accurate screw placement.

Results: There were 16 B1 (oblique), 15 B2 (waist), four B3 (proximal pole) and nine B5 (comminuted) fractures in each group. The average operation time was 19 minutes. The union rate was 97.7% in the operated group, and 81.8% (36/44) in the non-operated group (p< 0.05). The average time to union was significantly quicker in the operated group (seven weeks compared to 12 weeks, p< 0.05). At 12 weeks post-treatment the range of motion as well as the pinch and grip strengths were better in the operated group. After 24 weeks the two groups had comparable functional results. The mean time taken return to work was 2.5 weeks with percutaneous fixation compared to 13 weeks with cast treatment (p< 0.05). The average delay with cast group in return to work was 10.8 weeks with an average loss of income of $8815. The overall cost to the community with the screw treatment was $7640 more with cast treatment. There were no complications in the operated group and seven non-unions in the cast group.

Conclusion: Primary percutaneous screw fixation of scaphoid fractures is reliable, fast, cost-efficient and reproducible. The learning curve is moderately steep. It results in improved union rates, decreased time to union, improved early function and early return to work. Prone and supine oblique views are invaluable in assessing accurate screw placement.

Introduction and Aims: The Ponseti technique of clubfoot treatment consists of serial manipulation and casting. Most cases require a percutaneous Achilles tenotomy. Very few cases, if any, require surgical correction. This paper reports the short- to medium-term results of the Ponseti technique at one centre.

Method: All idiopathic clubfeet presenting at the clinic over a two-year period from October 2001 to September 2003 were included in the study. The feet were graded weekly using the Pirani score. The first cast attempts to correct the cavus by lifting the first metatarsal. Subsequently, the foot is manipulated and caste weekly, to obtain maximum forefoot abduction, against a fulcrum at the lateral aspect of the talar head. The heel (calcaneum) is free to rotate under the talus at the subtalar joint. No attempt is made to correct the equinus till Achilles tenotomy.

Results: Fifty-four idiopathic clubfeet in 38 consecutive babies were treated using the Ponseti technique. All cases scored five or 6/6 on the Pirani score on presentation. Ten babies had been manipulated elsewhere and offered surgery due to ‘failure to respond’ to the manipulation. Four feet presented late at between six and 12 months of age. An average of six casts were applied prior to the Achilles tenotomy. Six feet (four babies) corrected without a tenotomy. Forty-eight feet required the tenotomy, with a score of 1.5/6 prior to the tenotomy. Four of these six feet required a delayed tenotomy. Correction without surgery was obtained in all cases. All feet were maintained in straight lace shoes with abduction bar, with the feet externally rotated to 45 degrees. Abduction bar compliance issues were seen in three babies. At walking age the babies wore straight last high-top lace-up shoes. Residual dynamic forefoot adductus was seen in 11 feet and may require a tibialis anterior tendon transfer at age three years. Inadequate heel descent was seen in four cases. Residual internal tibial torsion was seen in one case.

Conclusions: The Ponseti method offers a reliable alternative to ‘traditional’ casting and surgery. Babies presenting early had an excellent chance of achieving full correction without surgery. We included children older than six months in the Ponseti program; the treatment is considered to work best with children under three months at presentation.

Introduction and Aims: Distraction osteogenesis can be used to stimulate healing in hypertrophic non-unions (HNU). We evaluated the use of closed (without opening the non-union) Ilizarov distraction for HNU with associated angulation, malrotation, and shortening.

Method: Sixty-seven consecutive patients (mean age, 38.3 years) with 71 HNU were treated (1988–2001) using Ilizarov distraction. Patients had undergone an average of five previous operations. HNU classified as stiff (< 5 degrees mobility) were distracted, and those classified as partially mobile (5–20 degrees mobility) were first compressed and then distracted.

Results: Non-unions included: 59 tibiae, six femora, two radii, and five ankle arthrodeses. Mean limb length discrepancy, 3.5cm; mean deformity, 16°; history of osteomyelitis, six cases. Closed distraction alone was successful in achieving union in 61 cases (86%) (mean follow-up, six years; mean time to union, eight months). Union rate was 91.6% (55 of 60 cases) for stiff HNU and only 54% (six of 11 cases) for partially mobile HNU. Distraction treatment alone failed to achieve union in 10 cases. In seven, union was achieved after bone grafting. Two required resection of infected non-union with bone transport to achieve union. One had persistent non-union. There were numerous superficial pin infections and three deep infections. Two cases had deformity at proximal tibial lengthening osteotomy site.

Conclusion: Closed distraction is safe and reliable for stimulating union in stiff HNU. It is especially effective in a scarred limb that has undergone previous operations. It allows for simultaneous correction of deformity and length. Main disadvantage is lengthy time spent in external fixator.

Introduction and aims: Infected non-unions of long bones with failure of internal fixation are difficult problems with a high amputation rate. Infection following intra-medullary nail fixation is associated with medullary osteomyelitis throughout the length of the bone. We present the results of management of these infected non-unions with intra-medullary lavage, antibiotic cement rod and Ilizarov bifocal transport.

Method: Pre-operative management included management of limb dystrophy and planning for soft tissue cover including angiography. The first stage consisted of removal of the infected hardware, intra-medullary lavage, excision of the necrotic bone with acute (or gradual) shortening, soft tissue coverage including muscle flaps, stabilisation with the Ilizarov device and insertion of a custom-made antibiotic cement rod. Second stage consisted of removal of the rod at six to eight weeks, with a proximal (or distal) lengthening osteotomy for bifocal transport. The docking site was grafted when necessary. Outcome measures used were union, time for treatment completion and the Baltimore/ASAMI bone and functional scores.

Results: Eleven consecutive infected non-unions with failure of internal fixation at three tertiary teaching hospitals were treated with staged salvage. All cases had been offered an amputation by their original treating teams. Nine cases had infected intra-medullary nails; one had a plate and one an external fixator for an infected nail. There were 10 tibial and one femoral non-union. Four cases required muscle flaps. The average length of bone resected was 4.8cm (range 3–8). The average time for completion of treatment was 9.8 months (range 5.5–11.25). All 11 cases went on to solid union, both at the resection site and the lengthening osteotomy site. The mean post-treatment radiographic leg-length-discrepancy was less than 0.5cm. All cases had an excellent to good functional score and an excellent to good bone score.

Conclusions: Antibiotic cement rod and Ilizarov bifocal transport offer a viable alternative to amputation in salvaging infected non-unions following internal fixation of long bones. Treatment is long and difficult, but a functional limb is salvaged as the end result.

Introduction Infected non-unions of long bones with failure of internal fixation are difficult problems with a high amputation rate. Infection following intra-medullary nail fixation is associated with medullary osteomyelitis throughout the length of the bone. We present the results of management of these infected non-unions with intra-medullary lavage, antibiotic cement rod and Ilizarov bifocal transport.

Methods Pre-operative management included management of limb dystrophy and planning for soft tissue cover including angiography. The first stage consisted of removal of the infected hardware, intra-medullary lavage, excision of the necrotic bone with acute (or gradual) shortening, soft tissue coverage including muscle flaps, stabilisation with the Ilizarov device and insertion of a custom-made antibiotic cement rod. The second stage consisted of removal of the rod at six to eight weeks, with a proximal (or distal) lengthening osteotomy for bifocal transport. The docking site was grafted when necessary. Outcome measures used were union, time for treatment completion and the Baltimore/ASAMI bone and functional scores. Eleven consecutive infected non-unions with failure of internal fixation at three tertiary teaching hospitals were treated with staged salvage. All cases had been offered an amputation by their original treating teams. Nine cases had infected intramedullary nails, one had a plate and one an external fixator for an infected nail. There were 10 tibial and one femoral non-unions. Four cases required muscle flaps. The average length of bone resected was 4.8 cm (range 3 to 8).

Results The average time for completion of treatment was 9.8 months (range 5.5 to 11.3). All eleven cases went on to solid union, both at the resection site and the lengthening osteotomy site. The mean post-treatment radiographic leg-length-discrepancy was less than 0.5 cm. All cases had an excellent to good functional score and an excellent to good bone score.

Conclusions Antibiotic cement rod and Ilizarov bifocal transport offer a viable alternative to amputation in salvaging infected non-unions following internal fixation of long bones. Treatment is long and difficult, but a functional limb is salvaged as the end result.