There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis.

This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time.

860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p < 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p < 0.00001).

Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area.

A number of classification systems exist for posterior malleolus fractures of the ankle. The reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised fracture classification systems of the posterior malleolus.

60 patients across 2 hospitals sustaining an unstable ankle fracture with a posterior malleolus fragment were identified. All patients underwent radiographs and computed tomography of their injured ankle. 9 surgeons including pre-ST3 level, ST3-8 level, and consultant level applied the Haraguchi, Rammelt, and Mason & Molloy classifications to these patients, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss’ kappa and 95% confidence intervals (CI). Intra-rater reliability was assessed using Cohen's Kappa and standard error (SE).

Inter-rater reliability (Fleiss’ Kappa) was calculated for the Haraguchi classification as 0.522 (95% CI 0.490 – 0.553), for the Rammelt classification as 0.626 (95% CI 0.600 – 0.652), and the Mason & Molloy classification as 0.541 (95% CI 0.514 – 0.569). Intra-rater reliability (Cohen's Kappa) was 0.764 (SE 0.034) for the Haraguchi, 0.763 (SE 0.031) for the Rammelt, 0.688 (SE 0.035) for the Mason & Molloy classification.

This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis & Koch (1977), inter-rater reliability was rated as ‘moderate’ for the Haraguchi and Mason & Molloy classifications; and ‘substantial’ for the Rammelt classification. Similarly, the intra-rater reliability was rated as ‘substantial’ for all three classifications.

The purpose of this study is to report the clinical and radiological outcomes of patients undergoing primary or revision reverse total shoulder arthroplasty using custom 3D printed components to manage severe glenoid bone loss with a minimum of 2-year follow-up.

After ethical approval (reference: 17/YH/0318), patients were identified and invited to participate in this observational study. Inclusion criteria included: 1) severe glenoid bone loss necessitating the need for custom implants; 2) patients with definitive glenoid and humeral components implanted more than 2 years prior; 3) ability to comply with patient reported outcome questionnaires. After seeking consent, included patients underwent clinical assessment utilising the Oxford Shoulder Score (OSS), Constant-Murley score, American Shoulder and Elbow Society Score (ASES), and quick Disabilities of the Arm, Shoulder, and Hand Score (quickDASH). Radiographic assessment included AP and axial projections. Patients were invited to attend a CT scan to confirm osseointegration. Statistical analysis utilised included descriptive statistics (mean and standard deviation) and paired t test for parametric data.

3 patients had revision surgery prior to the 2-year follow-up. Of these, 2/3 retained their custom glenoid components. 4 patients declined to participate. 5 patients were deceased at the time of commencement of the study. 21 patients were included in this analysis. The mean follow-up was 36.1 months from surgery (range 22–60.2 months). OSS improved from a mean 16 (SD 9.1) to 36 (SD 11.5) (p < 0.001). Constant-Murley score improved from mean 9 (SD 9.2) to 50 (SD 16.4) (p < 0.001). QuickDASH improved from mean 67 (SD 24) to 26 (SD 27.2) (p = 0.004). ASES improved from mean 28 (SD 24.8) to 70 (SD 23.9) (p = 0.007). Radiographic evaluation demonstrated good osseointegration in all 21 included patients.

The utility of custom 3D-printed components for managing severe glenoid bone loss in primary and revision reverse total shoulder arthroplasty yields significant clinical improvements in this complex patient cohort.

Introduction and Objective

Tranexamic acid (TXA) is used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in all types of shoulder surgery on bleeding and non-bleeding related outcomes.

Introduction and Objective

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis.

Aim

Diagnosing periprosthetic joint infection after total joint arthroplasty is often challenging. The alpha defensin test has been recently reported as a promising diagnostic test for periprosthetic joint infection. The goal of this study was to determine the diagnostic accuracy of alpha defensin testing.

Background

Radiation exposure remains a significant occupational hazard for Orthopaedic surgeons. There are no references values for trauma procedures performed with Image Intensifier (II). We aimed to determine and compare reference values for patient radiation exposure for common trauma operations, and to analyse the effect of surgeon grade on II usage.

Our aim was to accurately determine whether muscle atrophy and fatty infiltration are reversible following cuff repair. Patients with a repairable cuff-tear were recruited and assessed clinically and radiologically (Magnetic Resonance Imaging). At surgery, supraspinatus was biopsied. Post-operatively, patients underwent clinical evaluation at standardised intervals, with further MRI and an ultrasound guided biopsy of supraspinatus at 12 months.

MRI was used to characterize cuff-tears and determine the degree of muscle atrophy and fatty infiltration. Biopsy samples were fixed on-site and transported for processing. Morphometric assessments of myofibres were made and mean cross-sectional areas calculated using validated techniques. The pathologist was blinded to sample details. Statistical analysis was performed to assess differences in mean myofibre area following cuff repair and correlated with radiological findings.

Eight patients were available for completed histological and radiological analysis. Six (two re-tears) demonstrated sizeable and highly statistically significant improvements in mean myofibre cross-sectional area (P=0.000–0.0253). Of the two not showing any increase in myofibre area, neither result was statistically significant (P=0.06, 0.2); one was a re-tear and one was a repair of a partial-thickness tear. Radiologically, the muscle and fatty changes had not demonstrably changed.

Our finding that myofibre cross-sectional area increases following cuff repair suggests muscle atrophy is a potentially reversible process. Even with re-tears, improvements were seen. MRI features of fatty infiltration and muscle atrophy were not seen to improve however. It is likely that radiological assessment is not sensitive enough to demonstrate the reversibility of muscle atrophy seen on histological analysis at one year.

Taylor Spatial Frame (TSF) is a six axis deformity correction frame and accuracy of correction depend on the accuracy of parameters input in to the web based software. There are various methods of obtaining frame and deformity parameters (13 in total) including the use of dedicated software known as SpatialCAD™. We tested the accuracy of SpatialCAD™ using a saw bone two ring frame construct of known parameters. We mounted a two-ring (155mm) frame on a saw bone tibia and fibula unit and worked out the accurate mounting and deformity parameters. Then we obtained orthogonal and nonorthogonal antero-posterior and lateral images of frame using a metallic sphere of known dimensions placed at the level of the bone, to aid calibration of x-ray images. We also obtained orthogonal and non-orthogonal images without a calibrating sphere. We then uploaded the images in to SpatialCAD™ software and obtained the mounting and deformity parameters and compared with the real parameters. SpatialCAD™ is capable of yielding measurements within 1–2mm of actual measurements when Calibrated orthogonal images were used. The software was inaccurate when frame hardware of known dimensions was used for calibration because the hardware was not in the same plane as the bone

Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living.

We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening.

Objectives

Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG).

Introduction: Hip fractures guidelines suggest that ‘all patients with fracture neck of femur should be operated upon as soon as possible (within 24hrs). Despite this different studies suggest that still 11% of hip fractures are treated conservatively (varies 3–37%).

Aim: Our main aim was to find out whether there is a place for non-operative treatment as a definitive primary option in patients with significant medical comorbidity. We also wanted to audit best practice for conservative treatment in medically compromised patients and in those patients whose hip fractures are not suitable for surgical repair.

Methods: We did this audit in 2007 collating information on 1010 hip fracture patients across 14 NHS hospitals in England. 50 out of 1010 (4.95%) patients were treated conservatively. We reviewed the records of these 50 patients (range 66–99, mean age 78 years) and looked at patient demographics, radiographic features, mobility, accommodation, cognition, and ASA class were recorded.

Results: There were 17 males and 33 females patients managed conservatively in our study. Before injury, 37 (74%) were living at home and 13 (26%) were institutionalised. During hospitalisation, 4 became bedridden and 30 died (mainly due to medical comorbidities). Among these 50 patients, eight were deemed physically unfit for surgery by anaesthetists and two by medical consultants. The decision of conservative treatment was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. Five patients refused surgery and five patients were palliative due to terminal illnesses. Patients who did not proceed to surgery (either treated conservatively by choice or presented at admission with complications) had significantly higher mortality rates (overall mortality rate 60 %) suggesting that they were physiologically much worse group of patients.

Discussion: As the average life span of our population increases, some hip fractures are now treated non-operatively because of the possibility of severe or fatal complications due to surgery. Often, refusal of surgery by the patient or the patients’ family obligates the need for non-operative treatment. It is acceptable to postpone the surgery if the patients are medically unfit for these reasons (eg. acute cardiac event, patient dying, severe aortic stenosis, multi-organ failure). It is not considered appropriate if surgery is cancelled due to pyrexia, chest infection, borderline Hb or awaiting ECHO for murmur. Administrative or logistic reasons (eg. no HDU bed) needs to be looked at higher levels as well.

One of the most challenging cases encountered by orthopaedic surgeons is chronic osteomyelitis. The mainstays of successful treatment include: radical debridement, stabilisation of the bone if necessary; control of infection and finally skin cover or closure.

Negative pressure dressings have been used for over 10 years in the treatment of acute and chronic wounds with recognised benefits. Topical negative pressure wound therapy with instillation of solution in the local area (VAC Instill Therapy System®) is a new device available in the armamentarium of a limb reconstruction surgeon. This device automatically delivers instillation fluid into the infected wound, where this fluid is held for a while before application of topical negative pressure. This cycle helps remove infectious material leading to clean closed moist environment for better wound healing.

Senior authors (MGD and SLR) have used this VAC Instill therapy in 10 cases of chronic osteomyelitis from April 2007 to November 2008. All patients have been included in this study. All patients had (thorough) bony and soft tissue debridement followed by application of VAC Instill therapy with local delivery of antibiotics.

All patients were male with mean age of 39 years (range 20–56 years). There were eight cases of tibial osteomyelitis, one distal radial and one calcaneal osteomyelitis. Most had mixed growth, with Staphylococcus being most common infecting organism. Average duration for VAC Instill therapy was 32 days (range 20–71 days). Average hospital stay was 33 days (range 15–85 days) and average time to wound closure was 39 days (range 19–90). There were two failures of treatment one later had Lautenbach procedure and other had below knee amputation.

We conclude that VAC Instill therapy is very successful in the management of chronic osteomyelitis. These are the only early results available in the literature. Further studies are needed to back these findings.

Aims: To compare rates of blood transfusion post knee arthroplasties for patients treated with and without tranexamic acid (TA) and assess for any haemoglobin change perioperatively between the groups.

Methods: This retrospective observational study included 207 patients undergoing primary unilateral knee replacement surgery who were divided by administration of TA intraoperatively (n=120) or without (n=87). The TA group was further subdivided into patients undergoing a standardised autogenic retransfusion procedure (n= 86) and those without (n=44). Case notes and laboratory results were used to study pre and post operative haemoglobin, administration of TA and blood products. The exclusion criteria consisted of patients in ASA classes III & IV, revision surgery, and patients undergoing bilateral or unicompartmental knee replacements. Analysis of haemoglobin change was undertaken using the student t-test. Significance was concluded when p < 0.05.

Results: The average haemoglobin drop in the TA group (without auto-transfusion) was 1.96g/dL versus 1.8g/dL in the no drug group which was not significant (p= 0.459). The average drop in the TA group (with auto-transfusion) was 1.78g/dL, also not significant (p=0.922). 3 of the 44 patients (7%) from the TA group (without auto-transfusion) required blood transfusions compared against 7 of the 87 non tranexamic acid group (8%) which was not significant.

Conclusion: There was no significant difference between all three groups. This study raises questions over the efficacy of TA treatment as a means to reduce perioperative blood loss in total knee replacements. Further, TA does not reduce blood loss and transfusion requirements even when autogenic retransfusion was used.

Purpose of study: Non-fusion stabilisation of degenerative lumbar spine with hinged pedicle screws provides an alternative to spinal fusion in preventing junctional breakdown.

Methods and Results: In this prospective cohort study, clinical, functional (Roland-Morris Disability Scale 18 question version) and radiological assessment of patients was performed pre-operatively and postoperatively at predetermined intervals. 36 patients were reviewed with a mean follow-up of 18 months (12 – 28 months). The indications of operation were symptomatic spinal stenosis, discogenic mechanical back pain, post discectomy syndrome and revision spinal surgery. Average age was 57 years (35 – 78 years). Average pre-operative duration of back pain was 6 years (2 – 25 years). 18 patients had stabilisation of single motion segment, 12 had two adjacent motion segments stabilised and six had three segments stabilised. 28 patients had spinal decompression along with stabilisation. On excluding one patient with wound infection average hospital stay was 5 days. There were 78 rods and 192 pedicle screws used with in-situ breakage of two screws and loosening of one screw.

Functional score (Roland-Morris Disability Scale 18 question version) improved from 11.33 to 4.44. Visual analogue score (VAS 0 – 100) improved from 79.29 to 13.29. Subjective outcome, measured with descriptive analogue scale, showed marked improvement in 76% of patients.

Conclusion: The posterior dynamic stabilisation eliminates the risks and complications of fusion surgery. Although long term results are not available yet but considering early results, this technique can be used safely as a first line surgical treatment for degenerate lumbar spine.

The use of volar locking compression plates for the treatment of fractures of the distal radius is becoming increasingly popular because of the stable biomechanical construct, less soft-tissue disturbance and early mobilisation of the wrist. A few studies have reported complications such as rupture of flexor tendons. We describe three cases of rupture of extensor tendons after the use of volar locking compression plates. We recommend extreme care when drilling and placing the distal radial screws to prevent damaging the extensor tendons.

Aim To assess the reliability of Stainsby’s operation for dislocated lesser toe metatarsophalangeal (MTP) joints.

Method Seventy-four patients underwent this operation between 1998–2003. Sixty-nine patients (93%) were reviewed at mean follow up of 32 months (range 10–67) post-operatively. Forty-eight patients had rheumatoid arthritis, two had psoriatic arthropathy, 19 had other causes. Ninety-four feet were reviewed, 73 had had multiple lesser toe operations, 21 had single lesser toe operations, 52 feet had surgery to the hallux. Assessments were made of pre- and post-operative pain, shoe problems, callosities, alignment and function.

Results Out of 94 feet, 89 (95%) had severe or moderate pain pre-operatively. Only 19 (20%) had significant pain at review. Pain under operated toes was relieved in 78 feet (83%). Tender plantar callosities were reduced from 76 feet pre-operatively (81%) to 31 feet (33%) at review, these mainly under un-operated metatarsal heads. Shoe problems were reduced from 89 feet (95%) pre-operatively to 61 feet (65%) at review. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were increased from a mean of 19 pre-operatively to 52 at review.

Residual valgus of big toe more than 25 degrees persisted in 33 feet (35%). Corrective osteotomy of 44 first metatarsals failed to prevent recurrent valgus in 16 feet (36%).

Conclusions The Stainsby operation was effective in relieving pain and skin callosities from under dislocated lesser metatarsal heads, and in reducing shoe problems but we found that varus osteotomy was unreliable in correcting valgus of the big toe. This was probably due to stretching of the repaired medial ligament.