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.

Introduction

Classical fixation using a circular frame involves two rings per segment and in many units this remains the norm whether using ilizarov or hexapod type frames. We present the results of two ring circular frame at King's College Hospital.

Higher uric acid levels or hyperuricemia is a product of more uric acid production, dysfunctional renal excretion, or a combination of both leading to deposition of urate crystals in the joints and kidneys and has been strongly linked with the development of gout, that is, acute inflammatory arthritis. Uric acid levels have been suggested to depend on multiple factors including lifestyle, diet, alcohol consumption, etc. As these are risk parameters for hyperuricemia and since lifestyle choices vary amongst different Indian communities, we sought to study the prevalence of hyperuricemia in these communities. Also, large-scale data (in terms of gender, age, lifestyle, community) on the prevalence of hyperuricemia in subjects amongst different community populations, Hindu, Muslim, Sikh, and Christian was generated.

In a retrospective study conducted at Dr. D. Y. Patil School of Medicine & Research Centre, Navi Mumbai from April 2018 to May 2021, information was gathered from four major communities on a range of indicators including serum uric acid levels followed by a thorough multilevel logistic analysis. We evaluated uric acid levels in 10,378 patients of four different communities. Outcomes were assessed biochemically as well as clinically based on the levels of serum uric acid.

The mean serum uric acid levels were highest in Sikhs (7.6 mg%, n=732) followed by Christians (7.3 mg%, n=892) and then by Hindus (5.9 mg%, n=6846) and Muslims (5.6 mg%, n=1908). About 83.7% of Christians consumed meat in a non-vegetarian diet followed by 45.7% Muslims. Percentage of Christians who binge drink were highest whereas percentage of Sikh people in the heavy drinkers’ category were 5.2%. Further, 9.5% Hindus were current smokers followed by 7.8% Sikhs who smoked at present.

Overall, our study of 10,378 patients demonstrated that the serum uric acid levels varied from one Indian community to another due to varying external factors like diet, age, lifestyle, and addictions. Thus, lifestyle modification in communities with higher serum uric acid levels is highly advocated and this may reduce the healthcare burden of gouty arthritis in these communities.

Abstract

Introduction and Objective

Management of gap non-union of the tibia, the major weight bearing bone of the leg remains controversial. The different internal fixation techniques are often weighed down by relatively high complication rates that include fractures which fail to heal (non-union). Minimally invasive techniques with ring fixators and bone transport (distraction osteogenesis) have come into picture as an alternative allowing alignment and stabilization, avoiding a graduated approach. This study was focused on fractures that result in a gap non-union of > 6 cm. Ilizarov technique was employed for management of such non-unions in this case series. The Ilizarov apparatus consists of rings, rods and kirschner wires that encloses the limb as a cylinder and uses kirschner wires to create tension allowing early weight bearing and stimulating bone growth. Ilizarov technique works on the principle of distraction osteogenesis, that is, pulling apart of bone to stimulate new bone growth. Usually, 4–5 rings are used in the setup depending on fracture site and pattern for stable fixation. In this study, we demonstrate effective bone transport and formation of gap non-union more than 6 cm in 10 patients using only 3 rings construct Ilizarov apparatus.

Introduction

Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity

Anterior cruciate ligament (ACL) injuries are one of the most common ligament injury occurring in young and active individuals. Reconstruction of the torn ligament is the current standard of care. Of the many factors which determine the surgical outcome, fixation of the graft in the bony tunnels has significant role. This study compared the clinical and functional outcome in patients who underwent ACL reconstruction by standard anteromedial portal technique with single bundle hamstring graft anchored in the femoral tunnel using rigidfix and cortical button with adjustable loops. The tibial fixation and rehabilitation protocol were same in both groups.

107 patients underwent ACL reconstruction over a two-year period (87 males, 20 females, 44 after motor vehicle accident, 34 after sports injuries, 79 isolated ACL tear, 21 associated medial meniscus tear, 16 lateral meniscus tear and 11 both menisci). Rigid fix group had 47 patients and adjustable loop 60 patients. Clinical evaluation at end of one year showed better stability in rigid fix group regarding Lachman, anterior drawer, pivot shift tests, KT 1000 arthrometer side to side difference and hop limb symmetry index. However, the differences were not statistically significant.

Functional evaluation using IKDC 2000 subjective score and Lysholm score showed better results in rigidfix group than variable loop, but was not statistically significant. However, lower scores were noted in patients with concomitant meniscal injury than in isolated acl tear patients and this was statistically significant in both groups.

Rigidfix seems to give better graft fixation on femoral side than variable loop, but by the end of one year the functional outcome is comparable in isolated acl reconstructions.

Background

The national back pain pathway sets out the gold standard pathway for patients with back and radicular pain. To improve implementation we needed to understand current practice and identify divergences from the pathway.

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions.

Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant.

11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery.

All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function.

A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems.

The purpose of this study was to identify the prevalence of common mental disorders in patients undergoing complex limb reconstruction.

Patients undergoing limb reconstruction are vulnerable to mental health problem as they must adapt to significant and prolonged physical disability. Treatment emphasis has been on restoration and rehabilitation of physical health with little or no attention given to spectrum of psychological consequences. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) is a King's Health Partners initiative aiming to develop informatics to improve detection and management of common mental disorders in medical settings. IMPARTS screening in the King's College Hospital limb reconstruction clinic commenced in April 2012.

Outpatients attending between April 2012 and November 2013 were screened prior to their appointment. Patients were screened for symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), alcohol dependence and drug use.

In total, 298 individual patients were screened. The prevalence of depression was found to be 21.8%, with 6.4% experiencing suicidal thoughts. Probable anxiety disorder was identified in 20.7% of patients. Symptoms of PTSD were reported by 29.2%, with 9.0% reporting severe symptoms. Probable alcohol dependence was identified in 2.7% of patients, and 3.0% screened positive for drug misuse.

The consequences of undergoing limb reconstruction stretch beyond the physical problem to mental well-being, rendering patients vulnerable to mental health problems and substance misuse. Early detection and management of such problems may have a significant effect on physical treatment outcome and rehabilitation to productive social life. There is urgent need to integrate mental health care as part of early management of severely injured patients.

The purpose of this study is to describe the use of intramedullary distraction coupled with an additional osteotomy to achieve union with simultaneous deformity correction and lengthening in femoral non-union.

Femoral non-union is a difficult problem often associated with shortening, angulation, and mal-rotation. We report the use of an intramedullary distraction device, with additional osteotomy, to achieve union, restore femoral length and alignment. Simple distraction in femoral non-union is often ineffective, possibly because the non-union site is relatively avascular. Osteotomy is known to increase blood flow and, with lengthening, promote union through distraction histiogenesis.

7 patients with posttraumatic diaphyseal femoral non-union with shortening were studied. Pre-operative planning included long leg standing views, with CT to measure mal-rotation. 6 patients were treated with the Intramedullary Skeletal Kinetic Distractor (ISKD) with an osteotomy distant from non-union site within the parameters required for the device. One patient underwent distraction without osteotomy. Patients were followed to union. Complications and adjuvant interventions were recorded.

All 7 patients with femoral non-union treated with ISKD were included and followed up. Patients treated with osteotomy united at average of 9 months with satisfactory deformity correction and lengthening. However patient who underwent pure distraction failed to unite. Complications included failure to lengthen, requiring manipulation, and delayed consolidation of regenerate requiring bone graft. The procedure was well tolerated

The initial results of the management of femoral non-union with deformity by intramedullary distraction coupled with osteotomy are encouraging. Complications were minor and readily manageable. We believe there is an important role for this method in the management of femoral non-unions associated with deformity and length discrepancy.

The controversy of the management of this common fracture still remains and even the recent literature is not conclusive. Controversy is mainly because the need for either conservative or operative and what type of internal fixation mainly depends on many factors like age and patient factors, the type and convection of fracture and the bone quality.

In the wake of the problem, the present study was undertaken mainly focusing on the importance of newer locking plates compared to percutaneous pinning, external fixatures or a combination.

This study of 106 cases fairly outlines what treatment is suited for what type of fractures though the ideal treatment is yet to be determined.

Background

Isolated fractures of the distal fourth or fifth metacarpal bones, known as boxer's fractures (BF), are the most common type of metacarpal fracture. Boxer's fractures received their name from one of their most common causes — punching an object with a closed fist. This injury has been described as “a tolerable fracture in an intolerable patient” (1) It occurs commonly during fistfights or from punching a hard object such as a wall. Greer and William demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self-defeating personality disorders, self harm and impulsive behaviour, compared with control groups (3). It has been suggested that all patients presenting with such an injury should have psychiatric assessment.

The majority of studies in the literature have concentrated on adults and little has been reported on children and adolescents who present with such fractures.

This study aims to assess aggression scores in young patients discharged with metacarpal fractures due to punching using a validated questionnaire and this abstract presents the interim analysis.

Split tendons are widely used for reconstructive procedures around wrist and hand. Different materials are used to split the tendons. There is no consensus about the most suitable material for splitting a live tendon. We compared a range of commonly available suture materials to find the best material for the purpose.

11 different suture materials (Vicryl 2/0, Ethibond 0, Ethibond 2/0, Prolene 2/0, Prolene 3/0, Silk 2/0, Steel Wire 2/0, Steel Wire 3/0, Steel Wire 4/0, PDS 2/0, Fibrewire 2/0) were used to split the flexor tendons of pig’s trotters. They were assessed for

their ablity to split the tendon successfully,

Each material was tested on 3 different tendons at different times. Quality of split tendons were assessed by 2 independent and blinded observers.

All suture materials except Vicryl 2/0 were successful in splitting the tendon. Silk produced a poor quality split whilst steel wire and fibre wire resulted in excellent quality grafts. The rest produced intermediate results. The force required to split the tendon was the least for PDS 2/0 followed by Fibrewire. Steel wire and silk required higher forces to split the tendon.

From our study we concluded that fibre wire is the best material to split a live tendon as it produced a high quality split with excellent handling characteristics and required minimal strength. Wire suture produced a high quality split, however they were awkward to use as they necessitated use of a holder due to the higher forces required to split the tendon.

Scaphoid non-union usually requires surgical treatment in form of reconstructive or salvage procedure. Imaging helps in planning the surgical procedure. Wrist arthroscopy may also be helpful in the pre-operative assessment. This study was conducted to find the usefulness of wrist arthroscopy in formulating a management plan to treat scaphoid non-union.

We prospectively studied 17 patients of scaphoid non-unions by wrist arthroscopy. Non-union was assessed; and site and extent of any articular wear if present was noted. Some patients had additional procedures such as synovial debridement, removal of loose bodies or debridement of TFC tears. It was possible to formulate the further management plan at the same time.

Our study included 14 men and 3 women with a mean age of 34.5 years (range 18 to 49). Arthroscopic findings included mild radiocarpal wear in 3 cases and severe articular wear in 1. Additionally, in two thirds of cases there was some degree of wear present over the radial styloid region. 6 cases had TFCC tears. 4 patients had synovial debridement and in 5 cases loose bodies were removed. Based on the arthroscopic findings, it was decided to proceed to a reconstructive procedure in 12 cases and a salvage procedure in remaining 5.

We concluded that in scaphoid non-unions:

Articular surface wear is often less than suggested by imaging.

The incidence of infection remains 1–2% after primary total joint arthroplasty and even higher after revision procedures in spite of advances in prophylactic antibiotics and clean air operating theatre environment. Detection of low-grade infection in a prosthetic joint can often be very difficult. None of the investigations available so far have 100% sensitivity and specificity. This has huge implications on the subsequent treatment, cost and patient morbidity. Revision of an unrecognized infected arthroplasty may lead to less satisfactory results in a high proportion of cases. We utilized Polymerase Chain Reaction, a molecular biology technique to detect bacterial DNA from the synovial fluid of patients undergoing revision surgery.

We prospectively assessed 70 patients undergoing revision arthroplasty (57 hips and 13 knees). Each patient was pre operatively assessed clinically and radiologically. ESR and CRP results were noted. During revision, synovial fluid and tissue cultures from capsule, bone and bone-cement interface were obtained. None of the patients received pre or intra operative antibiotics till the specimens were taken. Standard microbiology and histology study were done on tissue samples. In addition Polymerase Chain Reaction study was done on the synovial fluid. In this method, DNA is extracted from the bacterial cell, it is polymerized and finally visualized by gel electrophoresis. Post operatively patients were followed up at regular intervals.

Diagnosis of infection included correlation between clinical, radiological and laboratory investigations along with intraoperative findings, tissue culture and histology results and a period of post operative follow up (12 months to 36 months).

Six (8%) of the 70 cases that had revision arthroplasty were clinically infected. Polymerase chain reaction was positive in 25 cases, tissue cultures were positive in 5 cases and histology was positive in 5 cases for infection. PCR showed sensitivity and specificity of 83% and 69% respectively. Tissue culture showed sensitivity and specificity of 83% and 100% respectively. Histology showed sensitivity and specificity of 83% and 100% respectively.

20 out of 25 PCR positive cases did not show any clinical evidence of infection. It is unclear whether this represents contamination during surgery or in the PCR lab. Alternatively this may represent true positive PCR results in cases with low bacterial count that can be detected by ultrasonication of implant and immunofluorescence methods. PCR is more sensitive in detection of bacterial DNA. However it has low specificity and combination of tissue cultures and histology can still provide a reliable diagnosis of infection.