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.

Abstract

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.

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.