Aims

Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

Introduction and Objective

In anticipation of reduced workload and need for minimisation of staff contact with infectious patients during the COVID-19 lockdown in 2020, Cairns Hospital reduced the junior orthopaedic staffing and absolved team structure.

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.

Hip arthroscopy is becoming more popular. A literature review demonstrated paucity of published papers reporting the outcome of hip arthroscopy in teenagers without developmental dysplasia of the hip. Our aim was to record the type of lesions found and report the outcome and level of satisfaction following hip arthroscopy in teenagers.

From 2002 to 2008, 96 hip arthroscopies were undertaken in 76 patients. Pre-operative and two-week, six-week and current post-operative assessments were performed using the modified Harris hip score (HHS) and the Non Arthritic Hip Score (NAHS). In addition, a satisfaction survey was completed at their most recent review.

Patients enrolled in the study were under the age of 20. Patients with a history of developmental dysplasia of the hip, Perthes disease and arthritis were excluded from the study. Patients had at least a six-month follow-up from their surgery.

Our study cohort comprised 53 males and 43 females with an average age of 17 years old (range 13 to 19 years). The average duration of follow up was 19 months (range 3 to 75 months). There were 41 left and 54 right-sided hip arthroscopies. There were five re-operations. The average duration of hip traction was 19 minutes (range 6 to 47 minutes).

We found pathology in all hips that underwent arthroscopy. We report a significant improvement in MHHS and NAHS at six weeks and current review (p-value <0.01). Sixty-two percent of patients had returned to sport at the previous level of competition, 32% of patients returned to sport at a lower level of competition and 5% patients did not return to sport. Overall, 84% of patients were satisfied following their hip arthroscopy and 91% would have the surgery again if they had to. There were five re-operations.

Our study has revealed a range of intra articular hip pathologies amenable to surgical treatment using hip arthroscopy. We have observed a significant improvement in hip scores; with up to 94% of patients returning to sport in the short term with high satisfaction levels. Long term follow up of this group is ongoing.

Aim

We report our ten year experience of primary haematogenous non-tuberculous spinal infection.

Purpose: The purpose of this study was to evaluate the outcome of arthroscopic femoral osteochondroplasty for cam lesions of the hip with respect to the severity of acetabular chondral damage.

Methods: The study is a retrospective review of 170 patients (35 females, 135 males) who underwent surgery for symptomatic cam femoroacetabular impingement (FAI) between the years 2003 to 2008. The patients were categorized according to three different grades of chondral damage. No patients had evidence of labral pathology. Microfracture of the acetabular chondral damage was also performed when indicated. The clinical results in each grade were measured preoperatively and postoperatively with the modified Harris Hip Score (MHHS) and Non Arthritic Hip Score (NAHS).

Results: The mean follow-up time was 22 months (range 12 to 72 months). At the last follow-up, significantly better results were observed in hips with less chondral damage. The mean MHHS improved from 74.1±17.1 to 89.8±11.6 in grade 1 whereas it improved from 62.3±14.3 to 77.4±18.3 in grade 3 (p=0.02). The mean NAHS improved from 70.7±13.5 to 87±16.2 in grade 1 whereas it improved from 60.5±16.2 to 78±17.8 in grade 3 (p=0.04). Microfracture in limited zones of ace-tabular chondral damage had shown superior results.

Conclusions: Arthroscopic femoral osteoplasty for hip cam impingement with acetabular chondral damage provides a significant improvement in symptoms. Microfracture of the chondral lesion in selected cases has been demonstrated to be safe and benifical.

Publication of normal and expected outcome scores is necessary to provide a benchmark for auditing purposes following arthroplasty surgery. We have used the Oxford knee score to monitor the progress of knee replacements undertaken since 1995, the start of our review programme. 4847 Oxford assessments were analysed over an 8 year follow-up period.

The mean pre-operative Oxford knee score was 39.2, all post-operative reviews showed a significant improvement. Patients with a BMI > 40, and the under 50 age group showed early deterioration in outcome scores, returning to pre-operative levels by 5 and 7 years respectively. There was no significant difference in outcome between surgeons performing < 20 knee replacements a year and those performing > 100 / year.

The age of the patient at the time of surgery and the pre-operative body habitus have been identified as factors affecting long term outcome of total knee replacement surgery. Awareness of these factors may assist surgeons in advising patients of their expected outcomes following surgery.

Introduction: Metal on metal Hip Resurfacing Arthroplasty (MoMHRA) has gained popularity due to its perceived advantages of bone conservation and relative ease of revision to a conventional THR if it fails. This retrospective study is aimed at assessing the functional outcome of failed MoMHRA revised to THR and comparing it with a matched cohort of primary THRs.

Method: Since 1999 we have revised 53 MoMHRA to THR. The reasons for revision were femoral neck fracture (Group A, n=21), pseudotumour (Group B, n=16) and other causes (Group C, n=16: loosening, avascular necrosis and infection). Average follow-up was 3 years months (1.2–7.3). These revisions were compared with 106 primary THRs which were age, gender and follow-up matched with the revision group in a ratio of 2:1.

Results: The mean Oxford Hip Score (OHS) was 20.1 (12–51) for group A, 39.1 (14– 56) for group B, 22.8 (12–39) for group C and 17.8 (12–45) for primary THR group. In group A, there were three infections requiring further revisions. In group B, there were three recurrent dislocations, three patients with femoral nerve palsy and one femoral artery stenosis. In group C, there were no complications. The differences in clinical and functional outcome between group B and the remaining groups as well as the difference in the outcome between group B and control group were statistically significant (p < 0.05).

Conclusions: THR for failed MoMHRA was associated with significantly more complications, operation time and need for blood transfusion for the pseudotumour group. In addition, the revisions secondary to pseudotumour also had significantly worse functional outcome when compared to other MoMHRA revisions or primary THR.

Aim: To report our ten year experience of primary haematogenous spinal infection.

Method: Retrospective case note review of 42 patients presented to our unit with primary spinal infection between 1995–2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. Information with regard to Mobility, Domestic circumstances, Oswestry disability index(ODI), Hospital Anxiety and depression score(HAD), Visual Analogue Score (VAS) for pain and coping were obtained. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Mean age was 59.9 years (1–85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62%. Time from presentation to diagnosis averaged 19days (range 0–172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13–240). At mean follow up of 5.4 years (0.6–10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history(P=0.001), constitutional symptoms(p=0.001) and pyrexia at presentation(0.001) were positively associated with recurrence.

Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9).

Overall it was calculated that HIAS had saved a total of 940 in-patient days.

Conclusion: Primary spinal infection is a treatable condition. Disease and patient characteristics dictate the management strategy. Although most patients can regain their pre infection mobility and go back to their pre morbid domestic circumstances with little or no pain and psychological sequel, a proportion of patients end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection. Finally, HIAS was cost effective.

Background: There is increasing concern regarding radiation exposure to surgeons’ using fluoroscopic guidance during orthopaedic procedures. However, there is currently a paucity of information regarding the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery.

Methods: We conducted a 12 month prospective study to measure radiation dose absorbed by the hands of a dedicated right handed foot and ankle surgeon. A thermo-luminescent dosimeter ring (TLD) was worn on little finger of each hand. Measurement of the cumulative radiation dose was recorded on a monthly basis.

Results: A total of 80 foot and ankle cases involving fluoroscopy were performed. The total screening time was 3028seconds (s) (mean screening time 37.4s). Screening time correlated positively with the number of procedures performed (r=0.92, p< 0.001), and with radiation dose in both the left TLD (r=0.85, p=0.0005) and right TLD (r=0.59, p=0.0419). There was no significant difference in radiation dose between either hand (p=0.62). The total radiation dose to the right TLD over the 12 months was 2.4 milli-sieverts.

Conclusion: Radiation dose incurred during orthopaedic foot and ankle procedures is proportional to the screening time. Our results show radiation exposure to be well below the annual dose limit set by the International Commission on Radiological Protection. This work demonstrates a simple and convenient method for evaluating a single surgeon’s radiation exposure.

Aim: In this study we present our ten year experience of primary spinal infection.

Method: Retrospective case note review of 42 patients who presented to our institution with primary spinal infection between 1995–2005 was carried out. Demographic data and information with regard to timing and modes of presentation, results of radiological and laboratory investigations, and methods of treatment were collected. The financial impact of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Axial pain was the most consistent symptom seen in 100% of the patients. Only 62% had pyrexia at presentation. Major neurological deficit was seen in 10.2%.

Mean duration of symptoms was 25 days (range 1–202). Mean time from presentation to diagnosis was 19 days (range 0–172). Staphylococcus Aureus was the most common organism. Mean duration of Intravenous antibiotics was 60 days (range 13–240) followed by oral antibiotics for mean duration of 65 days (range 0–161). CRP was more reliable in monitoring the disease over time. At mean follow up of 5.4 years (0.6–10.5) there has been no mortality directly related to the infection. With our management there has been 14% recurrence rate. All re- presenting within the first year after initial presentation (Mean 5.5 Months, range 1–11).

HIAS saved a total of 940 in-patient days with a total cost saving of approximately £350,000.00.

Conclusion: In the majority of patients spinal infection can be successfully treated. Disease severity dictates the duration of antibiotic treatment and whether surgery is required. Recurrent infection occurred in a number of patients with more significant past medical history and pre-existing risk factors. Finally, HIAS is extremely cost effective in this group of patients.

Introduction: A posterior entry point, a neutral tip position and stem alignment are recommended for an even cement mantle and an optimal outcome in total hip arthroplasty (THA). Our aim was to highlight any differences between the two approaches in obtaining a neutral stem tip position, particularly in the saggital plane.

Methods: We examined the post op, digitised radiographs of 100 (50 each group) polished, tapered Exeter THA, inserted via the antero-lateral or posterior approaches. The stem tip position was defined as the distance, in millimetres, between the centre of the femoral canal and the centre of the stem tip, in both the coronal and saggital planes.

Results: There was a significant difference between the two approaches in the saggital stem tip position only (p= 0.01), but not in coronal tip position (p=0.1). When not in neutral, stems inserted by the antero-lateral approach showed a marked deviation towards the posterior cortex. This was not the case with the posterior approach.

Discussion: Our results illustrate that a neutral stem tip position in THA, and subsequently an even cement mantle, is significantly more difficult to obtain with an antero-lateral approach than a posterior approach. A posterior approach to the hip avoids the cuff of glutei that can lever the proximal stem anteriorally causing an anterior entry point and a posterior stem tip position. It also illustrates how the anatomy of the proximal femur in the saggital plane makes a neutral stem alignment difficult to achieve with either approach.

Aim: To assess the functional outcome following spinal infection.

Method: 42 patients who had been treated in our unit for primary spinal infection between 1995–2005 were identified. 33 who were still alive at the time of study, were sent postal questionnaires. Average length of follow up was 5.4 years (rang 0.6–10.5). The non-respondents were contacted by phone two weeks later. Overall 29 (88%) were traced.

Results: Mobility score dropped in 10 (34%) patients whilst domestic circumstances’ score dropped only in 1 (3.4%). Oswestry disability score averaged 18% (range 0–53%). 16 (62%) had mild or no disability, 7(27%) had moderate and 3 (12%) had severe disability. Neck disability index in all those with cervical spine infection was between 10–20% indicating mild disability. Hospital anxiety and depression score for anxiety was normal for 25 (86%) and that for depression was normal for 27(93%) patients. Ten point Visual Analogue Score (VAS) for pain intensity when doing the questionnaire averaged 1.3 (range 0–9) with 19 (66%) having no pain, 9 (31%) mild to moderate (1–5 score) and 1 (3%) having severe pain (6–10 score). Mean VAS over one week was 1.8(range 0–9) with 14(48%) having no pain, 13(45%) mild to moderate and 2 (7%) having severe pain. VAS for distress averaged at 1.8 (range 0–9), 22 (76%) patients were coping very well (8–10 score) and poor coping (0–4 score) was seen in 1 (3%).

Conclusion: Most patients after spinal infection return to activities of daily living with little or no pain and psychological sequelae. A proportion of patients however end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection.

Background: The safest and most effective method of early spine clearance in unconscious patients is the subject of intense debate.

Hypothesis: Helical CT is a sufficiently sensitive investigation to render dynamic screening of the cervical spine redundant.

Protocol: Our protocol for cervical spinal clearance in the unconscious patient since April 1994 involves the use of plain radiographs, CT scan (helical CT since 1997) and dynamic screening (DS).

Method: Over a ten-year period, April 1994 to September 2004, 839 patients were admitted to intensive care under the orthopaedic surgeons. 35 patients were excluded because of incomplete records.

Results:

Demographics: The mechanism of injury was a road traffic accident in 80% and the mean ISS was 24.1. There were 95 patients (10.9%) with a cervical spine fracture, 96 (10.8%) with a fracture in either / both thoracic and lumbar regions.

Conclusion: DS is a safe procedure but has no real advantage over helical CT. Power’s ratio calculation is essential to reduce the chance of a missing an upper cervical injury. The cervical spine can be reliably cleared using helical CT alone.

Background: There is increased concern regarding radiation exposure to surgeons using fluoroscopic guidance throughout various procedures. However, relatively little information exists on the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery.

Methods: We are conducting an ongoing proespective study to measure radiation exposure to the hands of a single orthopaedic foot and ankle surgeon (RD). Over a 12-month period, thermoluminescent dosimeter rings are worn on the little finger of each hand of the operating surgeon. The rings are changed at six week intervals. Measurement of the overall radiation exposure is being recorded over this time period.

Results: This is an ongoing prospective study started in December 2004. We are measuring: total number foot and ankle cases using fluoroscopy, the total screening time for foot and ankle procedures, the mean screening time per procedure and the total radiation exposure to the thermoluminescent dosimetry rings.

Conclusion: Preliminary results show that radiation exposure is well below the current annual dose limit. In our study, radiation exposure during orthopaedic foot and ankle procedures is expected to comply with current recommendations of the European Committee on Radiation Protection and is well below dose limits set by the International Commission on Radiological Protection.

Aims: To compare the femoral stem position and alignment, using different methods of insertion. The Exeter stem has been compared with a new tri-tapered, polished, cannulated, cemented, femoral component.

Method: We have reviewed 100 post operative AP and 50 lateral radiographs for each group. Analysis determined both stem tip position and stem alignment. The groups of subjects were of comparable age, sex and Body Mass Index.

Results: Values for mean distance from canal centre were calculated, for the Exeter group this was 1.511 ± 1.226 and Tri-Taper group 0.778 ±. 0.748. This was statistically signiþcant (p=0.0059). In our Exeter series of results we have shown that 71% of stem tips had been inserted within 2mm of central, this compares with 94% in the Tri-Taper series. On the lateral radiographs of the Exeter series the mean posterior distance was 2.245 ± 1.316, the mean anterior distance was 1.068 ± 0.528. In the Tri-Taper series the mean posterior distance was 1.123 ± 0.926, the mean anterior distance was 1.057 ± 0.590. The difference between the two groups was not statistically signiþcant (p=0.054). The alignment results show that only 78% of stems are aligned neutrally compared with 91% of tri-taper stems (p= 0.0454).

Conclusion: These results are comparable with previous cannulated and Exeter stem studies. This conþrms that optimal distal stem position and stem alignment can be achieved by using a cannulated stem rather than the application of a distal centralising device.

We report a three year Medical Devices Agency and Local Ethical Committee approved prospective study for a new tri-tapered polished cannulated cemented femoral component. Our stem was implanted in 53 primary total hip replacements. Eleven male patients (11 hips) and 39 female patients (39 hips). The mean age at surgery was 73 (range 65 to 84). The mean weight was 71.76 kg (range 49.3 kg to 94.6 kg) with a mean BMI of 28 (range 20.20 to 40.26). All patients had a pre operative diagnosis of osteoarthritis. All the hips were implanted via the anterolateral approach. Twenty-six (51%) hips were implanted by a single consultant and 24 (49%) were implanted by six different registrars. Pre-operative and sequential post-operative clinical and radiological evaluations were undertaken.

The mean pre-operative Oxford hip score was 47 points.which declined 19 points at three years. Radiological analysis, using the Johnston criteria, did not reveal any untoward features. Prosthetic stem migration was measured using a technique developed in our unit and validated as accurate to 0.61 mm; as previously reported. Stem migration measured averaged 1.38 mm (n=52; sd ±1.38) 6 months post implantation. This progressed to 1.71 mm (n=50; SD=1.18) at one year; 1.61mm (n=48; sd ±1.17) at 2 years. and 1.55 mm (n=28; SD 1.13). At 3 years average stem migration for hips implanted by the registrar group and the consultant group was not sig-nificantly different (p=0.2048) and the migration curve, against time was similar for both groups.

Our study has demonstrated initial component migration, comparable to that of other polished tapered cemented stem designs. The improvement in Oxford hip score parallels other reported series and no adverse radiological signs have been observed. Long-term surveillance of our cohort will provide further data to compare the new design with substantial equivalents. More sophisticated studies, such as RSA analysis would provide further data on early femoral component migration.

Aim: Evaluate a novel horseshoe shaped cup designed by the senior authors to minimise the resection of healthy bone in total hip arthroplasty.

Method: Fifty female patients with a displaced, subcapital, femoral neck fractures were chosen for the study. In half of the group of patients, the composite support shell was coated with HA, with the other half remaining uncoated. Clinical and radiological assessments were undertaken regularly for 5 years.

Results: To date 20 patients have died and 13 have withdrawn from the study due to poor medical health unrelated to the study. Charnley modified Merle d’Aubigne score at 5 years was as good as the preoperative score with 80% of patients having full range of movement, no pain and walking unaided.

Radiographic results showed no evidence of loosening of HA coated cups, in contrast to non HA coated cups which migrated significantly in 80% of cases. Four patients with loose non HA coated cups underwent revision surgery.

Conclusion: It replaces the cartilage and underlying sub-chondral bone of the acetabulum socket with a cup that is designed to flex in harmony with the surrounding bony structure. This trial has demonstrated success at 5 years with the HA coated Cambridge Acetabular Cup. Cups from which HA coating has been removed have migrated significantly in 80% of cases. There is an advantage of the HA fixation which will be taken into account before wider clinical usage is advocated.

Hip resurfacing is widely recognised as a bone conserving procedure with respect to proximal femoral resection. However, it has been argued that this is not the case for the acetabulum due to the thickness of the acetabular component and the large diameter bearing surfaces. We have investigated whether the Birmingham Hip is a bone conserving procedure with respect to the acetabular bone stock.

Data was obtained from 257 consecutive Midland Medical Technology (MMT) surface replacements and 458 primary hybrid total hip replacements implanted under our care. The surface replacement group comprised 185 males (185 hips) and 72 females (72 hips) with a mean age at surgery of 55 years. The hybrid primary total hip replacement group comprised 207 males (207) and 251 females (251 hips). The mean age at surgery was 65 years old. In the surface replacement group the mean uncemented acetabular size implanted was 54.88 mm (females = 51.9 mm; males = 57.8 mm). In the hybrid primary total hip replacement group the mean uncemented acetabular size of 55.04 mm (females =52.9 mm; males = 57.2 mm).

Statistical analysis was undertaken to compare the uncemented acetabular sizes in the surface replacement group with the uncemented acetabular sizes implanted in the primary hybrid total hip replacement group. We report no significant difference in the size of acetabular component used for the two groups (p = 0.4629; 95% C.I. −0.28 to 0.61). The effect of gender was analysed and the mean size of uncemented acetabular component implanted in males for the surface replacement group was not significantly different (p = 0.06) to the hybrid primary total hip replacement group. However the mean size of uncemented acetabular component in females for the surface replacement group was significantly smaller (p = 0.016) compared to the primary total hip replacement group.

We conclude hip resurfacing is not bone sacrificing on the acetabular bone stock and can be bone conserving for females.

The novel horseshoe shaped cup was designed by the senior authors to minimise the resection of healthy bone in total hip arthroplasty. It replaces the cartilage and underlying sub-chondral bone of the acetabulum socket with a cup that is designed to flex in harmony with the surrounding bony structure.

Fifty female patients with a displaced, subcapital, femoral neck fractures were chosen for the study. In half of the group of patients, the composite support shell was coated with HA, with the other half remaining uncoated. Clinical and radiological assessments were undertaken regularly for five years.

To date 20 patients have died and 13 have withdrawn from the study due to poor medical health unrelated to the study. Charnley modified Merle d’Aubigne score at five years was as good as the preoperative score with 80% of patients having full range of movement, no pain and walking unaided.

Radiographic results showed no evidence of loosening of HA coated cups, in contrast to non HA coated cups which migrated significantly in 80% of cases. Four patients with loose non HA coated cups underwent revision surgery.

This trial has demonstrated success at 5 years with the HA coated Cambridge Acetabular Cup. Cups from which HA coating has been removed have migrated significantly in 80% of cases. There is an advantage of the HA fixation which will be taken into account before wider clinical usage is advocated.