Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Multiligament knee injuries (MLKI) are associated with significant morbidity and healthcare requirements. The primary aim of this study is to report the patient reported outcomes measures (PROMs) after reconstructive surgery.

Patients undergoing surgery for MLKI between 2014 and 2018 in the single large-volume trauma centre were included. Electronic patient records were reviewed for demographic data, details of surgery and complications. PROMs collected were EQ-5D-5L, Lysholm Knee Score (LKS), UCLA Activity and Sport and patient satisfaction.

Thirty-five patients were included. Mean age was 31 years (range 16-66), and 71% were male. The most common mechanism of injury was sports-related (71%). Obesity was present in eight (23%) patients. No vascular injuries were recorded and four patients sustained nerve injuries. PROMs were available for 18 patients (51%) with a median follow up of 4.5 years. Median EQ-5D-5L was 0.78 (IQR 0.14). Median LKS was 84.5 (IQR 21) and there was no correlation with time to surgery (p=0.43). Grade of MLKI did not impact LKS (p=0.09). Fifteen patients (83%) saw a reduction in their activity level. All patients were satisfied with their surgical treatment. Recurrent instability was noted in four patients (11%). Three patients (8%) required further surgery (one revision reconstruction, one meniscectomy, one conversion to a hinged knee replacement.

This study demonstrates two groups of patients who sustain MLKI: the sporting population and obese patients. Health related quality of life, functional outcomes and satisfaction are high after surgery. Time to surgery did not impact on functional outcomes.

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance.

Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores.

A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37)

Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year.

The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures.

Aims

The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury.

Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services.

This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018.

11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation.

Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients.

Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce peri-operative bleeding. Increasingly, topical administration as an intra-articular injection or peri-operative wash is being administered at concentrations between 10–100mg/ml. This study investigated effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

Tendon, synovium and cartilage obtained from routine orthopaedic surgeries were used ex vivo or cultured for in vitro studies using various concentrations of TXA. They were stained with 5-chloromethylfluorescein diacetate and propidium iodide and imaged using confocal microscopy to identify the proportion of live and dead cells. The in vitro effect of TXA on primary cultured tenocytes, synovial like fibroblast (FLS) cells and chondrocytes was investigated using cell viability assays (MTT), fluorescent microscopy and multi-protein apoptotic arrays for cell death.

There was significant (p<0.01) increase in cell death in all tissue treated with 100mg/ml TXA, ex vivo. MTT assays revealed significant (p<0.05) decrease in cell viability following treatment with 50 or 100mg/ml of TXA within 4 hours of all cell types cultured in vitro. Additionally, there was significant (p<0.05) increase in cell apoptosis detected by fluorescent microscopy within 1 hour of exposure to TXA. Furthermore, multi-protein apoptotic arrays detected increased apoptotic proteins within 1 hour of TXA treatment in tenocytes and FLS cells.

Our study provides evidence of TXA cytotoxicity to human peri-articular tissues ex vivo and in vitro at concentrations and durations of treatment routinely used in clinical environments. Clinicians should therefore show caution when considering use of topical TXA administration.

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms.

All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams.

36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality.

Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes.

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft.

Cite this article: Bone Joint J 2016;98-B:884–91.

We present (with intra-operative imaging) 4 patients who sustained Pectoralis major ruptures on the same piece of equipment of the “Tarzan” assault course at the Commando Training Centre, Royal Marines (CTCRM). Recruits jump at running pace, carrying 21 pounds of equipment and a weapon (8 pounds) across a 6ft gap onto a vertical cargo-net. The recruits punch horizontally through the net, before adducting their arm to catch themselves, and all weight, on their axilla.

All patients presented with immediate pain and reduced function. 2 had ruptures demonstrated on MRI, 1 on USS and one via clinical examination. All 4 patients were found, at operation, to have sustained type IIIE injuries.

All patients underwent Pectoralis major repair using a uni-cortical button fixation and had an uneventful immediate post operative course. Patient 1 left Royal Marines training after the injury (out of choice, not because of failure to rehabilitate). All other patients are under active rehabilitation hoping to return to training.

Review of 10 years of records at CTCRM reveal no documented Pectoralis major rupture prior to our first case in October 2013. There has been no change to the obstacle or technique used and all patients deny the use of steroids.

We retrospectively reviewed 2989 consecutive patients with a mean age of 81 (21 to 105) and a female to male ratio of 5:2 who were admitted to our hip fracture unit between July 2009 and February 2013. We compared weekday and weekend admission and weekday and weekend surgery 30-day mortality rates for hip fractures treated both surgically and conservatively. After adjusting for confounders, weekend admission was independently and significantly associated with a rise in 30-day mortality (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.02 to 1.9; p = 0.039) for patients undergoing hip fracture surgery. There was no increase in mortality associated with weekend surgery (OR 1.2, 95% CI 0.8 to 1.7; p = 0.39). All hip fracture patients, whether managed surgically or conservatively, were more likely to die as an inpatient when admitted at the weekend (OR 1.4, 95% CI 1.02 to 1.80; p = 0.032), despite our unit having a comparatively low overall inpatient mortality (8.7%). Hip fracture patients admitted over the weekend appear to have a greater risk of death despite having a consultant-led service.

Cite this article: Bone Joint J 2014;96-B:373–8.

Assessment of stability in ankle fractures is key in deciding the most appropriate mode of treatment. Stress radiographs have been suggested as a potential method for assessing ankle stability in patients with apparently isolated lateral malleolar fractures. Whilst stress radiographs have been found to be both sensitive and specific in cadaveric experiments, recent clinical studies have suggested that a widened medial clear space (MCS) on stress radiographs may not equate to a functionally unstable ankle. We aimed to assess whether patients with an apparently isolated lateral malleolar fracture on presentation but with a positive gravity stress radiograph (GSR) could be successfully managed non-operatively.

A prospective study of all patients with lateral malleolar fractures presenting to our orthopaedic trauma department was undertaken. Patients with an oblique distal fibular fracture pattern and no obvious MCS widening on routine radiographs underwent a GSR. Measurements of the radiographic MCS and superior clear space (SCS) were made and compared with published criteria.

155 patients were included in the study and treated non-operatively fully weight bearing in either a cast or removable boot. Following fracture union all patients had both anatomical alignment of the ankle mortise and good or excellent function. The MCS of 79% of these patients was found to be greater than 4 mm with 19% greater than 6 mm. All of these patients were successfully managed non-operatively.

The currently used criteria for measurements on stress radiographs result in high numbers of false positive cases. This may be leading to unnecessary surgery. Further investigation is required in order to identify other clinical or radiographic criteria that may be of use in the assessment of functional ankle stability after fracture.

Introduction

Massive rotator cuff tears in the patient who is too young for a reverse shoulder replacement are a challenging situation. A technique using a ‘Grammont osteotomy’ of the acromion has been developed to allow a comprehensive approach, the so called “Full Monty”.

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability.

Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+).

The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software.

The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4).

In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis.

We reviewed all patients that suffered a deep infection following anterior cruciate ligament (ACL) repair kept between January 2007 and April 2011 at our teaching hospital NHS trust, and the two local private hospitals.

18 patients were identified. All patients underwent at least 2 arthroscopic washouts, with limited synovectomy if required. Targeted antibiotics were commenced according to the culture results, and following microbiological advice. These patients were reviewed at a minimum of 1 year following eradication of infection (range 12–46 months). There were 7 surgeons performing the ACL reconstructions.

The primary outcome measure was graft failure requiring revision. Our secondary outcome measures were a history of ongoing instability, KT 1000™ measurement, Tegner and Lysholm outcome scores. There were 18 patients identified as having suffered infection after ACL infection (mean age 24.3 years, range 15–38 years). Average C Reactive Protein (CRP) was 217 on admission (range 59–397). The most common organism isolated was coagulase negative staphylococcus in 47.3% of cases. There were 3 graft failures within the infection group. Of the remaining 15 patients there were no episodes of ongoing instability and mean pivot shift grade was 1.1, mean KT 1000™ side-to- side difference was +1.8mm. There was a reported drop on the Tegner activity score of 1.75 (range 0–6) and mean Lysholm score was 89 (range 56–100).

The failure rate is slightly higher than that reported in the literature. Patient reported outcome measures in the patients are broadly consistent. We recommend an aggressive approach to the treatment of deep infection following ACL reconstruction, in order to achieve a satisfactory outcome.

Introduction

Osteoarthritis (OA) represents a leading cause of disability and a growing burden on healthcare budgets. OA is particularly vexing for young, active patients who have failed less invasive therapies but are not yet candidates for arthroplasty. Often, patients suffering in this wide therapeutic gap face a debilitating spiral of disease progression, increasing pain, and decreasing activity until they become suitable arthroplasty patients. An implantable load absorber was evaluated for the treatment of medial knee OA in this patient population.

Joint overload has been cited as a contributor to OA onset or progression. In response, the KineSpring® System (Moximed, Inc, USA) has been designed to reduce the load acting on the knee. The absorber is implanted in the subcutaneous tissue without violating the joint capsule, thus preserving the option of future arthroplasty. The implant is particularly useful for young, active patients, given the reversibility of the procedure and the preservation of normal flexibility and range of motion.

Background

Impaction bone grafting with milled human allograft is the gold standard for replacing lost bone stock during revision hip surgery. Problems surrounding the use of allograft include cost, availability, disease transmission and stem subsidence (usually due to shear failure of the surrounding allograft). Aims. To investigate various polymers for use as substitute allograft. The ideal graft would be a composite with similar mechanical characteristics as allograft, and with the ability to form de novo bone.

Background

Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site.

Introduction

Since the introduction of 3rd generation Metal-on-Metal-Hip-Resurfacing-Arthroplasty (MoMHRA), thousands of such prostheses have been implanted worldwide in younger patients with end-stage hip osteoarthritis. However, no independent centre has reported their medium-to-long term outcome. The aim of this study is to report the ten year survival and outcome of the Birmingham Hip Resurfacing (BHR), the most commonly used MoMHRA worldwide.

Introduction

While clinically successful for decades, CR TKA is persistently compromised by inconsistent PCL function. Problems of mid-flexion instability, incomplete knee flexion, erratic kinematic behavior and posterior instability, not seen with PS devices, raise concerns about the consistency of the technique, and the devices used. Most TKA systems offer at least 2 different geometries of tibial inserts to address this clinical problem.

We hypothesize these problems are a result of compromise of PCL anatomy. To avoid compromise to the PCL 3 steps are required: 1) The slope of tibial resection must be less than 5°; 2) the depth of tibial resection must be based off the insertion footprint of the PCL, not the deficiencies of the tibial articular surface; and 3) the tibial insert must be modified to allow intraoperative balancing of the PCL.

INTRODUCTION

Femoral neck narrowing (NN) following Metal-on-Metal Hip Resurfacing Arthroplasty (MoMHRA) is a well-recognised clinical phenomenon. The incidence of resurfaced hips with NN > 10% is reported to be up to 27%. Its pathogenesis is thought to be multi-factorial secondary to stress shielding, impingement, osteolysis secondary to wear/ion particles and as a result of reduced vascularity and pressure effect on cancellous bone secondary to the presence of a soft-tissue mass around the resurfaced hip. Recognised risk factors for its development include: female gender and the presence of a pseudotumour. Serum Chromium (Cr) and Cobalt (Co) are recognised surrogate markers of in-vivo wear of MoMHRA. The aims of this study were to establish whether NN is associated with increased wear.