Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity.

Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week.

Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages.

New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance.

Evaluation of patient specific spinopelvic mobility requires the detection of bony landmarks in lateral functional radiographs. Current manual landmarking methods are inefficient, and subjective. This study proposes a deep learning model to automate landmark detection and derivation of spinopelvic measurements (SPM).

A deep learning model was developed using an international multicenter imaging database of 26,109 landmarked preoperative, and postoperative, lateral functional radiographs (HREC: Bellberry: 2020-08-764-A-2). Three functional positions were analysed: 1) standing, 2) contralateral step-up and 3) flexed seated. Landmarks were manually captured and independently verified by qualified engineers during pre-operative planning with additional assistance of 3D computed tomography derived landmarks. Pelvic tilt (PT), sacral slope (SS), and lumbar lordotic angle (LLA) were derived from the predicted landmark coordinates. Interobserver variability was explored in a pilot study, consisting of 9 qualified engineers, annotating three functional images, while blinded to additional 3D information. The dataset was subdivided into 70:20:10 for training, validation, and testing.

The model produced a mean absolute error (MAE), for PT, SS, and LLA of 1.7°±3.1°, 3.4°±3.8°, 4.9°±4.5°, respectively. PT MAE values were dependent on functional position: standing 1.2°±1.3°, step 1.7°±4.0°, and seated 2.4°±3.3°, p< 0.001. The mean model prediction time was 0.7 seconds per image. The interobserver 95% confidence interval (CI) for engineer measured PT, SS and LLA (1.9°, 1.9°, 3.1°, respectively) was comparable to the MAE values generated by the model.

The model MAE reported comparable performance to the gold standard when blinded to additional 3D information. LLA prediction produced the lowest SPM accuracy potentially due to error propagation from the SS and L1 landmarks. Reduced PT accuracy in step and seated functional positions may be attributed to an increased occlusion of the pubic-symphysis landmark. Our model shows excellent performance when compared against the current gold standard manual annotation process.

Introduction

The aim of this study was to identify the effects of first MTPJ arthritis, ankle arthritis and hallux valgus on patient reported outcomes, and to assess the efficacy of surgery.

The diagnosis of Lisfranc ligament disruption is notoriously difficult. Radiographs and MRI scans are often ambiguous therefore a stress-test examination under anaesthesia is commonly required. Two midfoot stress-tests are in current practice, namely the varus first ray stress-test and the pronation abduction test. The optimal type of stress-test is not however evaluated in the literature. We hypothesised that after the loss of the main plantar stabiliser (the Lisfranc ligament) the patient would demonstrate dorsal instability, not the classic 1^st/2^nd metatarsal diastasis commonly described. We therefore devised a push-up test (placement of a force under the 2^nd metatarsal in an attempt to elevate the base away from the middle cuneiform on the lateral radiograph). We aimed to initially test our hypothesis on a cadaveric model.

Twelve fresh frozen cadaveric specimens without previous foot injury were used. The 2^nd tarsometatarsal joint was exposed and the Lisfranc ligament and dorsal capsule were incised. An image intensifier was positioned and standard anteroposterior (AP) and lateral views were obtained. Two previously reported AP stress-tests (varus first ray stress test, pronation abduction test) and the novel test under investigation (‘Lisfranc Push-Up’ test) were duly performed. Images were obtained once the investigator felt the appropriate views were achieved.

All twelve of the Lisfranc Push-Up tests showed dorsal subluxation of the 2^nd metatarsal on the middle cuneiform of greater than 2mm on the lateral radiograph. No diastasis of the 1^st/2^nd metatarsals was seen in any of the specimens on the AP radiograph for either of the other two stress-tests.

The authors have described a novel way of demonstrating the dorsal instability associated with the ligamentous Lisfranc injury. Our results support the Lisfranc Push-Up test as a reproducible and sensitive method for assessing ligamentous Lisfranc injuries. In our cadaveric model the previously described stress-tests do not work.

Operative and non-operative treatment regimens for Achilles tendon ruptures vary greatly but commonly involve rigid casting or functional bracing. The aim of our study was to investigate the extent of tendon apposition following such treatments.

Twelve fresh-frozen, adult below knee lower-extremity cadaveric specimens with intact proximal tibiofibular joints were used. Each was prepared by excising a 10cm × 5cm skin and soft tissue window exposing the Achilles tendon. With the ankle in neutral position, the tendon was transfixed with a 2mm k-wire into the tibia, 8cm from its calcaneal insertion. A typical post-rupture gap was created by excising a 2.5cm portion of tendon between 3.5cm and 6cm from its calcaneal insertion.

The specimens were then placed into a low profile walker boot (SideKICK^TM, Procare) without wedges and a window cut into the back. The distance between the proximal and distal Achilles tendon cut edges was measured and repeated with 1, 2 and 3 (10mm) wedges. Subsequently the specimens were placed into a complete below knee cast in full equinus which was also windowed.

The Achilles tendon gap (mean +/− SD) measured: 2.7cm (0.5) with no wedge, 2.3cm (0.4) with 1, 2.0cm (0.4) with 2, 1.5cm (0.4) with 3 wedges and 0.4cm (0.3) in full equinus cast.

The choice of treatment had a significant effect on tendon gap (p< 0.0001 – repeated measures ANOVA), and all pairwise comparisons were significantly different (Bonferroni), with all p< 0.001, apart from 0 wedge vs. 1 wedge (p< 0.01) and 1 wedge vs. 2 wedges (p< 0.05).

Our results showed that each wedge apposed the tendon edges by approximately 0.5cm with the equinus cast achieving the best apposition. Surgeons should consider this when planning appropriate immobilisation regimes for Achilles tendon ruptures.

During surgical reduction of ankle injuries with syndesmotic instability surgeons often use the anteroposterior (AP) and mortise radiographs to assess reduction. Current literature predicts 50% are malreduced mainly in the sagittal plane. Our aim was to develop a radiographic measure based on the lateral view to assess both the normal and abnormal fibula/tibia relationship after simulated syndesmotic malreduction and to evaluate the effect on commonly used AP and mortise measurements.

Nine fresh-frozen cadaveric specimens were dissected to the level of the syndesmosis. AP, mortise and talar dome lateral radiographs were obtained before and following syndesmosis division and posterior fibula displacement. On the lateral radiograph a line was drawn (Orthoview) from the anterior border of the fibula bisecting a line drawn from the anterior to posterior lips of the distal tibia. The ratio of the anterior-posterior segments was calculated. Also a line was drawn from the posterior border of the fibula and the distance was measured to the posterior lip of the tibia.

At 0, 2, 4 and 6mm of displacement the ratio measured 1.3±0.2, 1.1±0.2, 0.9±0.2 and 0.7±0.2 respectively with all pairwise comparisons being significantly different. Inter- and intra-observer variability varied from substantial to perfect. The only significant medial clear space (MCS) difference was on the mortise view between 0mm (2.0±0.3mm) and 6mm (2.4±0.4mm) displacement.

Our new measure of syndesmotic reduction is reproducible and can detect from 2mm of saggital fibular displacement. At maximum fibular displacement the increase in MCS was less than 1mm. This demonstrates standard mortise radiographs are poor at detecting syndesmotic reduction. An interesting observation was in all specimens prior to any displacement, the posterior fibular line always bisected the posterior lip of the tibia or lay just anterior to it, never posterior. This could serve as a useful adjunct for surgeons when assessing syndesmotic reduction intra-operatively.

Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the axillary nerve as it courses posteriorly to the humerus.

This cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Drills were placed through the humerus at the superior, middle and inferior insertions of the PM tendon and the distance between these positions and the axillary nerve, which had previously been marked, was measured using computed tomography (CT) imaging.

This investigation demonstrates that the superior border of PM tendon insertion is the fixation position that poses the highest risk of damage to the axillary nerve.

Caution should be used when performing bicortical drilling during cortical button PM tendon repair, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for transosseus drilling of the humerus reflecting the risk posed to the axillary nerve.

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.

Optimum component orientation in hip arthroplasty is vital in an effort to avoid dislocation and excessive wear. Computer navigation in hip arthroplasty surgery has the potential to improve accuracy in component placement. However, it has been slow to gain widespread acceptance. One of the major concerns surgeons have is the difficulty in registering pelvic landmarks.

We used a retrospective series of 200 pelvic CT scans to validate a new methodology to construct the anterior pelvic plane, using anatomical landmarks that are easily palpated with the patient positioned and draped in the lateral decubitus position. Analysis of the scans was also made in an effort to stimulate the inaccuracies of obtaining the anterior pelvic plane through soft tissue.

When comparing the new registration methodology to the anterior pelvic plane, the error in acetabular component inclination was 0.69° (SD 2.96) and anteversion was 1.17° (SD 3.53). This compares favourably to the error in acetabular component inclination of −0.92° (SD 0.26) and anteversion of −5.24° (SD 2.09) when the anterior pelvic plane is registered through soft tissue. The data also shows that using the new registration method in more than 99.6% of cases the acetabular placement is within the safe zone as described by Lewinnek.

This study appears to show that through the identification of anatomical constants we are able to construct the anterior pelvic plane from anatomical landmarks that are easily palpable in the lateral decubitus position during hip arthroplasty. These landmarks also appear to be more accurate in obese patients than registering the anterior pelvic plane.

Introduction

The optimal treatment of elderly patients with unstable ankle fractures is a widely contested and as yet unresolved issue. Whereas the AO technique of anatomical reduction and plate fixation has been shown to give good functional results it is associated with a wound complication rate of up to 40%. This has led some surgeons to believe the risks of operative intervention are too great.

The fibula nail is an intra-medullary device with the benefit of requiring minimal soft-tissue dissection. It provides lateral column support over a greater area than the standard plate.

The study aims were to assess the clinical and radiographic outcome of a cohort of patients managed with the Fibula Nail (Acumed).

Earlier diagnosis is one of the key aims in achieving improved outcomes for patients with cancer. In general, the earlier a tumour is diagnosed, the easier it will be to treat and the greater the chance of cure. We have investigated how tumour size at diagnosis and duration of symptoms, both of which may act as a proxy for delay in diagnosis have varied over a 25 year period and whether there is evidence of improvement.

Data were available for 2568 patients with primary bone sarcomas and 2366 with soft tissue sarcomas. The mean size at diagnosis was 10.7 cm for bone tumours and 9.9cm for soft tissue sarcomas. The size of bone sarcomas had not changed with the passage of time but there had been a slight decrease in the size of soft tissue sarcomas (10.3 cm before 2000 vs 9.6cm after 2000, p=0.03). The duration of symptoms reported by patients varied widely with a median of 16 weeks for bone sarcomas and 26 weeks for soft tissue sarcomas. The median duration of symptoms for bone sarcomas had actually increased since 2000 (16 weeks before to 20 weeks after 2000, p⋋0.01), whilst it remained unchanged for soft tissue sarcomas. Further analysis showed that females tended to present with smaller tumours than males and that slower growing tumours (eg. liposarcoma and chondrosarcoma) tended to be larger and have a longer duration of symptoms than other tumours. 15% of patients with a soft tissue sarcoma had undergone a previous inadvertent excision – and this % has not changed over 20 years. Younger patients had smaller soft tissue soft tissue sarcomas than older patients but there was little difference for bone sarcomas.

Introduction

Clinical studies have shown distinct differences in later-onset idiopathic scoliosis (IS) between men and women, including curve severity, stiffness, and ease of operative intervention. Therefore, significant scoliosis in men was used as criteria to create a phenotypical subset of families with IS. The goal of this study is to identify genetic determinants that relate specifically to men with a scoliotic curvature of 30° or more.

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities.

Bone and Soft Tissue Sarcomas represent approximately 1% of all malignant tumours. Delays in diagnosis are frequent and the average size of Sarcomas at diagnosis has averaged 10cm for many years. In 1999 guidance was produced by NICE with the aim of leading to the earlier diagnosis of common cancers – including Sarcomas. We have attempted to analyze whether this guidance has had any impact on either the size of the tumours at diagnosis or the symptom duration prior to diagnosis experienced by the patients.

Data for patients referred to the Royal Orthopaedic Hospital in Birmingham between 1992 and 2007 with Bone Sarcomas (n=1592) and Soft Tissue Sarcomas (n=2004) were analysed to determine the effect of the guidance. For Bone Sarcomas the mean size of the tumours decreased from 11.2cm prior to the guidance to 10.7cm after the guidance but the change was not statistically significant (p=0.09). The mean duration of symptoms increased from 18 to 21.2 weeks (p=0.01). For Soft Tissue Sarcomas, mean size fell from 10.8cm to 9.5cm (p<0.001), however the duration of symptoms actually increased from 27.3 to 32.1 weeks (p=0.01). Statistical modelling using restricted cubic splines confirmed these trends in the data.

These results show that whilst there may have been a slight improvement in the size at diagnosis of Soft Tissue Sarcomas, overall most patients still experience a long delay between the onset of symptoms and diagnosis and commencement of treatment. It is difficult to conclude that the early diagnosis guidance produced in 1999 has had a significant effect on the basis of this study. Strategies to improve awareness of the symptoms and clinical features of Bone and Soft Tissue Sarcomas are still urgently required.

The suture properties associated with a successful tendon repair are: high tensile strength, little tissue response, good handling characteristics and minimal plastic deformation. Plastic deformation contributes to gap formation at a tendon repair site. Gaps greater than 4mm are prone to failing. This study investigates whether the plastic deformation demonstrated by two commonly used suture materials can be reduced by manual pre-tensioning.

Twenty sutures of both Prolene 3/0 (Ethicon, UK) and Ethibond 3/0 (Excel, Johnson and Johnson, UK) were tested. Half of the sutures in each group were manually pre-tensioned prior to knot tying and half were knotted without pre-tensioning. All knots were standard surgical knots with six throws. The suture lengths were measured before and after a standardised cyclical loading regime on an Instron tensile tester. The regime was designed to represent the finger flexion forces produced in a typical rehabilitation programme. All sutures were subsequently tested to their ultimate tensile strength.

After cyclical loading the pre-tensioned sutures demonstrated a mean increase in suture length of 0.7% (range 0.1-1.9%). The sutures not pre-tensioned showed a mean increase of 5.4% (range 3.3-7%). This equates to 87% less plastic deformation (p <0.05 Students' T-test) upon pre-tensioning. There were no differences with Ethibond. Pre-tensioning had no effect on ultimate tensile strength for either group.

Manual pre-tensioning reduces plastic deformation in Prolene 3/0 sutures without affecting the ultimate tensile strength. This simple technique could theoretically diminish gap formation at the site of a tendon repair.

Objectives

To assess the affects of a delay in diagnosis on the survival rates of Bone Sarcoma (BS) using size and symptom duration as measures of delay.

Objective

Sarcomas are a rare group of tumours, which pose numerous problems regarding correct diagnosis and appropriate management. This study aimed to examine whether symptom duration and tumour size at diagnosis have changed over time, using size and symptom duration as methods of comparison.

The purpose of this study was to determine the normal angle of rotation of the axis of each finger using digital image analysis, whether the rotation of the digits is symmetrical in the two hands of an individual, and the reliability of this method.

Standardised digital photographic images were taken of thirty healthy volunteers. The palm of each hand was placed on a flat bench top with their fingers held in extension and adducted, to give an end-on image of all four fingers. Three independent observers analysed the images using Adobe Photoshop software. The rotational angle of each finger was defined as the angle created by a straight line connecting the radial and ulnar border of the nail plate and the bench top horizon.

The three observers showed Inter-Rater Reliability of 92%. The mean angles of rotation were: Index 13°, Middle 10°, Ring 5°, Little 12°. The differences in angle of rotation of the index and middle finger between the left and right hand were statistically significant (p=0.003, and p=0.002 respectively), demonstrating asymmetry between the two sides. The differences in angle of rotation of the ring and little finger of the left and right hand were not significantly significant (p= 0.312 and p=0.716 respectively).

In conclusion, symmetry was seen in the little and ring but not in the index and middle fingers. Digital image analysis provides a non-invasive and reproducible method of quantifying the rotation of normal fingers and may be of use as a diagnostic tool in the assessment and management of hand injuries.

The contraindications for unicompartmental knee replacement (UKR) remain controversial. The views of many surgeons are based on Kozinn and Scott’s 1989 publication which stated that patients who weighed more than 82 kg, were younger than 60 years, undertook heavy labour, had exposed bone in the patellofemoral joint or chondrocalcinosis, were not ideal candidates for UKR. Our aim was to determine whether these potential contraindications should apply to patients with a mobile-bearing UKR. In order to do this the outcome of patients with these potential contraindications was compared with that of patients without the contraindications in a prospective series of 1000 UKRs. The outcome was assessed using the Oxford knee score, the American Knee Society score, the Tegner activity score, revision rate and survival.

The clinical outcome of patients with each of the potential contraindications was similar to or better than those without each contraindication. Overall, 678 UKRs (68%) were performed in patients who had at least one potential contraindication and only 322 (32%) in patients deemed to be ideal. The survival at ten years was 97.0% (95% confidence interval 93.4 to 100.0) for those with potential contraindications and 93.6% (95% confidence interval 87.2 to 100.0) in the ideal patients.

We conclude that the thresholds proposed by Kozinn and Scott using weight, age, activity, the state of the patellofemoral joint and chondrocalcinosis should not be considered to be contraindications for the use of the Oxford UKR.

Introduction: Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death.

We speculate that a significant proportion of the blood loss related to hip fracture has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury.

Methods: In a retrospective study over 12 months all patients with both a diagnosis of hip fracture and an operative delay of > 48 hours were assessed. The information collected included: fracture classification, serial haemoglobins and patient comorbidities. The exclusion criteria included a pre-injury diagnosis of anaemia and gastrointestinal bleeds.

Results: 68 intracapsular and 50 extracapsular hip fracture patients had serial haemoglobins and operative delays of > 48hrs (mean 75hrs, range 48–270hrs).

The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (+/−SEM 2.2) and 108.5 g/L (+/−SEM 2.2) respectively. The difference was statistically significant (Students t-test p< 0.05).

The mean haemoglobin drop for male and female patients with extracapsular hip fractures were 15.0 g/l (range 0–40 g/l) and 19.3 g/l (range 0–49 g/l) respectively and the mean haemoglobin drop for male and female intracapsular fracture patients were 10.2 (range 0–59 g/l) and 10.5 g/l (range 0–41 g/l) respectively.

Conclusions:

Hip fracture patients have a large drop in haemoglobin that is likely to be associated with the initial trauma. Patients with extracapsular fractures demonstrate a greater haemoglobin loss than those with intracapsular fractures. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients.