Patients with an acute Achilles tendon rupture (ATR) take a long
time to heal, have a high incidence of deep vein thrombosis (DVT)
and widely variable functional outcomes. This variation in outcome
may be explained by a lack of knowledge of adverse factors, and
a subsequent shortage of appropriate interventions. A total of 111 patients (95 men, 16 women; mean age 40.3, standard
deviation 8.4) with an acute total ATR were prospectively assessed.
At one year post-operatively a uniform outcome score, Achilles Combined
Outcome Score (ACOS), was obtained by combining three validated,
independent, outcome measures: Achilles tendon Total Rupture Score,
heel-rise height test, and limb symmetry heel-rise height. Predictors
of ACOS included treatment; gender; age; smoking; body mass index;
time to surgery; physical activity level pre- and post-injury; symptoms; quality
of life and incidence of DVT. Aims
Patients and Methods
There is not adequate evidence to establish whether external
fixation (EF) of pelvic fractures leads to a reduced mortality.
We used the Japan Trauma Data Bank database to identify isolated
unstable pelvic ring fractures to exclude the possibility of blood
loss from other injuries, and analyzed the effectiveness of EF on
mortality in this group of patients. This was a registry-based comparison of 1163 patients who had
been treated for an isolated unstable pelvic ring fracture with
(386 patients) or without (777 patients) EF. An isolated pelvic
ring fracture was defined by an Abbreviated Injury Score (AIS) for
other injuries of <
3. An unstable pelvic ring fracture was defined
as having an AIS ≥ 4. The primary outcome of this study was mortality.
A subgroup analysis was carried out for patients who required blood
transfusion within 24 hours of arrival in the Emergency Department
and those who had massive blood loss (AIS code: 852610.5). Propensity-score
matching was used to identify a cohort like the EF and non-EF groups.Aim
Patients and Methods
Positive ulnar variance is an established risk factor for idiopathic
ulnar impaction syndrome (UIS). However, not all patients with positive
ulnar variance develop symptomatic UIS and other factors, including
the morphology of the lunate, may be involved. The aim of this study
was to clarify the relationship between lunate morphology and idiopathic
UIS. A cohort of 95 patients with idiopathic UIS (UIS group) was compared
with 95 asymptomatic controls with positive ulnar variance. The
shape of the lunate was measured using the capitate-triquetrum distance
(CTD), ulnar coverage ratio (UCR), radiolunate distance and radiolunate
angle. The association of radiographic parameters and lunate types
with the development of UIS was investigated in univariable and
multivariable analyses. Receiver operating characteristic curves
were used to estimate a cutoff for any statistically significant
variables.Aims
Patients and Methods
We compared the incidence of pseudotumours after
large head metal-on-metal (MoM) total hip arthroplasty (THA) with
that after conventional metal-on-polyethylene (MoP) THA and assessed
the predisposing factors to pseudotumour formation. From a previous randomised controlled trial which compared large
head (38 mm to 60 mm) cementless MoM THA with conventional head
(28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males,
20 females, mean age of 64 years, standard deviation ( The incidence of pseudotumours, measured using a standardised
CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP
THA. Women with a MoM THA were more likely to develop a pseudotumour
than those with a MoP THA (15 Contrary to popular belief, pseudotumours occur frequently around
MoP THAs. Women with a MoM THA and an elevated cobalt level are
at greatest risk. In this study, pseudotumours had no effect on
the functional outcome after either large head MoM or conventional
MoP THA. Cite this article:
The Corail stem has good long-term results. After four years
of using this stem, we have detected a small group of patients who
have presented with symptomatic metaphyseal debonding. The aim of
this study was to quantify the incidence of this complication, to
delineate the characteristics of patients presenting with this complication
and to compare these patients with asymptomatic controls to determine
any important predisposing factors. Of 855 Corail collarless cementless stems implanted for osteoarthritis,
18 presented with symptomatic metaphyseal debonding. A control group
of 74 randomly selected patients was assembled. Clinical and radiological
parameters were measured and a logistic regression model was created
to evaluate factors associated with metaphyseal debonding.Aims
Patients and Methods
We reviewed all patients who sustained a fracture of the hip
and were treated in Northern Ireland over a period of 15 years to
identify trends in incidence, the demographics of the patients,
the rates of mortality, the configuration of the fracture and the
choice of implant. Since 01 January 2001 data about every fracture of the hip sustained
in an adult have been collected centrally in Northern Ireland. All
adults with such a fracture between 2000 and 2015 were included
in the study. Temporal changes in their demographics, the mode of
treatment, and outcomes including mortality were analysed.Aims
Patients and Methods
It is well established that there is a strong association between
Perthes’ disease and worsening socioeconomic deprivation. It has
been suggested that the primary determinant driving this association
is exposure to tobacco smoke. This study aimed to examine this hypothesis. A hospital case-control study (n = 149/146) examined the association
between tobacco smoke exposure and Perthes’ disease, adjusting for
area-level socioeconomic deprivation. Tobacco smoke exposure was
assessed by parental questionnaire of smoking habits during pregnancy,
and by quantitative assay of current exposure using the urinary
cotinine-creatinine ratio, which is a widely used and validated
measure of tobacco smoke exposure.Aims
Patients and Methods
Paediatric fractures are common and can cause
significant morbidity. Socioeconomic deprivation is associated with an
increased incidence of fractures in both adults and children, but
little is known about the epidemiology of paediatric fractures.
In this study we investigated the effect of social deprivation on
the epidemiology of paediatric fractures. We compiled a prospective database of all fractures in children
aged <
16 years presenting to the study centre. Demographics,
type of fracture, mode of injury and postcode were recorded. Socioeconomic
status quintiles were assigned for each child using the Scottish
Index for Multiple Deprivation (SIMD). We found a correlation between increasing deprivation and the
incidence of fractures (r = 1.00, p <
0.001). In the most deprived
group the incidence was 2420/100 000/yr, which diminished to 1775/100
000/yr in the least deprived group. The most deprived children were more likely to suffer a fracture
as a result of a fall (odds ratio (OR) = 1.5, p <
0.0001), blunt
trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7,
p <
0.0001) than the least deprived. These findings have important implications for public health
and preventative measures. Cite this article:
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:
Instability of the hip is the most common mode of failure after
reconstruction with a proximal femoral arthroplasty (PFA) using
an endoprosthesis after excision of a tumour. Small studies report
improved stability with capsular repair of the hip and other techniques,
but these have not been investigated in a large series of patients.
The aim of this study was to evaluate variables associated with
the patient and the operation that affect post-operative stability.
We hypothesised an association between capsular repair and stability. In a retrospective cohort study, we identified 527 adult patients
who were treated with a PFA for tumours. Our data included demographics,
the pathological diagnosis, the amount of resection of the abductor
muscles, the techniques of reconstruction and the characteristics
of the implant. We used regression analysis to compare patients
with and without post-operative instability.Aims
Patients and Methods
Recently, there has been considerable interest in quantifying
the associations between bony abnormalities around and in the hip
joint and osteoarthritis (OA). Our aim was to investigate the relationships
between acetabular undercoverage, acetabular overcoverage, and femoroacetabular
impingement (FAI) with OA of the hip, which currently remain controversial. A total of 545 cadaveric skeletons (1090 hips) from the Hamann-Todd
osteological collection were obtained. Femoral head volume (FHV),
acetabular volume (AV), the FHV/AV ratio, acetabular version, alpha
angle and anterior femoral neck offset (AFNO) were measured. A validated
grading system was used to quantify OA of the hip as minimal, moderate,
or severe. Multiple linear and multinomial logistic regression were
used to determine the factors that correlated independently with
the FHV, AV, and the FHV/AV ratio. Aims
Materials and Methods
Pain catastrophising is an adverse coping mechanism,
involving an exaggerated response to anticipated or actual pain. The purpose of this study was to investigate the influence of
pain ‘catastrophising’, as measured using the pain catastrophising
scale (PCS), on treatment outcomes after surgery for lumbar spinal
stenosis (LSS). A total of 138 patients (47 men and 91 women, mean age 65.9;
45 to 78) were assigned to low (PCS score <
25, n = 68) and high
(PCS score ≥ 25, n = 70) PCS groups. The primary outcome measure
was the Oswestry Disability Index (ODI) 12 months after surgery.
Secondary outcome measures included the ODI and visual analogue
scale (VAS) for back and leg pain, which were recorded at each assessment
conducted during the 12-month follow-up period The overall changes in the ODI and VAS for back and leg pain
over a 12-month period were significantly different between the
groups (ODI, p <
0.001; VAS for back pain, p <
0.001; VAS
for leg pain, p = 0.040). The ODI and VAS for back and leg pain
significantly decreased over time after surgery in both groups (p
<
0.001 for all three variables). The patterns of change in the
ODI and VAS for back pain during the follow-up period significantly
differed between the two groups, suggesting that the PCS group is
a potential treatment moderator. However, there was no difference
in the ODI and VAS for back and leg pain between the low and high
PCS groups 12 months after surgery. In terms of minimum clinically important differences in ODI scores
(12.8), 22 patients (40.7%) had an unsatisfactory surgical outcome
in the low PCS group and 16 (32.6%) in the high PCS group. There
was no statistically significant difference between the two groups
(p = 0.539). Pre-operative catastrophising did not always result in a poor
outcome 12 months after surgery, which indicates that this could
moderate the efficacy of surgery for LSS. Cite this article:
Older patients with multiple medical co-morbidities
are increasingly being offered and undergoing total joint arthroplasty
(TJA). These patients are more likely to require intensive care
support, following surgery. We prospectively evaluated the need
for intensive care admission and intervention in a consecutive series
of 738 patients undergoing elective hip and knee arthroplasty procedures.
The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk
factors, correlating with the need for critical care intervention,
according to published guidelines, were analysed to identify high-risk
patients who would benefit from post-operative critical care monitoring.
A total of 50 patients (6.7%) in our series required critical care
level interventions during their hospital stay. Six independent
multivariate clinical predictors were identified (p <
0.001)
including a history of congestive heart failure (odds ratio (OR)
24.26, 95% confidence interval (CI) 9.51 to 61.91), estimated blood
loss >
1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive
pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative
use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip
arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index
>
35 kg/m2 (OR 2.70, 95% CI 123 to 5.94). The model was
then validated against an independent, previously published data
set of 1594 consecutive patients. The use of this risk stratification
model can be helpful in predicting which high-risk patients would
benefit from a higher level of monitoring and care after elective
TJA and aid hospitals in allocating precious critical care resources. Cite this article:
Deep vein thrombosis is a common complication
of immobilising the lower limb after surgery. We hypothesised that
intermittent pneumatic compression (IPC) therapy in outpatients
who had undergone surgical repair of acute ruptures of the Achilles
tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of
the Achilles tendon were randomised to either treatment with IPC
for six hours per day (n = 74) under an orthosis or treatment as
usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively,
the incidence of deep vein thrombosis was assessed using blinded, double-reported
compression duplex ultrasound. At this point, IPC was discontinued
and all patients were immobilised in an orthosis for a further four
weeks. At six weeks post-operatively, a second compression duplex ultrasound
scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in
the treated group and 37% in the control group (p = 0.042). Age
over 39 years was found to be a strong risk factor for deep vein
thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI)
2.14 to 10.96). Treatment with IPC, corrected for age differences
between groups, reduced the risk of deep vein thrombosis at the
two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks,
the incidence of deep vein thrombosis was 52% in the treated group
and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC
appears to be an effective method of reducing the risk of deep vein
thrombosis in the early stages of post-operative immobilisation
of outpatients. Further research is necessary to elucidate whether
it can confer similar benefits over longer periods of immobilisation
and in a more heterogeneous group of patients. Cite this article:
The April 2015 Trauma Roundup360 looks at: Negative presure wound therapy in open tibial fractures; Priority-driven approach to pelvic injuries; Early surgery essential in hip fracture management; Sheer fractures to the posteromedial plateau; Fasciotomy closure under the spotlight; Why do patients die from hip fracture?; Acetabular fractures down the line; Biomechanics of femoral neck fractures reviewed
Vascularised fibular grafts (VFGs ) are a valuable
surgical technique in limb salvage after resection of a tumour.
The primary objective of this multicentre study was to assess the
risk factors for failure and complications for using a VFG after
resection of a tumour. The study involved 74 consecutive patients (45 men and 29 women
with mean age of 23 years (1 to 64) from four tertiary centres for
orthopaedic oncology who underwent reconstruction using a VFG after
resection of a tumour between 1996 and 2011. There were 52 primary
and 22 secondary reconstructions. The mean follow-up was 77 months
(10 to 195). In all, 69 patients (93%) had successful limb salvage; all of
these united and 65 (88%) showed hypertrophy of the graft. The mean
time to union differed between those involving the upper (28 weeks;
12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred
in 11 (15%), and nonunion in 14 (19%) patients. In 35 patients (47%) at least one complication arose, with a
greater proportion in lower limb reconstructions, non-bridging osteosynthesis,
and in children. These complications resulted in revision surgery
in 26 patients (35%). VFG is a successful and durable technique for reconstruction
of a defect in bone after resection of a tumour, but is accompanied
by a significant risk of complications, that often require revision
surgery. Union was not markedly influenced by the need for chemo-
or radiotherapy, but should not be expected during chemotherapy.
Therefore, restricted weight-bearing within this period is advocated. Cite this article: