This study compares the cost-effectiveness of
treating dorsally displaced distal radial fractures with a volar
locking plate and percutaneous fixation. It was performed from the
perspective of the National Health Service (NHS) using data from
a single-centre randomised controlled trial. In total 130 patients
(18 to 73 years of age) with a dorsally displaced distal radial
fracture were randomised to treatment with either a volar locking
plate (n = 66) or percutaneous fixation (n = 64). The methodology
was according to National Institute for Health and Care Excellence guidance
for technology appraisals. . There were no significant differences in quality of life scores
between groups at any time point in the study. Both groups returned
to baseline one year post-operatively. NHS costs for the plate group were significantly higher (p <
0.001, 95% confidence interval 497 to 930). For an additional £713,
fixation with a volar locking plate offered 0.0178 additional quality-adjusted
life years in the year after surgery. The incremental cost-effectiveness
ratio (ICER) for plate fixation relative to percutaneous fixation
at list price was £40 068. When adjusting the prices of the implants
for a 20% hospital discount, the ICER was £31 898. Patients who
underwent plate fixation did not return to work earlier. We found no evidence to support the cost-effectiveness, from
the perspective of the NHS, of fixation using a volar locking plate
over percutaneous fixation for the operative treatment of a dorsally
displaced radial fracture. Cite this article:
This study analysed the clinical and radiological outcome of
anatomical reduction of a moderate or severe stable slipped capital
femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified
Dunn osteotomy) through the surgical approach described by Ganz. We prospectively studied 31 patients (32 hips; 16 females and
five males; mean age 14.3 years) with SCFE. On the Southwick classification,
ten were of moderate severity (head-shaft angle >
30° to 60°) and
22 were severe (head-shaft angle >
60°). Each underwent open reduction
and internal fixation using an intracapsular osteotomy through the
physeal growth plate after safe surgical hip dislocation. Unlike
the conventional procedure, 25 hips did not need an osteotomy of
the apophysis of the great trochanter and were managed using an
extended retinacular posterior flap. Aims
Patients and Methods
Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace.
The degree of displacement of a fracture of the distal radius
is an important factor which can be assessed using simple radiographic
measurements. Our aim was to investigate the reliability and reproducibility
of these measurements and to determine if they should be used clinically. A 10% sample was randomly generated from 3670 consecutive adult
patients who had presented to University Hospitals of Leicester
NHS Trust between 2007 and 2010 with a fracture of the distal radius.
Radiographs of the 367 patients were assessed by two independent
reviewers. Four measurements of displacement of the fracture were recorded
and the inter-observer correlation assessed using the intra-class
correlation coefficient.Aims
Patients and Methods
Flail chest from a blunt injury to the thorax is associated with
significant morbidity and mortality. Its management globally is
predominantly non-operative; however, there are an increasing number
of centres which undertake surgical stabilisation. The aim of this
meta-analysis was to compare the efficacy of this approach with
that of non-operative management. A systematic search of the literature was carried out to identify
randomised controlled trials (RCTs) which compared the clinical
outcome of patients with a traumatic flail chest treated by surgical
stabilisation of any kind with that of non-operative management.Aims
Patients and Methods
We have reviewed the current literature to compare
the results of surgery aimed to repair or debride a damaged acetabular
labrum. We identified 28 studies to be included in the review containing
a total of 1631 hips in 1609 patients. Of these studies 12 reported
a mean rate of good results of 82% (from 67% to 100%) for labral debridement.
Of the 16 studies that reported a combination of debridement and
re-attachment, five reported a comparative outcome for the two methods,
four reported better results with re-attachment and one study did
not find any significant difference in outcomes. Due to the heterogeneity
of the studies it was not possible to perform a meta-analysis or
draw accurate conclusions. Confounding factors in the studies include
selection bias, use of historical controls and high rates of loss
of follow-up. It seems logical to repair an unstable tear in a good quality
labrum with good potential to heal in order potentially to preserve
its physiological function. A degenerative labrum on the other hand
may be the source of discomfort and its preservation may result
in persistent pain and the added risk of failure of re-attachment.
The results of the present study do not support routine refixation
for all labral tears. Cite this article:
The February 2015 Wrist &
Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures.
Revision total elbow arthroplasty (TEA) is often challenging.
The aim of this study was to report on the clinical and radiological
results of revision arthroplasty of the elbow with the Latitude
TEA. Between 2006 and 2010 we used the Latitude TEA for revision in
18 consecutive elbows (17 patients); mean age 53 years (28 to 80);
14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde
TEA in three. Stability, range of movement (ROM), visual analogue score (VAS)
for pain and functional scores, Elbow Functional Assessment Scale
(EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM)
and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed
pre-operatively and at each post-operative follow-up visit (six,
12 months and biennially thereafter). Radiographs were analysed
for loosening, fractures and dislocation. The mean follow-up was
59 months (26 to 89).Aims
Patients and Methods
Involvement of the posterior malleolus in fractures of the ankle
probably adversely affects the functional outcome and may be associated
with the development of post-traumatic osteoarthritis. Anatomical
reduction is a predictor of a successful outcome. The purpose of this study was to describe the technique and short-term
outcome of patients with trimalleolar fractures, who were treated
surgically using a posterolateral approach in our hospital between
2010 and 2014. The study involved 52 patients. Their mean age was 49 years (22
to 79). There were 41 (79%) AO 44B-type and 11 (21%) 44C-type fractures.
The mean size of the posterior fragment was 27% (10% to 52%) of
the tibiotalar joint surface.Aims
Patients and Methods
We analysed the clinical and radiological outcomes
of a new surgical technique for the treatment of heterozygote post-axial
metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations
with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet
in 36 patients (mean age 6.8 years (2 to 16)) were treated with
this new technique, which transfers the distal part of the duplicated
fourth metatarsal to the proximal part of the fifth metatarsal.
Clinical and radiological assessments were undertaken pre- and post-operatively
and any complications were recorded. Final outcomes were evaluated
according to the methods described by Phelps and Grogan. Forefoot width
was reduced and the lengths of the all reconstructed toes were maintained
after surgery. Union was achieved for all the metatarsal osteotomies
without any angular deformities. Outcomes at the final assessment
were excellent in 51 feet (89%) and good in six (11%). This newly
described surgical technique provides for painless, comfortable
shoe-wearing after a single, easy-to-perform operation with good
clinical, radiological and functional outcomes. Cite this article:
Cement augmentation of pedicle screws could be used to improve screw stability, especially in osteoporotic vertebrae. However, little is known concerning the influence of different screw types and amount of cement applied. Therefore, the aim of this biomechanical A total of 54 osteoporotic human cadaver thoracic and lumbar vertebrae were instrumented with pedicle screws (uncemented, solid cemented or fenestrated cemented) and augmented with high-viscosity PMMA cement (0 mL, 1 mL or 3 mL). The insertion torque and bone mineral density were determined. Radiographs and CT scans were undertaken to evaluate cement distribution and cement leakage. Pull-out testing was performed with a material testing machine to measure failure load and stiffness. The paired Objectives
Materials and Methods
The results of the DRAFFT (distal radius acute
fracture fixation trial) study, which compared volar plating with
Kirschner (K-) wire fixation for dorsally displaced fractures of
the distal radius, were published in August 2014. The use of K-wires
to treat these fractures is now increasing, with a concomitant decline
in the use of volar locking plates. We provide a critical appraisal of the DRAFFT study and question
whether surgeons have been unduly influenced by its headline conclusions. Cite this article:
The purpose of this study was to develop an accurate, reliable and easily applicable method for determining the anatomical location of the joint line during revision knee arthroplasty. The transepicondylar width (TEW), the perpendicular distance between the medial and lateral epicondyles and the distal articular surfaces (DMAD, DLAD) and the distance between the medial and lateral epicondyles and the posterior articular surfaces (PMAD, DLAD) were measured in 40 knees from 20 formalin-fixed adult cadavers (11 male and nine female; mean age at death 56.9 years, Objectives
Methods
Peri-acetabular tumour resections and their subsequent
reconstruction are among the most challenging procedures in orthopaedic
oncology. Despite the fact that a number of different pelvic endoprostheses
have been introduced, rates of complication remain high and long-term
results are mostly lacking. In this retrospective study, we aimed to evaluate the outcome
of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis
after a type 2 or type 2/3 internal hemipelvectomy. A total of 19 patients (11M:8F) with a mean age of 48 years (14
to 72) were included, most of whom had been treated for a primary
bone tumour (n = 16) between 2003 and 2009. After a mean follow-up
of 39 months (28 days to 8.7 years) seven patients had died. After
a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive,
of whom 11 were disease-free. Complications occurred in 15 patients.
Three had recurrent dislocations and three experienced aseptic loosening.
There were no mechanical failures. Infection occurred in nine patients,
six of whom required removal of the prosthesis. Two patients underwent
hindquarter amputation for local recurrence. The implant survival rate at five years was 50% for all reasons,
and 61% for non-oncological reasons. The mean Musculoskeletal Tumor
Society score at final follow-up was 49% (13 to 87). Based on these poor results, we advise caution if using the pedestal
cup for reconstruction of a peri-acetabular tumour resection. Cite this article:
The treatment of late presenting fractures of the lateral humeral
condyle in children remains controversial. We report on the outcome for 16 children who presented with a
fracture of the lateral humeral epicondyle at a mean of 7.4 weeks
(3 to 15.6) after injury and were treated surgically.Aims
Methods
Acetabular bone loss is a challenging problem
facing the revision total hip replacement surgeon. Reconstruction
of the acetabulum depends on the presence of anterosuperior and
posteroinferior pelvic column support for component fixation and
stability. The Paprosky classification is most commonly used when
determining the location and degree of acetabular bone loss. Augments
serve the function of either providing primary construct stability
or supplementary fixation. When a pelvic discontinuity is encountered we advocate the use
of an acetabular distraction technique with a jumbo cup and modular
porous metal acetabular augments for the treatment of severe acetabular
bone loss and associated chronic pelvic discontinuity. Cite this article:
In order to achieve satisfactory reduction of
complex distal humeral fractures, adequate exposure of the fracture fragments
and the joint surface is required. Several surgical exposures have
been described for distal humeral fractures. We report our experience
using the anconeus pedicle olecranon flip osteotomy approach. This
involves detachment of the triceps along with a sliver of olecranon,
which retains the anconeus pedicle. We report the use of this approach
in ten patients (six male, four female) with a mean age of 38.4
years (28 to 51). The mean follow-up was 15 months (12 to 18) with
no loss to follow-up. Elbow function was graded using the Mayo Score.
The results were excellent in four patients, good in five and fair
in one patient. The mean time to both fracture and osteotomy union
was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We
found this approach gave reliably good exposure for these difficult
fractures enabling anatomical reduction and bicondylar plating without
complications. Cite this article:
Giant cell tumours (GCTs) of the small bones
of the hands and feet are rare. Small case series have been published but
there is no consensus about ideal treatment. We performed a systematic
review, initially screening 775 titles, and included 12 papers comprising
91 patients with GCT of the small bones of the hands and feet. The
rate of recurrence across these publications was found to be 72%
(18 of 25) in those treated with isolated curettage, 13% (2 of 15)
in those treated with curettage plus adjuvants, 15% (6 of 41) in
those treated by resection and 10% (1 of 10) in those treated by
amputation. We then retrospectively analysed 30 patients treated for GCT
of the small bones of the hands and feet between 1987 and 2010 in
five specialised centres. The primary treatment was curettage in
six, curettage with adjuvants (phenol or liquid nitrogen with or
without polymethylmethacrylate (PMMA)) in 18 and resection in six.
We evaluated the rate of complications and recurrence as well as
the factors that influenced their functional outcome. At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence
was 50% (n = 3) in those patients treated with isolated curettage,
22% (n = 4) in those treated with curettage plus adjuvants and 17%
(n = 1) in those treated with resection (p = 0.404). The only complication
was pain in one patient, which resolved after surgical removal of remnants
of PMMA. We could not identify any individual factors associated
with a higher rate of complications or recurrence. The mean post-operative
Musculoskeletal Tumor Society scores were slightly higher after
intra-lesional treatment including isolated curettage and curettage
plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to
30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted
in the cure for all patients and is therefore a reasonable treatment
for both primary and recurrent GCT of the small bones of the hands
and feet. Cite this article:
Lateral clavicular physeal injuries in adolescents
are frequently misinterpreted as acromioclavicular dislocations. There
are currently no clear guidelines for the management of these relatively
rare injuries. Non-operative treatment can result in a cosmetic
deformity, warranting resection of the non-remodelled original lateral
clavicle. However, fixation with Kirschner (K)-wires may be associated
with infection and/or prominent metalwork. We report our experience
with a small series of such cases. Between October 2008 and October 2011 five patients with lateral
clavicular physeal fractures (types III, IV and V) presented to
our unit. There were four boys and one girl with a mean age of 12.8
years (9 to 14). Four fractures were significantly displaced and
treated operatively using a tension band suture technique. One grade
III fracture was treated conservatively. The mean follow-up was
26 months (6 to 42). All patients made an uncomplicated recovery. The mean time to
discharge was three months. The QuickDASH score at follow-up was
0 for each patient. No patient developed subsequent growth disturbances. We advocate the surgical treatment of significantly displaced
Grade IV and V fractures to avoid cosmetic deformity. A tension
band suture technique avoids the problems of retained metalwork
and the need for a secondary procedure. Excellent clinical and radiological
results were seen in all our patients. Cite this article:
