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We evaluated an operative technique, described by the Exeter Hip Unit, to assist accurate introduction of the femoral component. We assessed whether it led to a reduction in the rate of leg-length discrepancy after total hip arthroplasty (THA).

A total of 100 patients undergoing THA were studied retrospectively; 50 were undertaken using the test method and 50 using conventional methods as a control group. The groups were matched with respect to patient demographics and the grade of surgeon. Three observers measured the depth of placement of the femoral component on post-operative radiographs and measured the length of the legs.

There was a strong correlation between the depth of insertion of the femoral component and the templated depth in the test group (R = 0.92), suggesting accuracy of the technique. The mean leg-length discrepancy was 5.1 mm (0.6 to 21.4) pre-operatively and 1.3 mm (0.2 to 9.3) post-operatively. There was no difference between Consultants and Registrars as primary surgeons. Agreement between the templated and post-operative depth of insertion was associated with reduced post-operative leg-length discrepancy. The intra-class coefficient was R ≥ 0.88 for all measurements, indicating high observer agreement. The post-operative leg-length discrepancy was significantly lower in the test group (1.3 mm) compared with the control group (6.3 mm, p < 0.001).

The Exeter technique is reproducible and leads to a lower incidence of leg-length discrepancy after THA.

Cite this article: Bone Joint J 2015;97-B:154–9.

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: Bone Joint J 2015;97-B:240–5.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

The December 2014 Trauma Roundup³⁶⁰ looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures.

Our aim was to compare the one-year post-operative outcomes following retention or removal of syndesmotic screws in adult patients with a fracture of the ankle that was treated surgically. A total of 51 patients (35 males, 16 females), with a mean age of 33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic screw fixation, were randomly allocated to retention of the syndesmotic screw or removal at three months post-operatively. The two groups were comparable at baseline.

One year post-operatively, there was no significant difference in the mean Olerud–Molander ankle score (82.4 retention vs 86.7 removal, p = 0.367), the mean American Orthopedic Foot and Ankle Society ankle-hindfoot score (88.6 vs 90.1, p = 0.688), the mean American Academy of Orthopedic Surgeons foot and ankle score (96.3 vs 94.0, p = 0.250), the mean visual analogue pain score (1.0 vs 0.7, p = 0.237), the mean active dorsiflexion (10.2° vs 13.0°, p = 0.194) and plantar flexion (33.6° vs 31.3°, p = 0.503) of the ankle, or the mean radiological tibiofibular clear space (5.0 mm vs 5.3 mm, p = 0.276) between the two groups. A total of 19 patients (76%) in the retention group had a loose and/or broken screw one year post-operatively.

We conclude that removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle.

Cite this article: Bone Joint J 2014;96-B:1699–1705.

This paper investigates whether cortical comminution and intra-articular involvement can predict displacement in distal radius fractures by using a classification that includes volar comminution as a separate parameter.

A prospective multicentre study involving non-operative treatment of distal radius fractures in 387 patients aged between 15 and 74 years (398 fractures) was conducted. The presence of cortical comminution and intra-articular involvement according to the Buttazzoni classification is described. Minimally displaced fractures were treated with immobilisation in a cast while displaced fractures underwent closed reduction with subsequent immobilisation. Radiographs were obtained after reduction, at 10 to 14 days and after union. The outcome measure was re-displacement or union.

In fractures with volar comminution (Buttazzoni type 4), 96% (53 of 55) displaced. In intra-articular fractures without volar comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106 of 145) displaced while in non-comminuted fractures (Buttazzoni 1), 16 % (13 of 81 ) displaced.

A total of 32% (53 of 165) of initially minimally displaced fractures later displaced. All of the initially displaced volarly comminuted fractures re-displaced. Displacement occurred in 31% (63 of 205) of fractures that were still in good alignment after 10 to 14 days.

Regression analysis showed that volar and dorsal comminution predicted later displacement, while intra-articular involvement did not predict displacement. Volar comminution was the strongest predictor of displacement.

Cite this article: Bone Joint J 2014;96-B:978–83.

Most of the literature on surgical site infections following the surgical treatment of fractures of the ankle is based on small series of patients, focusing on diabetics or the elderly. None have described post-operative functional scores in those patients who develop an infection. We performed an age- and gender-matched case–control study to identify patient- and surgery-related risk factors for surgical site infection following open reduction and internal fixation of a fracture of the ankle. Logistic regression analysis was used to identify significant risk factors for infection and to calculate odds ratios (OR). Function was assessed using the Olerud and Molander Ankle Score. The incidence of infection was 4% (29/717) and 1.1% (8/717) were deep infections. The median ankle score was significantly lower in the infection group compared with the control group (60 vs 90, Mann–Whitney test p < 0.0001). Multivariate regression analysis showed that diabetes (OR = 15, p = 0.031), nursing home residence (OR = 12, p = 0.018) and Weber C fractures (OR = 4, p = 0.048) were significant risk factors for infection.

A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed. Both superficial and deep infections result in lower functional scores.

Cite this article: Bone Joint J 2014;96-B:636–40.

Infection remains a significant and common complication after joint replacement and there is debate about which contributing factors are important. Few studies have investigated the effect of the operating time on infection.

We collected data prospectively from 5277 hip and knee replacements which included the type of procedure, the operating time, the use of drains, the operating theatre, surgeon, age and gender. In a subgroup of 3449 knee replacements further analysis was carried out using the tourniquet time in place of the operating time. These variables were assessed by the use of generalised linear modelling against superficial, deep or joint-space post-operative infection as defined by the Australian Surgical-Site Infection criteria.

The overall infection rate was 0.98%. In the replacement data set both male gender (z = 3.097, p = 0.00195) and prolonged operating time (z = 4.325, p < 0.001) were predictive of infection. In the knee subgroup male gender (z = 2.250, p = 0.02447), a longer tourniquet time (z = 2.867, p = 0.00414) and total knee replacement (versus unicompartmental knee replacement) (z = −2.052, p = 0.0420) were predictive of infection.

These findings support the view that a prolonged operating time and male gender are associated with an increased incidence of infection. Steps to minimise intra-operative delay should be instigated, and care should be exercised when introducing measures which prolong the duration of joint replacement.

Fractures of the forearm (radius or ulna or both) in children have traditionally been immobilised in plaster of Paris (POP) but synthetic cast materials are becoming more popular. There have been no randomised studies comparing the efficacy of these two materials. The aim of this study was to investigate which cast material is superior for the management of these fractures. We undertook a single-centre prospective randomised trial involving 199 patients with acute fractures of the forearm requiring general anaesthesia for reduction. Patients were randomised by sealed envelope into either a POP or synthetic group and then underwent routine closed reduction and immobilisation in a cast. The patients were reviewed at one and six weeks. A satisfaction questionnaire was completed following the removal of the cast. All clinical complications were recorded and the cast indices were calculated. There was an increase in complications in the POP group. These complications included soft areas of POP requiring revision and loss of reduction with some requiring re-manipulation. There was an increased mean padding index in the fractures that lost reduction. Synthetic casts were preferred by the patients.

This study indicates that the clinical outcomes and patient satisfaction are superior using synthetic casts with no reduction in safety.

Cite this article: Bone Joint J 2013;95-B:1285–9.

The October 2013 Knee Roundup³⁶⁰ looks at: Make it easy, release the MCL; Do patients remember clinical information in day surgery?; Osteoarthritis and arthroscopy?; How best to double your bundles; When to operate for infection; Cementless unicompartment knee replacement?; Tibial tubercle-trochlear groove confusion; Tarts, cherries and osteoarthritis

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: Bone Joint J 2013;95-B:664–7.

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study.

Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality.

We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year.

We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

The first 325 Exeter Universal stems (309 patients) implanted at the originating centre were inserted between March 1988 and February 1990 by a group of surgeons with differing experience. In this report we describe the clinical and radiological results at a mean of 15.7 years (14.7 to 17.3) after operation with no loss to follow-up. There were 97 patients (108 hips) with replacements still in situ and 31 (31 hips) who had undergone a further procedure. With an endpoint of revision for aseptic loosening, the survivorship at 17 years was 100% and 90.4% for the femoral and acetabular component, respectively. The mean Merle D’Aubigné and Postel scores at review were 5.4 (sd 0.97) for pain and 4.5 (sd 1.72) for function. The mean Oxford score was 38.4 (sd 9.8) (0 to 48 worst-to-best scale) and the mean combined Harris pain and function score was 73.2 (sd 16.9). Radiological review showed excellent preservation of bone stock in the proximal femur and no failures of the femoral component.

We present our experience of managing patients with iatropathic brachial plexus injury after delayed fixation of a fracture of the clavicle. It is a retrospective cohort study of patients treated at our peripheral nerve injury unit and a single illustrative case report. We identified 21 patients in whom a brachial plexus injury occurred as a direct consequence of fixation of a fracture of the clavicle between September 2000 and September 2011.

The predominant injury involved the C5/C6 nerves, upper trunk, lateral cord and the suprascapular nerve. In all patients, the injured nerve was found to be tethered to the under surface of the clavicle by scar tissue at the site of the fracture and was usually associated with pathognomonic neuropathic pain and paralysis.

Delayed fixation of a fracture of the clavicle, especially between two and four weeks after injury, can result in iatropathic brachial plexus injury. The risk can be reduced by thorough release of the tissues from the inferior surface of the clavicle before mobilisation of the fracture fragments. If features of nerve damage appear post-operatively urgent specialist referral is recommended.

Cite this article: Bone Joint J 2013;95-B:106–10.

There are unacceptable delays in the management of pelvic trauma in the United Kingdom. In 2003 this became a political issue after TV and radio coverage. Changes to the service were introduced, including trauma coordinators and a special tariff, but has it made a difference?