We describe the outcome of tibial diaphyseal
fractures in the elderly (≥ 65 years of age). We prospectively followed 233
fractures in 225 elderly patients over a minimum ten-year period.
Demographic and descriptive data were acquired from a prospective
trauma database. Mortality status was obtained from the General
Register Office database for Scotland. Diaphyseal fractures of the
tibia in the elderly occurred predominantly in women (73%) and after
a fall (61%). During the study period the incidence of these fractures
decreased, nearly halving in number. The 120-day and one-year unadjusted
mortality rates were 17% and 27%, respectively, and were significantly
greater in patients with an open fracture (p <
0.001). The overall
standardised mortality ratio (SMR) was significantly increased (SMR
4.4, p <
0.001) relative to the population at risk, and was greatest
for elderly women (SMR 8.1, p <
0.001). These frailer patients
had more severe injuries, with an increased rate of open fractures
(30%), and suffered a greater rate of nonunion (10%). Tibial diaphyseal fractures in the elderly are most common in
women after a fall, are more likely to be open than in the rest
of the population, and are associated with a high incidence of nonunion
and mortality. Cite this article:
Both conservative and operative forms of treatment
have been recommended for patients with a ‘floating shoulder’. We
compared the results of conservative and operative treatment in
25 patients with this injury and investigated the use of the glenopolar
angle (GPA) as an indicator of the functional outcome. A total of
13 patients (ten male and three female; mean age 32.5 years (24.7
to 40.4)) were treated conservatively and 12 patients (ten male
and two female; mean age 33.67 years (24.6 to 42.7)) were treated
operatively by fixation of the clavicular fracture alone. Outcome
was assessed using the Herscovici score, which was also related
to changes in the GPA at one year post-operatively. The mean Herscovici score was significantly better three months
and two years after the injury in the operative group (p <
0.001
and p = 0.003, respectively). There was a negative correlation between
the change in GPA and the Herscovici score at two years follow-up
in both the conservative and operative groups, but neither were
statistically significant
(r = -0.295 and r = -0.19, respectively). There was a significant
difference between the pre- and post-operative GPA in the operative
group (p = 0.017). When compared with conservative treatment, fixation of the clavicle
alone gives better results in the treatment of patients with a floating
shoulder. The GPA changes significantly with fixation of clavicle
alone but there is no significant correlation between the pre-injury
GPA and the final clinical outcome in these patients. Cite this article:
In May 2012, in airports across the globe, seven
orthopaedic surgeons bravely said goodbye to their loved ones, and
slowly turned towards their respective aircraft. Filled with expectation
and mild trepidation they stepped into the unknown… the ABC fellowship
of 2012.
Symptoms of obstetric brachial plexus injury (OBPI) vary widely
over the course of time and from individual to individual and can
include various degrees of denervation, muscle weakness, contractures,
bone deformities and functional limitations. To date, no universally
accepted overall framework is available to assess the outcome of patients
with OBPI. The objective of this paper is to outline the proposed
process for the development of International Classification of Functioning,
Disability and Health (ICF) Core Sets for patients with an OBPI. The first step is to conduct four preparatory studies to identify
ICF categories important for OBPI: a) a systematic literature review
to identify outcome measures, b) a qualitative study using focus
groups, c) an expert survey and d) a cross-sectional, multicentre
study. A first version of ICF Core Sets will be defined at a consensus
conference, which will integrate the evidence from the preparatory
studies. In a second step, field-testing among patients will validate this
first version of Core Sets for OBPI.Background
Methods
The April 2013 Children’s orthopaedics Roundup360 looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.
We studied the prevalence of severe crouch gait
over a 15-year period in a defined population of children with spastic
diplegia and Gross Motor Function Classification System levels II
and III, to determine if there had been a decrease following changes
to the management of equinus gait. These changes were replacing
observational with three-dimensional gait analysis, replacing single
level with multilevel surgery, and replacing gastrocsoleus lengthening
with gastrocnemius recession. Of 464 children and adolescents with
spastic diplegia who underwent three-dimensional gait analysis,
27 had severe crouch gait. Seventeen of these had been managed by
isolated lengthening of the gastrocsoleus. Following changes in
the management of equinus gait, the prevalence of severe crouch
gait decreased from 25% and stabilised at a significantly lower
rate, fluctuating between 0% and 4% annually (p <
0.001). We conclude that severe crouch gait in this population was precipitated
by isolated lengthening of the gastrocsoleus. These findings may
be relevant to other surgical populations, as severe crouch gait
may be a useful way to monitor the quality of the surgical management
of abnormal gait in children with cerebral palsy and spastic diplegia.
The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its anatomical course and function, and documented the results of repair. From examination of our records, 111 patients with lesions of the spinal accessory nerve were treated between 1984 and 2007. In 89 patients (80.2%) the damage was iatropathic. Recognition and referral were seldom made by the surgeon responsible for the injury, leading to a marked delay in instituting treatment. Most referrals were made for painful loss of shoulder function. The clinical diagnosis is straightforward. There is a characteristic downward and lateral displacement of the scapula, with narrowing of the inferior scapulohumeral angle and loss of function, with pain commonly present. In all, 80 nerves were explored and 65 were repaired. The course of the spinal accessory nerve in relation to the sternocleidomastoid muscle was constant, with branches from the cervical plexus rarely conveying motor fibres. Damage to the nerve was predominantly posterior to this muscle. Despite the delay, the results of repair were surprising, with early relief of pain, implying a neuropathic source, which preceded generally good recovery of muscle function.
This brief annotation summarises the particular contributions made by the annual Edinburgh International Trauma Symposium in various areas of research into aspects of orthopaedic trauma and the management of acutely injured patients, during the 25 years since its establishment.
We undertook a randomised controlled trial to
compare bipolar hemiarthroplasty (HA) with a novel total hip replacement
(THR) comprising a polycarbonate–urethane (PCU) acetabular component
coupled with a large-diameter metal femoral head for the treatment
of displaced fractures of the femoral neck in elderly patients. Functional
outcome, assessed with the Harris hip score (HHS) at three months
and then annually after surgery, was the primary endpoint. Rates
of revision and complication were secondary endpoints. Based on a power analysis, 96 consecutive patients aged >
70
years were randomised to receive either HA (49) or a PCU-THR (47).
The mean follow-up was 30.1 months (23 to 50) and 28.6 months (22
to 52) for the HA and the PCU group, respectively. The HHS showed no statistically significant difference between
the groups at every follow-up. Higher pain was recorded in the PCU
group at one and two years’ follow-up
(p = 0.006 and p = 0.019, respectively). In the HA group no revision
was performed. In the PCU-THR group six patients underwent revision
and one patient is currently awaiting
re-operation. The three-year survival rate of the PCU-THR group
was 0.841 (95% confidence interval 0.680 to 0.926). Based on our findings we do not recommend the use of the PCU
acetabular component as part of the treatment of patients with fractures
of the femoral neck. Cite this article:
Autologous retransfusion and no-drainage are
both blood-saving measures in total hip replacement (THR). A new combined
intra- and post-operative autotransfusion filter system has been
developed especially for primary THR, and we conducted a randomised
controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood
transfusion (ABT)
(n = 102) or no-drainage (n = 102). In the ABT group, a mean of
488 ml ( The use of a new intra- and post-operative autologous blood transfusion
filter system results in less total blood loss and a smaller maximum
decrease in haemoglobin levels than no-drainage following primary
THR. Cite this article:
The February 2013 Oncology Roundup360 looks at: proximal fibular tumours; radiotherapy-induced chondrosarcoma; mega-prosthesis; CRP predictions of sarcoma survival; predicting survival in metastatic disease; MRI for recurrence in osteoid osteoma; and a sarcoma refresher
We report the functional and socioeconomic long-term
outcome of patients with pelvic ring injuries. We identified 109 patients treated at a Level I trauma centre
between 1973 and 1990 with multiple blunt orthopaedic injuries including
an injury to the pelvic ring, with an Injury Severity Score (ISS)
of ≥ 16. These patients were invited for clinical review at a minimum
of ten years after the initial injury, at which point functional
results, general health scores and socioeconomic factors were assessed. In all 33 isolated anterior (group A), 33 isolated posterior
(group P) and 43 combined anterior/posterior pelvic ring injuries
(group A/P) were included. The mean age of the patients at injury
was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44). At review the mean Short-Form 12 physical component score for
the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score
for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42),
being significantly worse compared with the other two groups (p =
0.004 and p = 0.024, respectively). A total of 42 patients (39%)
had a limp and 12 (11%) required crutches. Car or public transport
usage was restricted in 16 patients (15%). Overall patients in groups
P and A/P had a worse outcome. The long-term outcome of patients
with posterior or combined anterior/posterior pelvic ring injuries
is poorer than of those with an isolated anterior injury. Cite this article:
Studies describing the effect of body mass index (BMI) on the outcome of total hip replacement have been inconclusive and contradictory. We examined the effect of BMI on medium-term outcome in a cohort of 1617 patients who underwent a primary total hip replacement for osteoarthritis. These patients were followed prospectively for five years with the outcomes of dislocation, revision, duration of surgery and deep and superficial infection studied, as well as collecting Harris hip scores (HHS) and Short-Form 36 (SF-36) questionnaires pre-operatively and at review. A multivariate analysis was performed to see whether BMI is an independent predictor of poor outcome. We found that patients with a BMI of ? 35 kg/m2 have a 4.42 times higher rate of dislocation than those with a BMI <
25 kg/m2. Increasing BMI is also associated with superficial infection and poorer HHS and SF-36 scores at five years. These trends remain significant even when multivariate analysis adjusts for age, gender, prosthesis, operating consultant, pre-operative HHS and SF-36, and comorbidities including diabetes mellitus, cardiac disease and osteoporosis. Despite the increased risks, the five-year outcome scores indicate that obese patients have much to gain from total hip replacement. Thus total hip replacement should not be withheld from patients solely on the grounds of an elevated BMI. However, longer-term follow-up of this cohort is required to establish whether adverse outcomes become more evident with time.