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Peroneal tendon subluxation & dislocation is a rare phenomenon. It is a commonly misdiagnosed cause of lateral ankle pain and instability.
Aim(s)
Our aim was to establish the morphometric (quantification of components) features of retromalleolar fibular groove in cadavers using 3D technique.
Background
Benefits of day case foot and ankle surgery includes reduced hospital stay, associated cost savings for the hospital, high patient satisfaction and quicker recovery with no increase in complication rates.
In 2007, we set up the preoperative foot and ankle group. Patients were seen three weeks before surgery by a specialist nurse, physiotherapist and a preoperative evaluation is done. The therapist explains the patient's weightbearing status and advices on how to carry this out. Our aim was to reduce inpatient hospital stay and increase our day case procedures.
Methods
We evaluated length of stay and physiotherapy intervention for all our patients during the first three months of 2007 to 2011. Mean length of stay was calculated and Mann-Whitney U test was performed using median.
Introduction
Lisfranc joint injuries account for only 0.2% of all fractures but early diagnosis improves the chances of a better outcom]. Radiographic signs, such as diastasis (>2mm) of the 1–2 interspace, are subtle and. often missed, leading to a poorer outcome. We present a new radiographic sign, less likely to result in missed diagnoses. Null nypothesis: The intermetarsal angle remains unchanged in Lisfranc injuries.
Method
A series of radiographs demonstrating Lisfranc injury were interspersed with normal and postoperative cases. Evidence of fixation was obscured. A selection of Foundation and Core Trainee medical staff measured the intermetatarsal angle (IMA) on two separate occasions. The measuring technique was demonstrated with no explanation for the reason behind the measurement.
Introduction
Surgical approaches to the dorsum of the foot are common for management of midfoot fracture dislocations and arthritis. The anatomy can be difficult to identify and neurovascular injury can be a serious complication.
Extensor hallucis brevis (EHB) is a consistent and easily identifiable structure encountered in these approaches. This study assesses the close relationship of the EHB musculotendinous junction to the neurovascular bundle for use as a reliable landmark.
Method
The relationship of the medial branch of the deep peroneal nerve (DPN) in the dorsum of the foot to the EHB tendon was examined by dissection of ten adult cadaveric feet preserved in formalin. Using a dorsal approach, the anatomy of the DPN neurovascular bundle was studied relative to its neighbouring structures. Local institutional review board approval was obtained.
Introduction
We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery.
Materials and methods
We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B.
Background
The aim of our study was to assess the ability of orthopaedic surgical trainees to adequately assess ankle radiographs following operative fixation of unstable ankle fracture.
Methods and results
We identified 26 Supination-External rotation (SER) stage IV fractures, and 4 Pronation-External rotation (PER) stage III fractures treated surgically in our institution. Radiographs were evaluated for shortening of the fibula, widening of the joint space, malrotation of the fibula and widening of the medial clear space. Trainees were shown these radiographs and asked to comment on the adequacy of reduction. They were then given a simple tutorial on assessing adequacy of reduction and asked to reassess these radiographs. The parameters discussed included assessment of medial clear space, drawing of the tibiofibular line, use of the “circle sign” and measurement of the talocrural angle. There was a statistically significant improvement from 64% to 71.4% (P< 0.05) in the radiographs correctly assessed by orthopaedic trainees following a short tutorial on radiographical assessment.
Background
The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade.
Methods
All articles from the years 2000 and 2010 in Foot and Ankle International, Foot and Ankle Surgery, and all foot and ankle articles from JBJS A and JBJS B were analysed. Animal, cadaveric, basic science, editorials, surveys, letters to Editor and correspondence were excluded. Articles were ranked by a five-point level of evidence scale, according to guidelines from the Centre for Evidence Based Medicine.
Background
A large number of Tendo-Achilles (TA) injuries occur during sporting activity. Typically occurring in males aged 30–50, whom occasionally undertake sporting activities, the so called ‘weekend warriors’.
Aims
To assess the impact of TA rupture on return to sporting activity in the non-elite athlete.
Background
Anatomical reduction and stable internal fixation has been recommended as the standard treatment for fracture dislocations of the tarsometatarsal (Lisfranc) joint. Many methods of fixation have been utilised including K-wires and screw fixation, the latter being the preferred method as it provides a stronger more stable construct. However, the screws require removal after the injury has healed.
We present a different method and technique of stabilisation utilising memory staples. The technique is extra-articular and avoids breaching the TMTJ joint surface, is simple and avoids the necessity of removal of hardware.
Methods
11 patients with isolated ligamentous Lisfranc injuries were treated with memory staple fixation over the past 4 years at our centre. Patients' outcome was assessed with use of the Foot & Ankle Disability Index (FADI) Score, the American Foot & Ankle Score, radiographic and clinical follow-up at an average time of 2 years post surgery.
Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiograph to assess the talar shift.
A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. Tunning fork lines were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied.
Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, ‘Tunning Fork Lines’ (TFL) were drawn. The superior two vertical lines of the TFL were drawn above the ankle joint perpendicular to the distal tibial articular surface. First line tangent to anterior lip of the inferior tibio-fibular joint and second line tangent to the posterior lip of the inferior tibio-fibular joint parallel to each other. The horizontal third line was drawn parallel to distal tibial articular surface perpendicular to first two lines connecting them. The fourth line (handle of the tunning fork) was drawn vertically below the ankle joint midway between the first two lines perpendicular to the third line. In a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus crosses this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis.
We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint if proper ankle mortise view is not available.
Background
Most patients with Achilles tendinopathy (AT) are treated successfully with physiotherapy ie eccentric calf training. In some patients gastrocnemius contracture persists. Three other publications have reported improvement in AT following gastrocnemius release, but this is the first series of patients to have proximal medial gastrocnemius release (PMGR) for AT. The purpose of this study was to review patients with refractory non-insertional and insertional AT treated by PMGR with a minimum followup of 18 months.
Method
Sixteen PMGRs were performed over a two year period. Nine patients (10 PMGRs) were available for followup. The mean age of patients was 45 (Range, 25 to 63) years, with five female and four male subjects. The average followup period was 2.5 (range, 1.7 to 3.3) years. The sample was divided into non-insertional and insertional tendinopathy, with five PMGRs per group. Outcome measures were VAS scores, VISA-A scores, AOFAS ankle-hindfoot score and overall satisfaction. Complications and further procedures were also recorded.
Isolated talonavicular arthrodesis is a common procedure particularly for posttraumatic arthritis and rheumatoid arthritis. Two surgical approaches are commonly used: the medial and the dorsal approach. It is recognized that access to the lateral aspect of the talonavicular joint can be limited when using the medial approach and it is our experience that using the dorsal approach addresses this issue.
We performed an anatomical study using cadaver specimens, to compare the amount of articular surface that can be accessed, and therefore prepared for arthodesis, by each surgical approach. Medial and dorsal approaches to the talonavicular joint were performed on each of 11 cadaveric specimens (10 fresh frozen, 1 embalmed). Distraction of the joint was performed as used intraoperatively for preparation of articular surfaces during talonavicular arthrodesis. The accessible area of articular surface was marked for each of the two approaches using a previous reported technique. Disarticulation was performed and the marked surface area was quantified using an immersion digital microscribe, allowing a three dimensional virtual model of the articular surfaces to be assessed.
The median percentage of accessible total talonavicular articular surface for the medial and dorsal approaches was 71% and 92% respectively. This difference was significant (Wilcoxon Signed Ranks Test, p< 0.001).
This study provides quantifiable measurements of the articular surface accessible by the medial and dorsal approaches to the talonavicular joint. These data support for the use of the dorsal approach for talonavicular arthrodesis.
Introduction
Literature in respect to the MRI appearances of surgically confirmed spring ligament pathology is sparse. The authors conducted a retrospective review of MRI examinations comprising 13 patients with surgically proven spring ligament abnormality.
Methods
Records for operations performed for planovalgus foot deformity with operation notes confirming presence of spring ligament abnormality were obtained for patients treated 2010–11. Of 32 procedures 13 patients (3 male, 10 female) mean age 48.5 (range, 21–86 years) underwent preoperative MRI scanning using a standard musculoskeletal protocol on a T1.5 unit. Scans were retrospectively reviewed by one of the senior authors and consultant musculoskeletal radiologist for pathological findings.
The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures.
We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace.
All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures.
Introduction
The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.
Methods
Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in positions ranging from 10 degrees of dorsiflexion to 60 degrees of plantarflexion using a Micro Scribe, enabling quantitative analyses in a virtual 3D environment.
Background
Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency.
Methods
We performed a retrospective study of all consecutive patients who underwent modified Brostrom repair for symptomatic recurrent instability of the ankle. All patients underwent a MRI scan prior to surgery. Arthroscopy was performed in all the patients before lateral ligament reconstruction. Seventy seven patients with 78 ankles were included in the study. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Data was obtained from clinical and radiological records. Arthroscopic findings were recorded in detail during the surgery.
Introduction
During broach preparation and implant insertion of the proximal femur the surgeon may be able to use audible pitch changes to judge broaching adequacy and implant position. The aim of this study was to analyse the sound produced and explain the sound spectra using acoustic physics.
Methods
A highly sensitive microphone was used to digitally record the sound made during femoral preparation and definitive implant insertion in 9 patients undergoing total hip arthroplasty. The sound data was analysed using a fast Fournier transformation spectrum analyser. The highest 4 peak spectral amplitudes of the first broach, the last strike of the final broach and the definitive implant were recorded. The sound spectra produced by striking the implant introducer in isolation were analysed in a similar manner.
Background
High functional aspirations and an active ageing population equate to a growing number of patients awaiting hip arthroplasty demanding superior biomechanical function. The purpose of this study was to compare the biomechanics of top walking speed between two commonly used hip arthroplasty procedures to determine if a performance advantage existed.
Methods
A retrospective comparative study was performed using sixty-seven subjects, twenty-two subjects in both hip resurfacing and total hip arthroplasty groups along with twenty-three healthy controls. All arthroplasty subjects were recruited based on high psychometric scoring and had been performed through a posterior approach, and had been discharged from follow-up. On an instrumented treadmill each subject was measured by a researcher blinded to which procedure that patient had undergone. After a six minute acclimatization period, the speed was increased incrementally until top walking performance had been attained. At all increments, ground reaction forces and temporospatial measurements were collected.
Introduction
Subtle deformities of the acetabulum and proximal femur are recognised as biomechanical risk factors for the development of hip osteoarthritis (OA) as well as a cause of hip and groin pain. We undertook this study to examine relationships between a number of morphological measurements of the acetabulum and proximal femur and the hip pain in a 20-year longitudinal study.
Methods
In 1989 women of 45–64 years of age were recruited. Each had an AP-Pelvis radiograph at Year-2. These radiographs were analysed using a validated programme for measuring morphology. All morphological measurements were read blinded to outcome. At year 3 all participants were asked whether they experienced hip pain (side specific). This was repeated at visits up to and including 20-years. Logistic regression analysis (with robust standard errors and clustering by subject identifier) was performed using hip pain as a binary outcome. The model adjusted for baseline age, BMI and joint space and included only participants who were pain free on initial questioning.
Background
Ultrasound and MRI are recommended tools in evaluating postoperative pain in metal-on-metal hip (MoM) arthroplasty.
Aim
To retrospectively compare MRI and ultrasound results of the hip with histopathology results in failed (MoM) hip arthroplasty.
Creating cement keyholes (i.e. drilling simple holes in cancellous bone to allow cement filling) is a practice used in multiple scenarios in orthopaedic surgery to ensure improved fixation between the bone-cement interface and as such between bone and prosthesis. It is most commonly used in hip arthroplasty to secure fixation of the cup to the acetabulum by drilling keyholes in acetabulum. However very little research has been conducted into what the dimensions of such cement keyholes should be. The following laboratory based research was performed to provide insight into the optimum dimensions of cement keyholes.
The investigator designed a novel arrangement to enable testing of keyholes. Beechwood block models were then made to this design testing keyholes of varying diameters and depths. These were cemented with acrylic bone cement and then loaded to failure. A finite system analysis was also performed.
Results show that stresses are concentrated at the base of the keyhole. As such increasing diameter of keyhole infers greater strength, but there is no relationship between depth and strength. This has been further confirmed with finite element analysis. We suggest the width of cement keyholes bears more importance than the depth and propose drilling wide but shallow keyholes.
Introduction
Solid or cystic pseudotumour is a potentially destructive complication of metal on metal (MoM) couples, usually needing revision surgery. However, complete clearance of the pseudotumour is unlikely at times. This prospective case-controlled study reports cases which had recurrence after revision surgery for pseudotumour related to metal on metal hip couples.
Methods
A total of 37 hips (33 MoM hip resurfacing and four big head MoM total hip arthroplasty (THA)) were revised for pseudotumour during the last 10 years. The patient demographics, time to revision, cup orientation, operative and histological findings were recorded for this cohort. Patients were divided into two groups - group R (needing re-revision for disease progression) and group C (control - no evidence of disease progression). Oxford hip scores (OHS, 0–48, 48 best outcome) were used to assess clinical outcome. The diagnosis of disease progression was based on recurrence of clinical symptoms, cross-sectional imaging, operative and histological findings.
Introduction
Total hip arthroplasty (THA) is undertaken to relieve pain and to restore mobility. The orthopaedic community remains divided on the influence of surgical approach in achieving functional recovery most quickly and effectively. We report a study comparing THA performed through a posterior (Posterior) against anterior approach (Heuter).
Methods
Fifty patients were prospectively enrolled and randomized for Posterior or Heuter procedures. Informed patient consent and local ethics approval was obtained. All patients received an uncemented, ceramic-on-ceramic prosthesis performed by a single surgeon.
Functional outcome was assessed by time to achieve milestones of walking, stair climbing, hip movement and balance. Kinematic data on level-ground walking and the effect of fatigue was assessed using a portable gait analysis system at 6-, 12-, and 24-weeks post-operatively.
Introduction
The ideal method of fixation for femoral components in total hip arthroplasty (THA) is unknown. While good results have been reported for cemented and uncemented components, there is relatively little published prospective data with twenty years or more of follow up.
Results of the Furlong femoral component have been presented at an average of 17 years follow up. We have extended this follow up period to an average of 22.5 years with a minimum of 22 years and a maximum of 25 years.
Methods
This study included all patients treated using the Furlong femoral component between 1986 and 1991. Patients were reviewed preoperatively and then at 6, 12, 26 and 52 weeks post operatively and annually thereafter.
They were assessed clinically and radiographically and the Merle d'Aubigne Postel hip score was calculated at each visit. A Visual Analog Score (VAS) was also recorded to assess patient satisfaction with their procedure. A Kaplan Meier survival analysis was performed.
The quality of femoral stem cementation has been shown to be a useful indicator of long-term survival of the total hip arthroplasty. Barrack's cementation grading is widely used but has certain limitations. It is based upon second-generation cementation technique and has high inter- and intra-observer variability. We introduce a new femoral cementation index based upon lengths of radiological lucency and cement-bone interface on AP and lateral views.
Five observers graded femoral cementation of radiographs of 30 primary hip arthroplasties using Barrack's grading and the new index on two occasions and Inter- & Intra-observer reliability was assessed. We also assessed the correlation between proximal femoral anatomy (calcar-canal ratio) & structural bone quality (using cortical index) with cementation using the new index in 50 patients.
Inter- and intra-observer reliability of the new index showed intraclass correlation coefficient 0.79 and 0.82 respectively and Barrack's grading system showed Kappa value- 0.20 (inter-observer) and 0.55 (intra-observer) reliability.
There was poor correlation between the calcar-canal ratio and the quality of cementation [Pearson's coefficient −0.04 (p< 0.05)]. There was some correlation between the cortical index and the quality of cementation [Pearson's coefficient 0.46 (p < 0.05)].
Our new index is a reliable method of assessing femoral cementation. The anatomy of femoral canal didn't have any significant influence on the quality of cementation achieved as assessed by our new index. The femoral cortical structural quality seemed to have some positive influence on the quality of cementation.
Introduction
Different classification systems for acetabular deficiencies, including AAOS and Paprosky, are commonly used. Classification of these bone defects is often performed based on Xrays or CT images. Although the amount of bone loss is rarely measured quantitatively in these images, objective and quantitative data on the degree of bone loss could facilitate correct and consistent classification. Recently, a computerized CT-based tool was presented to quantitatively asses bone loss: TrABL (Total radial Acetabular Bone Loss). This study demonstrates on an extended patient population that TrABL combined with standard classification systems provides more detailed, quantitative information on bone defects.
Methods
CT scans of 30 severe acetabular defects, classified Paprosky IIIA and IIIB, were collected and analysed with TrABL. The tool automatically calculated the total amount of bone that was missing around the acetabulum, seen from the hip's original rotation centre. Six anatomical regions were defined for which the degree of bone loss was expressed: anterosuperior, anteroinferior, inferior, posteroinferior, posterosuperior and medial.
Introduction
Following in-depth analysis of the market leading brand combinations in which we identified implant influences on risk of revision, we compared revision in patients implanted with different categories of hip replacement in order to find implant with the lowest revision risk, once known flawed options were removed.
Methods
All patients with osteoarthritis who underwent a hip replacement (2003–2010) using an Exeter-Contemporary (cemented), Corail-Pinnacle (cementless), Exeter-Trident (Hybrid) or a Birmingham Hip resurfacing (BHR) were initially included within the analysis. Operations involving factors that were significant predictors of revision were excluded. Cox proportional hazard models were then used to assess the relative risk of revision for a category of implant (compared with cemented), after adjustment for patient covariates.
Background
Previous studies have suggested that the modular junction of metal on metal (MoM) total hip replacements (THR) is an important source of metallic debris.
Methods
We carried out a prospective study using custom techniques to analyse one of the largest collections of failed contemporary MoM devices in the world. All explants from patients who had suffered adverse reactions to metal debris (ARMD) were included in this study. These explants included: 82 36mm THRs, and 147 resurfacing head THRs and 140 resurfacing arthroplasties from several manufactures. Volumetric wear analysis of the bearing surfaces and taper junctions was carried out using a coordinate measuring machine. The relationships between total metallic loss and metal ion concentrations and the macroscopic and histological tissue appearance of THR patients were compared to those in resurfacing patients. Mann Whitney test for non-parametric data was used to assess significant differences between groups.
Background
We have previously described the relationship between wear rates of MOM components and soft tissue necrosis. In this study we investigated the link between wear rates, metal ion concentrations and osteolysis.
Methods
All unilateral patients who underwent revision of hip resurfacings at our centre were included. Retrieved components were analysed using a coordinate measuring machine to determine total volumetric material loss and rates of wear. Given the accuracy of the wear calculations (which we have previously published), wear rates were considered “abnormal” if ≥3mm3/yr. ROC curves were constructed to determine a Co concentration which would be clinically useful to detect abnormal wear. During revision, the presence/absence of osteolysis was documented.
Introduction
Typical UK patients spend 5–7 days in hospital following total hip replacement (THR). Decreasing length of stay (LOS) increases throughput and reduces cost. We have developed a short stay THR programme (SSP), which has been used in all patients since May 2006; we present the first 100.
Methods
Every patient undergoing THR is included in the dataset. All attend ‘bone school’ before admission, with talks and individual assessments by the senior sister, physiotherapist and occupational therapist. Medical concerns are discussed with an anaesthetist. Patients receive training with crutches; crutches are provided for home practice.
All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. ‘Low dose’ spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree fully weightbearing mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores.
Introduction
The aim of this study was to see if the evaluation of the initial postoperative radiograph following primary knee and hip arthroplasty correlated with clinical outcome at five years postoperatively.
Methodology
Using our institution database we identified forty-nine hip replacements and fifty-two knee replacements performed between 2000 and 2006. All the patients underwent postoperative radiographs one day after surgery and clinical evaluation up to at least five years postoperatively. A consultant radiologist evaluated the radiographs for alignment and component position. The hip arthroplasty patients were assessed clinically using the Harris hip score, Oxford hip score, and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). The knee arthroplasty patients were assessed using the Knee Society score, Oxford knee score, and the WOMAC score.
A retrospective analysis was carried out to determine the influence of pre-existing spinal pathology on the outcome of Total Knee Replacement surgery. Data was collected from 345 patients who had undergone Total Knee Replacement, at four centres in the UK, between 2000 and 2007. Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 questionnaires were recorded prospectively. Data was collected pre-operatively and then post-operatively at 3 months, 1 year and 2 years. Patients were divided into those with (n=40) and without a history of low back pain (n=305). In addition to determining the influence of low back pain on outcome after Total Knee Replacement we also examined the influence of concomitant hip and ankle pathology in the same cohort of patients.
OKS scores were significantly worse for patients with symptomatic low back pain at 3 (p=0.05), 12 (p=0.009) and 24 months (p=0.039) following surgery. SF-12 physical scores followed a comparable pattern with significance demonstrated at 3 (p=0.038), 12 (p=0.0002) and 24 months (p=0.016). AKSS followed a similar pattern, but significance was only reached at 1 year (p=0.013). The mental component of the SF-12 measure demonstrated a significant improvement in patients' mental health post-operatively for patients with no history of low back pain. In contrast patients with low back pain showed no improvement in mental health scores post-operatively.
In contrast to low back pain, hip and ankle pathology had no statistically significant detrimental effect on the outcome of Total Knee Replacement surgery.
This study demonstrates that low back pain significantly affects the functional outcome after Total Knee Replacement surgery and that patients with low back pain show no improvement in mental health post-operatively.
Study Aim
To assess the impact of two oral thromboprophylaxis agents against Clexane with regard to range of movement (ROM) following TKR with or without haemostasis following tourniquet release.
Methods & Results
Thromboprophylaxis choice following total knee replacement (TKR) has become of interest with the introduction of oral anticoagulants and support for these by NICE. Specific concerns with oral agents include a perceived elevated level of anti-coagulation and soft tissue complications.
The population (n=264) was subclassified into cohorts regarding thromboprophylaxis cover: Clexane, Rivaroxaban and Dabigatran. Each subgroup was subdivided into whether surgery was performed with or without haemostasis following tourniquet release.
This study demonstrates Clexane is associated with a better and earlier return of ROM post-operatively as compared to oral the thromboprophylaxis agents. This effect was more obvious when combined with haemostasis following early tourniquet release (p< 0.05). The oral thromboprophylaxis agents Rivaroxaban and Dabigatran had a relative negative effect on ROM as compared against Clexane. This was independent of whether the surgery was performed with or without haemostasis following tourniquet release. There was no different between the subgroups with repect to change of serum haemoglobin, symptomatic venous thromboembolism or rate of return to theatre.
Objectives
The goal of this study was to describe and evaluate the implementation of a tailored care pathway as an alternative to a standard joint care protocol in the postoperative in-hospital rehabilitation after total knee replacement (TKR) on clinically relevant outcome parameters.
Methods
We monitored an orthopaedic department regarding postoperative rehabilitation after TKR on several outcome parameters throughout a period of 32 months, whilst introducing a new care pathway after 17 months. Outcome parameters were monitored and comprised: Time to get functionally recovered (in days), length of stay (in days) and destination of discharge. Key-differences between the joint care protocol and the new tailored pathway were: 1. determination of individual short term rehabilitation goals on the basis of a preoperative clinical prediction rule and postoperative monitoring of functional recovery, 2. Enhancement of expertise of and collaboration between health care professionals and 3. implementation of fast track rehabilitation. We compared the patients operated after implementation of the tailored care pathway with those who were treated according to the joint care protocol. Regression analysis was used to estimate differences between the two groups of patients while correcting for baseline differences in risk profile between the groups.
Objectives
This study examines variations in knee arthroplasty patient reported outcome measures according to patient age.
Methods
We analysed prospectively collected outcome data (OKS, Eq5D, satisfaction, and revision) on 2456 primary knee arthroplasty patients. Patients were stratified into defined age groups (< 55, 55–64, 65–74, 75–84, and ≥85 years). Oxford Knee Score and Eq5D were analysed pre-operatively, and postoperatively at 6 months and 2 years. Absolute scores and post-operative change in scores were calculated and compared between age groups. Satisfaction scores (0–100) were analysed at 6 months post-operatively. Linear, logistic and ordinal regression modelling was used to describe the association between age and outcomes, for continuous, binary and ordinal outcomes, respectively. Kaplan-Meier analysis was performed to describe revision rates at 2 years.
Introduction
Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty but do not recommend one particular pharmacotherapy over another.
Objectives
We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban, with respect to average length of stay, postoperative wound leakage, readmission within 30 days of surgery and re-do surgery
Aim
To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period.
Material and methods
Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates.
A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks.
A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results.
Purpose
To determine how patient characteristics; health status and pre-operative knee function effect patient reported satisfaction and operative success following total knee replacement (TKR). We hypothesised that a number of patient factors would influence the reported levels of symptomatic improvement (success) and satisfaction and that these two outcomes would represent different aspects of the patient's perception of outcome.
Design
Retrospective cohort analysis of patient reported outcome measures (PROMs) and National Joint Registry (NJR) data. Complete patient data was available for 9,874 TKRs performed for osteoarthritis between 1/8/08 and 31/12/10. The relationship of the background factors to patient perceived satisfaction and success was investigated using ordinal logistic regression and structural equation modelling (SEM).
Background
The most appropriate form of chemical thromboprophylaxis following knee replacement is a contentious issue. Most national guidelines recommend the use of low molecular weight Heparin (LMWH) whilst opposing the use of aspirin. We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or LMWH.
Methods
Data from the National Joint Registry for England and Wales was linked to an administrative database of hospital admissions in the English National Health Service. A total of 156 798 patients undergoing knee replacement between April 2003 and September 2008 were included and followed up for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin.
Introduction
Health Economists in Denmark have recently reported low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). Surgeons however are reporting that patients achieve good pain relief and a high standard of activities of daily living (ADL) after surgery.
Aim
To evaluate the effectiveness of ASAD for patients with SAIS and correlate clinical outcome with rate of return to work.
Hypothesis
Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions.
Material and methods
We dissected 14 cadaveric shoulders. A bony Bankart lesion was created in form of an inverted pear glenoid. The humeral head was attached to a pulley system that was sequentially loaded until the shoulder dislocated anteriorly. The force needed to dislocate was noted. This was repeated after coracoid transfer with two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet.
Introduction
The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically.
Methods
Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test.
The anterior portion of the anatomical neck is used as a reference for the osteotomy in shoulder arthroplasty. Resection at this level is thought to remove a segment of a sphere which can accurately be replaced with a prosthetic implant. The objective of the study was to analyse the cartilage/metaphyseal interface relative to an ideal osteotomy plane to define points of reference the may recover retroversion accurately. Data were collected from 24 humeri using a novel technique, combining data acquired using a Microscribe digitiser and surface laser scanner. Rhinocerus NURBS modelling software was used to analyse the Cartilage/metaphyseal interface. The retroversion angle was calculated for the normal geometry and for the standard osteotomy along the anterior cartilage/metaphyseal interface. An ideal osteotomy plane was then created for each specimen and the perpendicular distance from the cartilage/metaphyseal interface was determined, identifying points of least deviation. The reference points were used to simulate a new osteotomy for which retroversion was calculated. Paired t-tests were used to compare the novel osteotomy and traditional osteotomy to the normal geometry. The mean retroversion for the normal geometry was 18.5±9.0 degrees. The mean retroversion for the traditional osteotomy technique was 29.5±10.7 degrees, significantly different from the original (p< 0.001). The mean retroversion using the novel osteotomy was 18.9±8.9 degrees and similar to the normal geometry (p=0.528). The traditional osteotomy resulted in a mean increase in retroversion of 38%. The increase in version may result in eccentric load on the glenoid, an alteration to the rotator cuff balance and poor clinical outcome. The novel osteotomy based on points identified around the cartilage/metaphyseal interface that deviated least from an ideal osteotomy plane resulted in more accurate recovery of head geometry. The novel technique may improve clinical outcome. Further investigation is warranted.
We obtained approval from the local research and ethics committee and prospectively evaluated the incidence of Deep vein thrombosis (DVT) in arthroscopic shoulder sub acromial decompression in 72 patients. All patients were assessed clinically for DVT risks as per the established guidelines. Patients with previous history of DVT, those on anticoagulants and those positive for DVT on pre op scans were excluded from the study. All patients had doppler scans on 4 limbs performed by a single consultant radiologist at an average of 4 weeks pre and post operative period. All operations were performed by a single surgeon under GA in beach chair position with routine precautions for DVT, as a day case procedure. Arthroscopy and additional procedures were performed on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. Demographic data, co-morbidities, patient position, ASA risk, nerve blocks, surgery duration, medications, intra operative findings, were documented. No patient received any DVT prophylaxis. All patients were available for followup and clinical and doppler findings were documented at an average 4 week period. 3 patients had bilateral procedures. There were 38 female and 34 male patients with an average age of 54.6 years. 47 were classified as ASA1, 15 as ASA2 and 10 ASA 3. Common co morbidities included hypertension, diabetes, acid peptic disease in 34 patients. 37 patients had additional interscalene nerve blocks for pain relief. The average operating time was 52 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVT's on all doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients.
Introduction
Ulnar nerve entrapment is the second most common nerve entrapment syndrome of the upper extremity. Despite this, only a few studies have assessed the outcome of ulnar nerve decompression. The objectives of the study were to review the pre-operative symptoms, nerve conduction studies, the co-morbidities, operative procedures undertaken and the post-operative outcomes; and investigate and ascertain prognostic factors particularly in cases of persistence of symptoms after the surgery.
Methods
We reviewed the case notes of ulnar nerve decompressions surgery performed over a period of six year period. A structured proforma was created to document the demographics, patient complaints, method of decompression, per-operative findings and symptom status at the last follow up. Outcome grading was recorded as completely relieved, improved, unchanged or worse. Analysis of data was carried out using the SPSS software (Version 16.0; Illinois). The significance level was set at 5%.
Introduction
Tennis and Golfers elbows (TE, GE) are difficult conditions to treat. Ultrasound guided steroid injection (UGSI) is one of the treatment modalities in treating refractory TE and GE. We present our clinical experience and short to mid-term results of patients with TE and GE treated with UGSI.
Methods
Patients with persistent TE and GE treated with UGSI (Marcaine and kenalog) at a tertiary centre between 2007 and 2010 were retrospectively reviewed. Mean follow up was 4 months (Range 2–21 months). Patients were assessed for pain relief, recurrence of symptoms and surgical release.
Distension arthrography of the glenohumeral joint was adopted as a mainstream treatment for adhesive capsulitis before any randomised controlled trials were performed. Interpretation of the effectiveness of this procedure rests on data from cohort studies of which there are few of high quality. Papers reporting on the long-term results have either excluded diabetic patients or failed to report on patient orientated outcomes.
We present a prospective cohort study of 51 patients with adhesive capsulitis of the shoulder who had a distension arthrogram performed by a single radiologist as a primary intervention. We included diabetic patients.
Range of movement (ROM), Oxford shoulder score (OSS) and a visual analogue pain score (VAS) were recorded pre-procedure, at 2 days and 1 month. OSS and VAS were recorded again at a mean of 14 months post procedure (range 8–26 months).
OSS improved from pre-procedure mean of 22.3 by 16.9 points at final follow up in September 2011 (p < 0.001) whilst VAS improved from a mean pre-procedure of 7.1 by −3.5 by September 2011 (p< 0.001). ROM improved with a mean increase of 39.3 degrees in flexion, 55.2 degrees in abduction and 19.5 degrees in external rotation by 1 month (p < 0.001 for all). The outcome in diabetic patients was the same as in non-diabetic patients.
We conclude that distension arthrography is a safe and effective treatment for adhesive capsulitis.
Introduction
Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation.
Objective
The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20mm shortening/displacement.
Background
Absence of rotator cuff allows unbalanced muscle forces of the shoulder to cause vertical migration of the humeral head. The translation of the humerus causes impaction of articular surface against the acromion. The purpose of the study is to assess outcome of Cuff tear arthropathy (CTA) Hemiarthroplasty prosthesis in this group of patients.
Methods
Retrospective review was undertaken in 42 patients who underwent Global CTA Hemiarthroplasty between Jan 2001-Jan 2009. The mean length of follow up was 6 years.
Introduction
The Constant Score (CS) and the Oxford Shoulder Score (OSS) are shoulder scoring systems routinely used in the UK. Patients with Acromio-Clavicular Joint (ACJ) and Sterno-Clavicular Joint (SCJ) injuries and those with clavicle fractures tend to be younger and more active than those with other shoulder pathologies. While the CS takes into account the recreational outcomes for such patients the weighting is very small. We developed the Nottingham Clavicle Score (NCS) specifically for this group of patients.
Methods
We recruited 70 patients into a cohort study in which pre-operative and 6 month post-operative evaluations of outcome were reviewed using the CS, the OSS the Imatani Score (IS) and the EQ-5D scores which were compared with the NCS. Reliability was assessed using Cronbach's alpha. Reproducibility of the NCS was assessed using the test/re-test method. Each of the 10 items of the NCS was evaluated for their sensitivity and contribution to the total score of 100. Validity was examined by correlations between the NCS and the CS, OSS, IS and EQ-5D scores pre-operatively and post-operatively.
Background
Accurate and reproducible radiological assessment of shoulder replacement prostheses over time is important for identifying failure or to provide reassurance. A number of clearly defined radiological parameters have been described to help standardise the radiological assessment of prostheses. To our knowledge, this is the first study conducted to test the reproducibility and reliability of these measurements.
Aim
The aim of this work was to test intraobserver reproducibility and interobserver reliability in the measurement of humeral component orientation (HCO), humeral head offset (HHO), humeral head size (HHS), humeral head height (HHH), and acromiohumeral distance (AHD.)
Aim
Two different techniques to release subscapularis during total shoulder replacement (TSR) have been described (tenotomy and osteotomy) with no consensus as to which is superior. In this study we review the clinical outcomes of a sequential series of patients in whom a TSR for primary osteoarthritis had been performed using either technique at our institution. Subscapularis function was tested using a new graded belly press test, a modification of the traditional belly press test which is described for the first time here.
Methods
All patients who underwent surgery at our institution between January 2002 and January 2010 and met the eligibility criteria, were included for analysis. Subscapularis function was assessed post-operatively using a range of functional assessments including; a graded belly press test, lift off test, and an assessment of each patient's range of movement.
Total Elbow Replacements are indicated for pain and disability in patients with rheumatoid and osteoarthritis of the elbow. The quality of the cementation has been specifically studied and shown to be directly related to the clinical outcome and implant survival.
Aim
The aim of our study is to radiologically assess and grade the cementation around the components following total elbow replacement (GSB 3 or Coonrad Morrey) in two groups of patients.
Materials and methods
Group I underwent total elbow replacement using Heraeus cement gun with medium palacos viscosity cement and group 2 using Zimmer cement gun with simplex medium viscosity cement. Average age in Group 1 was 72.3 (range 67–88 yrs) and group 2 was 69 years (range 52–87 yrs)
3 Coonrad Morrey and 13 GSB 3 total elbow replacement were used in Group 1 and 2 Coonrad Morrey and 14 GSB 3 in group 2. The primary indication for surgery was osteoarthritis, rheumatoid arthritis, post traumatic arthritis and seronegative arthritis in both groups. The cementation was assessed radiologically using three grading system (Morrey, Gerber & Bristol).
Regional nerve block for upper limb surgery is an established procedure. Our study was undertaken to look at the patient experience of this. We prospectively studied 59 consecutive patients undergoing shoulder arthroscopic surgery under regional anaesthesia in our department. They completed a questionnaire which they brought back at their first follow up appointment. The questionnaire gathered information of their experience of anaesthesia and surgery, adequate postoperative information. We reviewed if intra-operative pain occurred and if the patients would undergo such a procedure again. All surgeons were upper limb specialists.3 out of 59 patients required conversion to general anaesthetic (5%) due to failure of the block. The introduction of the block was mainly painless;with patients giving a mean scoring of 0.59 on the visual analog pain score (VAS, range 0–5). 26 patients (44%) expressed interest and watched their operation. Of those, 7 patients felt anxious after having the proceedings explained.1 patient discontinued to watch due to this. 10 patients experienced intraoperative pain, 2 requiring local anaesthetic, 8 receiving sedation, giving a mean score of 3.2 on the VAS. 81.4% of patients would have surgery with regional anaesthetic again, 85% would recommend to others. 83% of patients received adequate information. Overall satisfaction of the experience was rated out of 10, with a mean score of 8.7 (median 9). Regional blocks are an established technique. Since patients are awake and can watch their surgery, it is important to consider the patients perception of this experience. The majority of viewing patients were reassured by explanations of their pathology. Most patients would undergo another procedure with regional anaesthesia and would recommend it, suggesting that this is an effective and popular choice. The overall experience is positive. This supports our intention of offering regional blocks for all upper limb surgery, facilitating increasing use of day case facilities, reducing inpatient stays
Reverse shoulder arthroplasty (RSA) is increasingly performed recently. The patients seeking internet as a source of information may get misleading and a false sense of expectation. This study aimed at analysing patient information on internet and establish list of available quality websites to safely recommend to the patients.
The study analysed 310 websites from 10 top search engines exploring the quality of patient information using an assessment tool. Search engines used were metasearch (Metacrawlers and Mamma), general search (Google, Altavista, Yahoo, MSN, AOL, Lycos) and health search engines (Medhunt and Excite Health). The study was undertaken by two independent researcher over a four-week period in November 2011. Each Website was evaluated according to RSA-specific content using a point value system with shoulder disease and surgery specific key words on an ordinal scale. Adequacy of the content was analysed in regard with description of diagnosis, procedure, alternate options, postoperative protocol, complications and prognosis.
Excluding the repetitions 104 websites were analysed for accessibility, relevance, authenticity, adequacy of patient information and accountability. The median time since update was 12 months. More than 90% of the websites were found to be of poor quality. Only 25% sites targeted mainly people with shoulder problems. 8% of websites were from non profit organisations. Most of these websites were promoting either their service 80 (76%) or some product 12 (11%). The strength of association between two reviewers was very high (r = 0.899). Intra-rater reliability was significant (r = 0.955) with p level < 0.01. The reading level of most of websites were too high for average consumers.
There is need for government organizations and professional societies to regulate the information provided by Internet. Until long-term data are available, patients should be warned when using the Internet as a source for health care information.
The conflict in Afghanistan has been epitomised by the emergence of the Improvised Explosive Device(IEDs). Improvements in medical treatments have resulted in increasing numbers of casualties surviving with complex lower extremity injuries. To date, there has been no analysis of foot and ankle blast injuries as a result of IEDs. Therefore the aims of this study are to firstly report the pattern of injury and secondly determine which factors were associated with a poor clinical outcome in order to focus future research.
Using a prospective trauma registry, UK Service Personnel who sustained lower leg injuries following an under-vehicle explosion between Jan 2006 and Dec 2008 were identified. Patient demographics, injury severity, the nature of lower limb injury and clinical management was recorded. Clinical endpoints were determined by (i)need for amputation and (ii)need for ongoing clinical output at mean 33.0 months follow-up.
63 UK Service Personnel (89 injured limbs) were identified with lower leg injuries from explosion. 50% of casualties sustained multi-segmental injuries to the foot and ankle complex. 26(29%) limbs required amputation, with six amputated for chronic pain 18 months following injury. Regression analysis revealed that hindfoot injuries, open fractures and vascular injuries were independent predictors of amputation.
Of the 69 limbs initially salvaged, the overall infection rate was 42%, osteomyelitis 11.6% and non-union rates was 21.7%. Symptomatic traumatic osteoarthritis was noted in 33.3% salvaged limbs. At final follow-up, 66(74%) of injured limbs had persisting symptoms related to their injury, with only 9(14%) fit to return to their pre-injury duties.
This study demonstrates that foot and ankle injuries from IEDs are frequently associated with a high amputation rate and poor clinical outcome. Although, not life-threatening, they remain a source of long-term morbidity in an active population. Primary prevention of these injuries remain key in reducing the injury burden.
Introduction
Degenerative, inflammatory, and posttraumatic arthritis of the ankle are the primary indications for total ankle arthroplasty
Ankle arthrodesis has long been the “gold standard” for the surgical treatment
Total Ankle Arthroplasty. implant survivorship has been reported to range from 70% to 98% at three to six years
The combination of younger age and hindfoot arthrodesis or osteoarthritis may lead to a relative increase in failure rates after TAA
Intraoperative complication include malaligment, fracture and tendon Postoperative complications include syndesmotic nonunion, wound problems, infections and component instability and lysis
After TAA few difficulties mainly due to poor Talar and Tibial bone stock. It is difficult to stabilize the fusion and usually there is shortening after removal of the implant. Also there is a need for massive bone graft-allograft or autograft.
In cases when there is significant bone loss there is a need for stable reconstruction and stabilization of the hindfoot. Bone grafting with structural bone graft may collapse and it has to be stabilized with screws or nail.
Methods
We developed technique which included distraction of the fusion area and inserting a Titanium cylindrical spinal cage filled with bone graft. Than guide wire was inserted in through the cage under fluoroscopy and a compression screw was introduced causing compression of the fusion area against the cage gaining stabilization of the fusion area.
We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.
Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.
30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p< 0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.
We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.
Background
Morton's neuroma is the enlargement of an interdigital nerve most commonly located between the third and fourth metatarsals. It is susceptible to entrapment and therefore is a common cause of disabling foot pain. Greek foot is a normal variant where the first metatarsal is shorter than the second metatarsal. To our knowledge there is currently no reported association between Greek foot and Morton's neuroma in the literature.
Material and methods
Retrospective study of 184 patients. Two separate cohorts were recruited.
Cohort (A): 100 randomly selected patients with no foot pain.
Cohort (B): 84 patients with foot pain and Mortons's neuroma.
The foot shape was determined by using a self-assessment tool and plain radiographs.
Statistical analyses were performed using the Chi square test on the association between Greek foot and Morton's neuroma. A value of P = < 0.05 was considered statistically significant.
Background
Morton's neuroma (MN) is a common cause of metatarsalgia. Whilst there are a many treatment modalities available, studies looking at the long term effectiveness of most forms of treatment are scarce. The injection of MN with alcohol has gained popularity over the past ten years with widespread media coverage. Many surgeons have anecdotally questioned the long-term effectiveness. Sixty patients underwent alcohol injection for the treatment of MN by Radiologists at our institution. These results were originally published showing 92% (92/100) success rates and only 3% (3/100) requiring surgical excision at a mean follow up of 10.5 mths. The authors concluded that alcohol injection was comparable to results for surgical excision.
Methods
We were able to review forty five of this original cohort with an average follow up of 61 (range, 33 to 73) months. The modified Johnson score and visual analogue scales were used to assess the patients and compare these results to five year results available in the literature for surgical management.
Background
As hallux valgus (HV) worsens clinical and radiological signs of arthritis develop in metatarsophalangeal joint due to incongruity of joint surfaces. The purpose of this prospective study was to determine if intraoperative mapping of articular erosion of the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity
Materials and methods
We analysed 50 patients prospectively who underwent surgery between Jan 2009-Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS score were recorded. Intraoperative evaluation and quantification of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading.
Introduction
Despite the multiple patho-aetiological basis of Hallux valgus (HV), corrective osteotomy is a common and globally performed orthopaedic procedure. Over-correction of the inter-metatarsal angle (IMA), however, is not without consequence. Through increased joint pressures, over-correction may predispose to joint degeneration. Hypothesizing that over-correction leads to an increase in intra-articular joint pressures, we constructed a mechanical simulation of the 1st metatarsal-phalangeal joint.
Methods
The vector forces of Flexor Hallucis Longus, Extensor Hallucis Longus, Extensor Hallucis Brevis and Adductor Hallucis, acting upon the 1st proximal phalanx were simulated with tensioned weighted rope. A Foley catheter balloon inflated to 1.5ml, simulated intra-articular distractive vector forces. The joint was freely mobile.
At 5° IMA intervals from 10° valgus to 15° varus, intrarticular pressures were recorded using a contact pressure (Graseby™,
Osteochondral lesions (OCL) of the talus occur in 38% of the patients with supination external rotation type IV ankle fractures and 6 % of ankle sprains. Osteoarthritis is reported subsequently in 8–48% of the ankles. Several marrow stimulation methods have been used to treat the symptomatic lesion, including arthroscopic debridement and micro fracture. Encouraging midterm results have been reported, but longterm outcome is unknown in relation to more invasive treatments such as transfer of autologous osteoarticular tissue from the knee or talus (OATS), autologous chondrocyte implantation (ACI), frozen and fresh allograft transplantation.
Aim
The aim of our study was to review our long term results of arthroscopic treatment of osteochondral lesions of the talus.
Materials and methods
65 patients underwent arthroscopic treatment of the OCL between 1993 and 2000. There were 46(71%) men and 19(29%) women. The mean age at surgery was 34.2 years. The right side was affected in 43 patients and the left side in 22 patients.
Background
Patellar instability is a complex, multi-factorial disorder. Radiological assessment is regarded as an important part of the management of this population. The purpose of this study was to determine the intra- and inter-rater reliability of common radiological measurements used to evaluate patellar instability.
Methods
One hundred and fifty x-rays from 51 individuals were reviewed by five reviewers: two orthopaedic trainees, a radiological trainee, a consultant radiologist and an orthopaedic physiotherapist. Radiological measurements assessed included patellar shape, sulcus angle, congruence angle, lateral patellofemoral angle (LPA), lateral patellar displacement (LPD), lateral displacement measurement (LDM), boss height, and patellar height ratios (Caton-Deschamps, Blackburne-Peel, Insall-Salvati). All assessors were provided with a summary document outlining the method of assessing each measurement. Bland-Altman analyses were adopted to assess intra- and inter-rater reliability.
Background
The knee is the commonest joint to be affected by osteoarthritis, with the medial compartment commonly affected. Knee osteoarthritis is commonly bilateral, yet symptoms may initially present unilaterally. Higher knee adduction moment has been associated with the development and progression of medial compartment knee osteoarthritis.
Objectives
To assess the effect of lateral wedge insoles on the asymptomatic knee of patients with unilateral symptoms of medial compartment knee osteoarthritis.
Indications for Unicompartmental Knee Arthroplasty (UKA) vary between units. Some authors have suggested, and many surgeons believe, that medial UKA should only be performed in patients who localise their pain to the medial joint line. This is despite research showing a poor correlation between patient-reported location of pain and radiological or operative findings in osteoarthritis. The aim of this study is to determine the effect of patient-reported pre-operative pain location and functional outcome of UKA at one and five years.
Pre-operative pain location data were collected for 406 knees (380 patients) undergoing Oxford medial UKA. Oxford Knee Score, American Knee Society Scores and Tegner activity scale were recorded preoperatively and at follow-up. 272/406 (67%) had pure medial pain, 25/406 (6%) had pure anterior knee pain and 109/406 (27%) had mixed or generalised pain. None had pure lateral pain. The primary outcome interval is one year; 132/406 patients had attained five years by the time of analysis and their five year data is presented.
At one and five years, each group had improved significantly by each measure (mean δOKS 15.6 (SD 8.9) at year one, 16.3 (9.3) at year five). There was no difference between the groups, nor between patients with and without anterior knee pain or isolated medial pain.
We have found no correlation between preoperative pain location and outcome. We conclude that localised medial pain should not be a prerequisite to UKA and that it may be performed in patients with generalised or anterior knee pain.
Unicompartmental Knee Replacement (UKR) is associated with fewer complications, faster recovery and better function than Total Knee Replacement (TKR). However, joint registries demonstrate a higher revision rate in UKR, limiting its use. Currently most UKRs are cemented and performed using a minimally invasive technique. In joint registries, common reasons for revision include aseptic loosening and pain. These problems could potentially be addressed by using cementless implants, which may provide more reliable fixation.
The objectives of this study were to compare the quality of fixation (determined by the incidence and appearance of radiolucencies), and clinical outcomes of cemented and cementless UKR at five years.
A randomised controlled trial was established with 63 knees (62 patients) randomised to either cemented (32 patients) or cementless UKR (30 patients). Fixation was assessed with fluoroscopic radiographs aligned to the bone-implant interface at one and five years. Outcome scores were collected pre-operatively and at one, two and five years, including Oxford Knee Score (OKS), American Knee Society Score, objective and functional (AKSS-O/F) and Tegner Activity Scale (TAS), expressed as absolute scores and 0–5 year change (δ) scores.
Four patients died during the study period. There were no revisions. Mean operative time was 11 minutes shorter in the cementless group (p=0.029). At five years, there was no significant difference in any outcome measure except AKSS-F and δAKSS-F which were significantly better in the cementless group (both p=0.003). There were no femoral radiolucencies in either group. There were significantly more tibial radiolucencies in the cemented group (20/30 vs 2/27, p< 0.001). There were nine complete radiolucencies in the cemented group and none in the cementless group (p< 0.001).
Cementless fixation provides improved fixation at five years compared to cemented fixation in UKR, maintaining equivalent or superior clinical outcomes with a shorter operative time and no increase in complications.
Implant alignment in knee arthroplasty has been identified as critical factor for a successful outcome. Human error during the registration process for imageless computer navigation knee arthroplasty directly affects component alignment. This cadaveric study aims to define the error in the registration of the landmarks and the resulting error in component alignment.
Five fresh frozen cadaveric limbs including the hemipelvis were used for the study. Five surgeons performed the registration process via a medial parapatellar approach five times. In order to identify the gold standard point, the soft tissues were stripped and the registration was repeated by the senior author. Errors are presented as mm or degrees from the gold standard registration.
The error range in the registration of the femoral centre in the coronal plane was 6.5mm laterally to 5.0mm medially (mean: −0.1, SD: 2.7). This resulted in a mechanical axis error of 5.2 degrees valgus to 2.9 degrees varus (mean: 0.1, SD: 1.1). In the sagittal plane this error was between −1.8 degrees (extension) and 2.7 degrees (flexion). The error in the calculation of the tibial mechanical axis ranged from −1.0 (valgus) to 2.3 (varus) degrees in the coronal plane and −3.2 degrees of extension to 1.3 degrees of flexion. Finally the error in calculating the transepicondylar axis was −11.2 to 6.3 degrees of internal rotation (mean: −3.2, SD: 3.9).
The error in the registration process of the anatomical landmarks can result in significant malalignment of the components. The error range for the mechanical axis of the femur alone can exceed the 3 degree margin that has been previously been associated with implant longevity. The technique during the registration process is of paramount importance for image free computer navigation. Future research should be directed towards simplifying this process and minimizing the effect of human error.
Introduction
High flexion knee arthroplasties have been designed to allow up to 155 degrees flexion and enable high flexion activities such as kneeling and squatting. To date randomised controlled trials have shown no difference in range of movement (ROM) between high flexion and standard designs.
Objectives
The aim of this study was to determine if there is a difference in functional outcome and ROM between the standard and high flexion design of the PFC Sigma TKA system.
This RCT compared electromagnetic (EM) navigated and conventional total knee arthroplasty (TKA) in terms of clinical and functional outcomes. 200 patients (navigated=102, conventional=98) were recruited. Oxford Knee Scores (OKS) and the American Knee Society Score (AKSS) were recorded pre operation, 3 and 12 months after surgery. Post operative (coronal, sagittal and rotational) alignment was analysed from 3D CT scans taken 3 months after surgery. An objective functional assessment was completed using electrogoniometry on a sub group (navigated=60, conventional=57) at 12 months post surgery.
The EM group showed statistically significantly improved OKS (p=0.04) and AKSS (p=0.03) scores at 3 months post operation. However at 12 months post surgery there was no difference between the two groups. At the 1 year follow up it was reported that 9% of the navigated compared to 14% of the conventional group were dissatisfied with their surgical outcome.
The mechanical axis alignment of 90% of the navigated group was within 3 degrees of neutral compared to 84% of the conventional group. Although all alignment parameters except for tibial rotation was improved in the navigated group they did not reach significance apart from femoral slope alignment (p=0.01).
There was no statistically difference between the surgical groups in terms of the maximum, minimum and excursion knee joint angles during 12 functional activities. Only the knee kinematic function cycles for level walking resulted in statistically significant higher knee joint angles during 55–70% of the gait cycle in the navigated group.
Knee alignment was better restored following EM navigated TKA relative to conventional TKA, but the difference was not significant. The EM group showed greater clinical and functional improvements at early follow-up; however this difference was not sustained at 12 months. The EM group reported minimal gait improvements. Proving cost-effectiveness for navigation systems in TKA remains a challenge.
Background
The combination of patient-specific “just-in-time” implant manufacture and robotic technology has not yet been reported. The robot enables accurate placement of anatomically-matched implants. It should be cost-effective, simplify the procedure, and reduce instrumentation. The aims of this study were to determine whether the procedure was safe, radiographically accurate, and comparable in time and cost to conventional arthroplasty.
Methods
All patients over 3 months post-op were included. Component position, orientation and size were determined from CT scans by the surgeon prior to manufacture. The implants were inserted using the Sculptor robot, which is supplied free of cost (Savile Row, Stanmore Implants, UK). Following registration, bone was milled away using a high-speed burr under haptic control of the robot. The implants were cemented and a mobile bearing inserted. Patients were followed up clinically and radiographically. Oxford and EQ-5D scores were obtained. Costs of the implant, instruments, and consumables were calculated and compared to published data for conventional UKA and TKA.
Introduction
Many prosthetic design changes have been introduced in attempt to improve outcomes following TKA; however there is no consensus as to whether these changes confer benefits to patients. This study aimed to assess whether patients treated with a modern implant design had an enhanced patient outcome compared to a traditional model in a double blind randomised controlled trial.
Methods
212 consecutive patients were prospectively randomised to receive either a modern (Triathlon) or a traditional (Kinemax) TKA (both Stryker Orthopaedics). 6 surgeons at a single unit performed all procedures in a standardised manner. A single researcher, blinded to implant allocation, performed all assessments. Patients were assessed pre-operatively, and at 6, 26, 52 weeks post-surgery with the Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, goniometry, timed functional assessment, lower limb power (Leg Extensor Power Rig) and pain numerical rating scales (NRS). Change in scores and between group differences were assessed with Two-Way Repeated Measures ANOVAs.
Background
The Enhanced Recovery Programme (ERP) is an evidence based initiative aimed at speeding up patient recovery after major surgery and improving their outcomes. The Royal National Orthopaedic Hospital, Stanmore (RNOH) is a specialist orthopaedic and implemented an ERP for primary knee arthroplasties from October 2010.
Aims
To analyse the initial results of patients participating in our ERP for primary knee arthroplasty to identify what factors predict their Length of Stay (LoS) and establish where changes can be made to improve outcomes further.
Purpose of the study
The aim of this study was to prospectively study the safety, functional outcomes and complications of all patients undergoing bilateral single-stage sequential (BSSS) unicompartmental knee arthroplasty (UKA) in our unit.
Methods and results
394 cemented UKAs were performed in this unit between 2006–2010. A retrospective review identified 38 patients (76 knees) who underwent BSSS UKA, performed by a single surgeon. Patient demographics were recorded as well as pre and post-operative Oxford knee scores, tourniquet times, time to mobilisation, length of in-patient stay and any complications.
There were 22 women and 16 men with a mean age of 64. The mean duration of follow-up was 30 months. The mean total tourniquet time was 83 minutes. The mean time to mobilisation was 18 hours and the average length of stay was 3.5 days. This compares favourably with an institutional average length of stay of two days for a single UKA.
There was a significant improvement in the mean pre- to post-operative Oxford Knee Score (from 14 to 34, p< 0.0001).
One patient required operative fixation of a tibial plateau fracture after sustaining a mechanical fall two months following surgery. There were no other major complications, including thrombo-embolic events or deep infections. Two patients required excision of a superficial suture granuloma.
Critics of Unicompartmental knee replacement (UKR) highlight poor survivorship in national joint registries and argue that revision to Total Knee Replacement (TKR) is technically difficult with inferior function and survivorship compared to primary TKR.
We prospectively reviewed outcomes of UKRs in our institution undergoing early revision to a TKR, comparing conventional revisions to those performed using computer navigation. 20 cases were identified, 7 conventional and 13 navigated. 13 were male and 7 female, mean age at primary UKR was 63.6 years (range: 47–81).
Mean follow up time after revision was 5.2 years (2–9.5). Mean surgical time was 152 mins in conventional revisions and 163 mins for navigated. 43% of conventional cases required revision stems or augments, compared to 15% of conventional cases. Mean Oxford Knee Scores for revised knees were 32.8 in the conventional group and 34.64 in the navigated group, compared to 30.02 in the national joint registry. This compares to a mean Oxford score of 37.16 for primary TKRs in the registry. One of the conventional revisions required a further revision of the tibial component for loosening. This equates to a 95% suvivorship at mean 5 year follow up, or 1.10 revisions per 100 component years. Joint registry data had 1.97 revisions per 100 component years for UKR to TKR revisions, and 0.48 for primary TKRs.
Our results are significantly improved compared to other published series of UKR revisions to TKRs. Only one other series has reported outcomes of these revisions using navigation. Despite small numbers, our results suggest that navigation makes revisions of UKRs more straightforward with similar surgical times. Fewer revision components were required with navigation and functional scores were marginally improved.
Background
Current analysis of unicondylar knee replacements (UKR) by national registries is based on the pooled results of medial and lateral implants. Using data from the National Joint Registry for England and Wales (NJR) we aimed to determine the proportion of lateral UKR implanted, their survival and reason for failure in comparison to medial UKR.
Methods
By combining information on the side of operation with component details held on the NJR we were able to determine implant laterality (medial vs. lateral) for 32,847 of the 35,624 (92%) UKR registered before December 2010. Kaplan Meier plots, Life tables and Cox' proportion hazards were used to compare the risk of failure for lateral and medial UKRs after adjustment for patient and implant covariates.
Introduction
The optimal treatment for isolated patello-femoral arthritis is unclear. Patello-femoral arthroplasty (PFA) may offer superior knee function in isolated patello-femoral osteoarthritis compare to TKA. The literature is controversial for patient outcomes in PFA. Some reports showed improved outcomes while others were disappointing. We assessed our outcomes to try to identify causes for poor outcomes.
Methods
The Trent Arthroplasty was established in 1990 to collect prospective data on knee arthroplasty surgery. Data is entered by surgeons at the time of surgery, with patient consent. PFA constitute less than 1% of the arthroplasties performed in this region. Patients were sent self-administered outcome forms 1 year post-op. Re-operation and revision procedures were reported. 334 PFA have been registered from 17 hospitals. 79% were female patients with 43% of the patients aged 55 years or less, suggesting dysplasia as the cause of their osteoarthritis. Age range 28–94 yrs (SD 11.8 yrs). The implants were Stryker Avon 236, Corin Leicester 47, Link Lubinus 24, Smith & Nephew Journey 10, DePuy LCS 7, Wright FPV 2, other 8.
Introduction
Pneumatic tourniquets (PTs) are commonly used in local anaesthetic cases in the upper limb to provide a bloodless operating field. They give excellent efficacy however their limitations have prompted the introduction of a new single-use sterile silicone ring tourniquet (SRT). The evidence of use of the SRT over the standard PT is limited.
Aim
To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb.
Background
The current treatment options available for Trapezio-metacarpal arthritis are injection, splint and ultimately surgery. The injections are predominantly done by General practitioners and no data is available to specialist.
Aim
To investigate accuracy of injection and efficacy of injection in terms of short and long term pain relief.
Background
Steroid injections can be used safely to treat trigger fingers. We aimed to determine the accuracy of referring General Practitioner (GP) diagnoses of trigger finger made to an upper limb surgeon. We also aimed to determine the efficacy of a serial two steroid injection then surgery technique in the management of trigger fingers.
Methods
Data was collected prospectively from a “one-stop” trigger finger clinic (based in a district general hospital). 200 trigger fingers identified from September 2005 to November 2008, giving a minimum 1 year follow-up. Data was analysed for correct referring diagnosis, resolution/recurrence rate following injection and the effect of age, injector grade, diabetes on the rate of recurrence.
Aim
The purpose of this study was to develop and test the utility of a hybrid barbed-suture in the core repair of digital flexor tendon injuries. Despite offering advantages over traditional suture methods, concerns over the cost, strength to failure and biocompatibility of barbed sutures have hindered their development. Moreover the recent designs have been very complex. We have attempted to develop and test a simple barbed suture, to assess it's viability in flexor tendon repair and in particular to establish a baseline for the efficacy and modes of failure barbed sutures, in order to help provide a basis for future research.
Method
The barbed suture device was constructed by inserting 3 steel barbs into the weaved construct of a braided polyester suture. The barbed sutures were inserted into 28 porcine lateral extensor tendons yielding a single sided core repair. Tensile testing of the repair was undertaken using a tabletop load frame with the distal end of the tendon fixed in a cryo clamp.
Linear load testing to failure was undertaken. Maximum load, repair excursion and repair stiffness were recorded.
The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible.
We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision.
With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used.
An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe.
A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear.
Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue.
It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis
Introduction
We reports the accuracy of direct Magnetic Resonance Arthrography (MRA) in detecting Triangular Fibrocartilage Complex (TFCC), Scapho-Lunate Ligament (SLL) and Luno-Triquetral Ligament (LTL) tears using wrist arthroscopy as the gold standard.
Methods
We reviewed the records of all patients who underwent direct wrist MRA and subsequent arthroscopy over a 4-year period between June 2007 and March 2011. Demographic details, MRA findings, arthroscopy findings and the time interval between MRA and arthroscopy were recorded. The scans were performed using a 1.5T scanner and a high resolution wrist coil. All scans were reported by a musculoskeletal radiologist. Sensitivity, specificity, positive and negative predictive values (PPV & NPV) were calculated.
The aim of this study was to describe the measurements of range of circumduction in normal volunteers and develop summaries of the data, develop the rate and rhythm of circumduction of the wrist with the use of Biometric electrogoniometer, reproducibility, reliability and accuracy of these measures of circumduction.
Forty healthy subjects with a mean age of 42.6 years were assessed with flexible biaxial electrogoniometry in standard 90° pronated position of wrist for kinematic assessment of movement in orthogonal planes. Functional range of flexion-extension, ulnar-radial deviation and circumduction was measured and analysis of the digital output produced a visual display of the results as Lissajous's figures. This also allowed measurement of the total range of circumduction as two-dimensional area under the curve measurement. The rate and rhythm of movements were mathematically calculated and displayed over the two dimensional circumduction curves. The average arc of uniplanar flexion and extension is greater than the flexion and extension component of the circumduction curve but mean uniplanar radial ulnar deviation arc is similar to the radial-ulnar deviation component of the circumduction curve. The area of circumduction and circumference of the circumduction curve was used to measure the total range of circumduction. The four quadrants for the velocity of circumduction showed that the rate was faster in the deviation components as compared to flexion and extension. Quadrant analysis showed the changes in the rhythm was less in the deviation components compared to flexion and extension. The accuracy for measuring uniplanar movements showed a standard deviation of 6°. The accuracy for measuring circumduction showed a standard deviation of 347 °° (7%). Accuracy for measuring velocity of circumduction showed a standard deviation of 17°/s. This technique was found to be accurate and reliable in measuring the rate, range and rhythm of wrist circumduction.
Both intrinsic and extrinsic hand muscles contribute to finger flexion; however there are different ways in which individuals can flex their fingers. Due to different muscle insertions, it is possible to distinguish the mechanical effect of intrinsic muscles from extrinsic muscles. The aim of this observational study was to investigate the degree to which individuals in the population rely on either their intrinsic or extrinsic hand muscles. A high frequency camera was used to record the hands of 31 healthy participants, aged between 18 to 40, while they made a fist repeatedly. The hands were placed on a horizontal plane and the video was taken from the ulnar side, aligned horizontally with the hand. The maximum vertical distance between the fingertip and the distal palmer creases (XY) was recorded using WIN analyze 3D software. Three examiners independently analysed the videos and classified them into intrinsic dominant, extrinsic dominant or a mixed pattern. A t-test was performed on the XY values for the three different categories. The XY height difference between the intrinsic and extrinsic groups were statistically significant (P=0.001). The XY of mixed and intrinsic was also statistically significant (p=0.012) but not for mixed and extrinsic (p=0.46). Assessment of time when movement starts at each individual joint showed significant difference with intrinsic predominant moving the MCPJ before IPJ and extrinsic dominant individual moving their IPJ before MCPJ. This study shows that there is a difference in hand muscle dominance between individuals. More importantly it shows that there are individuals who rely on their intrinsic hand muscles more than their extrinsic muscles.
Background
Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods.
Methods
Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes.
Introduction/Aim
Flexor tendon injuries of the hand are common with an incidence of over 3000 per annum in the UK. These injuries can affect hand function significantly. Early treatment with optimal repair is crucial to prevent disability.
This study aimed at investigating the re-rupture rate following primary flexor tendon repair at our institution and to identify potential risk factors for re-rupture.
Methods
100 flexor tendons' injuries that underwent primary repair over a one-year period were reviewed retrospectively.
Data was collected on age, gender, occupation, co morbidities, injured fingers, hand dominance, smoking status, zone of injury, time to surgery, surgeon grade, type of repair and suture, and antibiotic use on included patients. Causes of re-rupture were examined. We compared primary tendon repairs that had a re-rupture to those that did not re-rupture. Univariate and multivariate analysis was undertaken to identify the most significant risk factors for re-rupture.
Historically human and animal bites to the hand have resulted in significant morbidity in relation to the high risk of contamination and subsequent infection. Our study aimed to assess the outcomes following such injuries in terms of infection requiring further intervention through specialist referral to the hand surgery team at our hospital.
124 consecutive patients attending the A&E department over a three month period in 2011 were included in this retrospective study which provided 126 separate cases due to bilateral injuries (110 animal: 16 human). Data was obtained from the electronic patient management system. The demographics of each patient were recorded followed by type of bite sustained including number and size of lacerations.
79% of patients presented within 24 hours and the majority before 6 hours from injury. The majority of the forearm bites were documented as superficial abrasions and none of these went on to develop problems with infection, so the study concentrated on bite injuries to the hand of which there were 99 cases. Most hand injuries were a single puncture or laceration (64%) but in 9 cases there were greater than 3 separate wounds.
5 cases were directly referred to the Hand surgery team with 4 requiring admission and of these 3 required washout and debdridement in theatres. The remaining 94 cases were managed solely by A&E. Of these 94 cases 87 pts received Abx and 78 pts had a lavage. Overall 68% received both Abx and lavage. Subsequent to discharge from A&E only 3 developed problems with infection later (2 requiring specialist input) they were all dog bites and in keeping with the ‘typical’ bite pattern seen in other pts.
The study concluded that bites not involving joint, tendon or bone have only a small chance of causing infection provided good initial treatment.
Introduction
The management of chronic wrist pain is a challenging clinical problem. Wrist denervation aims to achieve an improvement in pain through selective neurotomy, irrespective of cause. Numerous authors have reported their experience and demonstrated a range of clinical outcomes. No studies to date have reliably identified patient populations in whom denervation surgery is most likely to succeed. We aimed to establish and investigate a new approach, combining local anaesthetic injections with a uniquely tailored functional assessment by a hand therapist, to act as a tool to identify individuals in whom surgical denervation is more likely to yield benefit.
Methods
We conducted a retrospective review of 17 patients who had undergone wrist denervation procedures following our method of pre-operative assessment and selection. Patients in whom denervation was combined with other diagnostic or therapeutic surgical procedures were excluded. Each patient underwent an initial assessment by a hand therapist in which pain and functional scores were recorded using the Patient Rated Wrist Evaluation (PRWE). Further unique assessments of function were made, tailored to the functional goals and requirements of each patient. Pain scores were measured for each task. Local anaesthetic injections were then administered around the nerves considered for neurotomy and the assessments were repeated. Patients who demonstrated clear improvements in pain and function underwent surgery. Post-operative assessments of pain and function were repeated.
Background
Collagenase represents a novel non-surgical treatment for Dupuytrens disease. Xiapex (Injectable collagenase, Pfizer pharmaceuticals) was recently approved by the MHRA for clinical use. The main objective of this study was to assess the proportion of patients with Dupuytrens disease that are suitable for treatment with collagenase and the financial implications of its introduction.
Methods
All new patients diagnosed with Dupuytrens disease over a three month period (Sept-Nov) were enrolled into study. Patients were assessed in clinic by a senior surgeon. All patients with a palpable Dupuytrens cord without significant skin tethering were offered collagenase. Comparisons were made with the corresponding quarter in the previous 2 years. Management trends were compared over the three years (2009–11) to identify the impact of collagenase. Cost effectiveness analysis was based on a comparison with costs incurred by a fasiectomy, the most common intervention in the management of Dupuytrens disease.
Aim
To review the outcome of deep prosthetic infection in patients following hip hemiarthroplasty surgery.
Method
A retrospective case-note analysis was performed of deep infection coded hip hemiarthroplasty patients between 2004–2009. Patients were selected when there was proven microbiology from deep wound swabs or tissue specimens.
A clinical evaluation of the effect of MRI scan to bring about a change in surgical management of elderly patients who present with hip fracture with no history of trauma or a suspicious looking lesion on x-rays. Many of these patients present with or without history of previous malignancy or bone disorder.
We evaluated that if the delay in treatment within 36 hours as per national guide lines is justified to benefit patients.
Methods
A clinical review of six hundred hip fracture patients where one hundred and four patients who had MRI scan of hip for fracture with either no history of trauma or a fracture with suspected pathological features with or without history of malignancy or bone disorder.
The final outcome of hundred patients who had MRI scans 32 male and 68 female with median age of 65 years. Four patients were excluded as were unable to tolerate the MRI scan.
Statistical analysis software SAS/STAT® was used to conduct data collation and analyses.
A further radiological analysis of MRI scans with positive lesion to the plain X-rays to correlate the finding of a lesion on femoral side on MRI scan to a lesion on acetabular side.
Results
Out of hundred patients who had MRI scan for a suspected metastatic or pathological lesion only 12 showed a metastatic lesion despite the fact 31 had previous history of malignancy, CI 4.03; 101.91, P < 0.0003. No primary lesion detected in any patient.
We also found if the acetabular side was not seen to be involved on pain x-ray, MRI scan did not detect any acetabular lesion, contingency coefficient 0.5632, P < .0001.
Purpose of study
This RCT is to determine whether or not there is a clinical benefit from inserting a dynamic stabilising implant such as the Wallis ligament on the functional recovery of patients who have undergone lumbar decompression surgery. This Interspinous implant was developed as an anatomically conserving procedure without recourse to lumbar spinal fusion surgery. The biomechanical studies have shown that unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels. The aim of this study was to identify a patential Wallis affect.
Methods
Ethicallly approved. Patients were randomized into 2 groups, decompression alone or decompression with wallis interspinous ligament stabilisation. Patients were assessed pre operatively and post operatively every 6 months by VAS pain score and Oswestry Disability Index.
Hip dysplasia represents a wide spectrum of disease, and interest in the treatment of the disorder has increased with the development of newer surgical techniques and a greater understanding of young adult hip disorders. National hospital episode statistics (HES) were studied from 1999 to 2010. This data remains the current best source of information on surgical procedures outside of dedicated registries. Age stratified data was analysed for 7 separately coded operations for the treatment of hip dysplasia. Overall in the paediatric population there were 898 procedures in 2010 compared to 793 procedures in 2000, but with no detectable trend across that period. Equally, there were no great fluctuations in the small numbers of arthroplasty procedures recorded in either the paediatric or adult populations. There was, however, a clear increase in surgery being performed in adult patients. 210 primary pelvic osteotomies were performed in 2010, compared with only 77 in 2000, with a noticeable increase from 2005 onwards. A similar trend in other extra-articular procedures is seen, rising from 2 to 55 per year over the period studied. Overall, the level of surgical intervention has steadily risen from 104 procedures in 2000 to 422 in 2010, representing a fourfold rise in the number of operations being performed for hip dysplasia in the adult population over an 11 year period. The reasons for this are unclear. It may reflect improvements in the ability to diagnose and intervene earlier to prevent disease progression, but further research is also needed to better define the aetiology underlying these cases that present to the hip surgeon later in life.
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
Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011.
Methods
Using procedure and diagnosis codes, we interrogated the Hospital Episode Statistics (HES) Database for all hip procedures performed between 2001 and 2011, excluding those relating to arthroplasty, tumour or infection. Osteotomy procedures were also excluded.
Aims
To determine whether there is any benefit using a minimally invasive trans-sartorial approach as described by Professor Søballe compared to the ilio-femoral for peri-acetabular osteotomy
Methods
30 consecutive patients were operated on by a single surgeon. The first 15 underwent an ilio-femoral (I-F) approach whilst the following 15 had a trans-sartorial (T-S) approach. Fixation was achieved with 3 or 4 screws. All other aspects of surgery and rehabilitation were the same. Data was collected prospectively and included operation time, intra-operative blood loss and length of stay. Acetabular correction was measured using the sourcil and centre edge angle (CEA) on pre and post-operative radiographs.
Objective
To evaluate the volume of cases, causes of failure, complications in patients with a failed Thompson hemiarthroplasty.
Methods
A retrospective review was undertaken between 2005–11, of all Thompson implant revised in the trust. Patients were identified by clinical coding. All case notes were reviewed.
Data collection included patients demographic, time to revision, reason for revision, type of revision implant, surgical time and technique, transfusion, complications, HDU stay, mobility pre and post revision,
Introduction
Early identification and conservative management of paediatric Monteggia fractures has been shown to correlate with good results. Nevertheless, several authors advocate more aggressive management with open reduction and internal fixation (ORIF) for unstable fractures. We herein present the experience of a tertiary paediatric hospital in the management of Monteggia fractures.
Methods
41 patients with Monteggia fractures (26 male and 15 female) were admitted and treated over a period of 20 years (1989 to 2009). The age of the patients ranged between 3 and 14 years (mean 7.5 years). Based on the Bado Classification, 29 fractures were type I, 3 were type II, 8 type III and 1 fracture was classified as type IV. Out of the 41 patients, 32 were managed with manipulation under anaesthesia (MUA) and above elbow plaster, whereas 9 underwent open reduction and internal fixation (ORIF) of the ulna.
Aims
Compartment syndrome (CS) is a well-recognised, serious complication of long bone fractures. The association between CS and tibial shaft fractures is well documented in adult patients and in children with open or high velocity trauma. There is, however, little literature on the risk of developing CS in children with closed tibial fractures. In a number of units these children are routinely admitted for elevation and monitoring for CS.
We audited our experience of managing paediatric tibial fractures to ascertain whether it may be safe to discharge a sub-group of these children.
Methods
We audited all children up to the age of 12 years admitted to our hospital over a 5 year period. We reviewed radiographs and clinical notes to determine fracture pattern, modality of treatment, and complications.
Purpose
To analyse the effectiveness of using outpatient management of paediatric bone and joint infections with parenteral antibiotic therapy in terms of its efficacy, safety and cost-effectiveness compared to prolonged inpatient treatment.
Method
Paediatric cases of septic arthritis or osteomyelitis were identified over a seven year (2004–2011) period in a regional teaching hospital. This included patients either treated as long-term inpatients or given outpatient parenteral antibiotic therapy. The outcome measures recorded included: whether treatment was successful, complications, and length of hospital stay. A cost analysis was also calculated.
Introduction
Patients who are symptomatic with concurrent acetabular dysplasia and proximal femoral deformity may have Perthes disease. Osteotomies to correct both the acetabular and proximal femur deformities may optimise biomechanics and improve pain and function. In this study, we assessed the long-term results for such a combined procedure.
Methods
We included patients who underwent concurrent pelvic and proximal femoral osteotomies by the senior surgeon (JNOH) with a minimum follow-up of 5 years. A modified triple pelvic interlocking osteotomy was performed to correct acetabular inclination and/or version with a concurrent proximal femoral osteotomy to correct valgus/varus and/or rotational alignment. We assessed functional scores, radiological paramenters, arthroplasty conversion rate, time interval before conversion to arthroplasty and other associated complications.
Introduction
Perthes disease is associated with coxa breva, plana and magna, and a high riding prominent greater trochanter causing abductor shortening and weakness, leg shortening and extra-articular impingement. A trochanteric advancement with an infero-lateralizing sliding osteotomy of the proximal femur would lengthen femoral neck, improve abductor length and strength, relieve impingement and improve leg length. We assessed the mid-term outcomes for this procedure.
Method
We included patients who underwent the operation by the senior author (JNOH) with more than 2 years follow-up. The osteotomies were performed under image intensifier guidance and fixed with blade plate or locking plates. We assessed functional scores, radiological changes in neck length, Tonnis grading for arthritis and evidence of progression in femoral head avascular necrosis, time interval for conversion to hip arthroplasty and associated complications.
Total hip arthroplasty (THA) in teenagers is uncommon and previously associated with poor survival rates. However it is sometimes the only option remaining to relieve pain and improve function in patients with advanced hip disease. We report on the clinical and radiological outcomes of THA in teenage patients. Medical records and radiographs of all consecutive teenage patients undergoing THA at a tertiary referral centre between 2006–2011 were reviewed. Mean follow-up was 3.4 years (range 0.6–6.8) with 9 patients having at least 5 years follow-up. Post-operative Harris hip, Oxford hip (OHS) and University of California Los Angeles (UCLA) activity scores were recorded. 51 THAs were performed in 43 patients (21 male, 22 female) with a mean age of 17 years (range 12–19). The 5 most common indications were slipped upper femoral epiphysis osteonecrosis 15 (29.4%), developmental hip dysplasia osteonecrosis 5 (9.8%), multiple/spondylo-epiphyseal dysplasia 5 (9.8%), chemotherapy-induced osteonecrosis 4 (7.8%) and idiopathic osteonecrosis 4 (8.2%). 46 (90%) were uncemented THAs and 5 (10%) were reverse hybrid THAs with 7 computer assisted design/manufacture (CADCAM) femoral implants. Articular bearings were ceramic/ceramic in 40 (78.4%), metal/metal 6 (11.8%), metal/polyethylene 3 (5.9%) and ceramic/polyethylene 2 (3.9%). The survival rate was 96% with 2 acute head revisions for 1 sciatic nerve palsy and 1 instability. Other complications (8.2%) included 1 dislocation, 1 sciatic nerve palsy that resolved, 1 surgical site infection and 1 unexplained pain. At latest follow-up, the mean Harris hip score was 90 (68–99), OHS was 42 (32–48) and UCLA activity score was 6 (4–9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. As one of the largest studies on teenagers undergoing THA, we report good clinical and radiological outcomes at short to intermediate term follow-up.
Background
Gram stain microscopy is a routinely requested investigation in the evaluation of septic arthritis in both paediatric and adult patients. Recent evidence suggests that gram stain microscopy has poor diagnostic accuracy in adults with a sensitivity of only 45%, however the diagnostic accuracy remains unknown in children. We sought to establish the diagnostic utility of gram stain microscopy in the diagnosis of septic arthritis in children.
Methods
We conducted a retrospective review of all patients of 16 years and under that underwent aspiration and washout of suspected septic joints in theatre from March 2005 to February 2011. Theatre data were cross referenced with microbiology results and analysed by simple descriptive methods in Excel.
Objective
The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost.
Methods
This was a retrospective review of prospectively collected data from our hip instability clinic database. All patients presenting to our hip instability clinic that required any form of treatment for DDH between 1990 and 2005 were included. Children were grouped according to age at presentation and then treatment requirements were reviewed. Average costs were calculated based on procedures performed.
Aim
To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury.
Method
We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made.
All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit.
Background
Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children under 16 years of age in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial.
Objectives
The main purpose of this study was to systematically search for and critically appraise articles comparing functional outcomes, radiographic outcomes and complications of nailing and plating for both-bone diaphyseal forearm fractures in children.
Introduction
Lateral humeral condyle fractures account for 17% of the distal humeral condyle fractures. They affect children between 5 and 10 years of age. Recent reports advocate closed reduction and internal fixation for the less displaced fractures.
Methods
We retrospectively reviewed children treated with open reduction internal fixation of these fractures at a single institution over a period of 13 years. All cases of lateral humeral condyle fractures treated with ORIF were identified through the trauma register. Case notes and radiographs were retrieved. Fracture classification, mode of fixation, time to union, and clinical examination at latest follow up were reviewed.
Introduction
We present a single surgeon series of 20 modified Dunn osteotomies without surgical dislocation of the femoral head for slipped upper femoral epiphysis (SUFE).
Method
All patients from 2007 to 2011 who had a Dunn osteotomy for SUFE had their notes reviewed and we obtained an updated Non Arthritic Hip Score.
Background
The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision.
Materials and methods
We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D).
Aims
Solitary plasmacytoma of bone is a locally aggressive lesion seen by sarcoma teams. Some patients progress to myeloma. Local therapy decisions can be complex. This study reviews the experience of this condition in a single centre with a view to informing future treatment.
Methods
This was a retrospective review of clinical records.
Background
Myxofibrosarcomas are malignant soft tissue tumours that often present as painless slowly growing masses in the extremities of older males. Locally infiltrative growth means risks of local recurrence is high. Management emphasises negative surgical margins and adjuvant therapy. The aim of this retrospective case series was to review our experience of this tumour, and make recommendations about a minimum resection margin and how best to utilise the expertise of the multidisciplinary team.
Methods
A computerised database identified patients with myxofibrosarcoma surgically treated in our centre between 1997 and 2011. Clinical records were reviewed. Margins were positive if tumour was at or within 1mm of the resection plane.
Background
Membrane type 1 matrix metalloproteinase (MT1-MMP) plays a role in the progression of several common solid cancers. Given that osteosarcoma features extensive local invasion and haematogenous metastases, we hypothesised that osteosarcoma cells utilise MT1-MMP to drive these processes. Moreover, since hypoxia regulates MT1-MMP expression in breast cancer we investigated the effects of hypoxia on MT1-MMP expression in osteosarcoma cells.
Aims
Examination of MT1-MMP expression in osteosarcoma biopsy tissue in relation to clinical outcome Assessment of MT1-MMP, together with hypoxia inducible factors HIF-1α and HIF-2α expression in a panel of osteosarcoma cell lines under normoxia and hypoxia
Introduction and aims
Solitary fibrous tumours (SFT) are rare soft tissue sarcomas. Challenges in management include the variation in anatomical location and uncertain malignant potential. We retrospectively reviewed our experience with the aim of formulating guidelines on appropriate treatment.
Methods
An electronic database identified patients with SFT presenting between 2003–2011. Clinical records were reviewed.
Aims
To evaluate the incidence, patient demographics, primary tumour characteristics and treatment modalities of patients with radiation induced soft tissue sarcoma (RISTS) presenting to the East Midlands Sarcoma Service at Nottingham City Hospital.
Methods
All consecutive patients with histologically proven RISTS were identified from our pathology database. Case notes were retrospectively reviewed to identify patient demographics, oncological features and treatment outcome.
We reviewed 100 consecutive primary sarcoma patients identified from coding records from January 2009 to April 2011. A computerised system was used to access theatre records, and operative details were checked against patient notes to ensure accuracy. Data on demographics, pathology, surgical and oncological management was collected.
Of the 100 patients reviewed, 52 were male and 48 female with an average age of 64.9 years (range 23–102 years). Of the 100 operations performed, 13 had primary reconstruction with a myocutanoeus flap, of which 9 varieties were used. Twenty-five patients had reconstruction with a split or full thickness skin graft and 9 patients had a limb amputation. Length of inpatient stay ranged from 0 to 63 days and was greatest for our amputee's. Mean operative time did not increase significantly with rise in case complexity. 31 of our patients received post-operative radiotherapy, one patient had induction radiotherapy whilst another had induction chemotherapy.
5 out of the 100 patients underwent re-excision due to incomplete margins being obtained at primary wide local excisions. We had one patient with a failed free latissimus dorsi flap, in which secondary reconstruction with pedicled gastrocnemius and skin grafting was successful. One patient had a scalp flap following a re-excision of a positive margin of an angiosarcoma.
Using a combined oncological orthopaedic and reconstructive plastic surgery approach, in our centre 38% of patients require some form of soft tissue reconstruction following tumour resection, with 13% of all patients requiring microvascular flap reconstruction. We have a 9% amputation rate, which is comparable with other published series.
Reconstruction following soft tissue sarcoma is complex and highly demanding, the challenges being best met by a combined orthoplastic surgical team.
Aims
Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement.
Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates.
Methods
Patients that underwent palliative surgery for metastatic bone lesions were identified from operative records. Demographics, clinical details and outcomes were recorded. Kaplan-Meier analysis was used to calculate survivorship.
Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age.
The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery.
Aims
To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery.
Methods
A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected.
Aims
Delays to diagnosis and management of soft tissue sarcomas are preventable but still occur. The introduction of a referral proforma to the Thames Valley Cancer Network in 2005 and National guidelines in 2006 aimed to decrease the incidence of partially and inadequately managed soft tissue sarcomas. This study aims to assess referrals for partially or inadequately managed soft tissue sarcomas and their subsequent management.
Methods
A prospective analysis of all patients referred to the Oxford Sarcoma Service following inadvertent excision of a soft tissue sarcoma between January 2010 and August 2011 was carried out. Pre-operative investigation and subsequent secondary managements were recorded. Patients with a diagnosis of dermatofibrosarcoma protuberans were excluded.
The aim of this study is to review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism, in order to determine the injury pattern, clinical management and outcome of these devastating injuries.
All patients were serving soldiers who were injured whilst on operations in Afghanistan. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the 1st 24 hours was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7(24%) had a bowel injury, 11 (38%) had a genital injury and 7(24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required ORIF. Of those patients who underwent ORIF, 4 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.2 days, and mean total operative time was 29.6 hours. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability.
The “Global War on Terror” has resulted in incidents that were previously confined exclusively to conflict areas can now occur anywhere, and surgeons who are involved in trauma care may be required to manage similar injuries from terrorist attacks. Our study clearly demonstrates that the management of this injury pattern is extremely resource intensive with the need for significant multi-disciplinary input. Given the nature of the soft tissue injury, we would advocate an approach of minimal internal fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases.
Background and Purpose
Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures.
Method and Results
Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02–1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L.
Background
Orthopaedic surgeons are increasingly pressured to consider
Methods
Between October 2004 and September 2006 details of all new patients referred to our orthopaedic fracture clinic were prospectively entered into an audit database. Patients did not receive any form of thromboprophylaxis. Data was cross referenced with a national mortality database to identify all patients who subsequently died within 90 days of attendance in fracture clinic.
Introduction
Assessment for and treatment of osteoporosis is recommended following hip fracture. All forms of osteoporosis treatment require an adequate calcium intake and normal vitamin D levels. This study assesses vitamin D levels in patients with hip fractures and describes guidelines on how to manage low vitamin D levels with high dose oral vitamin D3 (cholecalciferol).
Materials and methods
Circulating 25-hydroxyvitamin D levels were measured in consecutive patients with a hip fracture over an 18 month period. Substitution therapy with high dose oral cholecalciferol was started in 2 selected cohorts; one group received substitution therapy for 3 days, the second group for 7 days.
Pelvic ring fractures usually result from significant trauma, frequently requiring operative stabilisation. The use of an anterior internal fixator (INFIX) is a new technique. This temporary construct is quick and easy to apply using pre-existing spinal implants. No reports of functional outcomes or compartive studies with existing surgical techniques exist in indexed literature.
We present a prospective comparative case matched series of 21 patients treated with pelvic INFIX. 1:1 matching was achieved to a cohort of patients treated with open reduction and internal fixation (ORIF) based on fracture pattern. All patients with rotationally and/or vertically unstable pelvic ring fractures treated within our level 1 trauma centre were considered for inclusion. Patients were prospectively followed up with health outcome measures (SF-36, EQ-5D) and joint specific outcome scores (Oxford and Harris hip scores).
Results
No statistically significant differences in age (mean 42v38 p=0.3143), length of stay, or operative time were seen. The ISS was significantly higher in the INFIX group (32v22 p=0.0019). Mean INFIX removal was at 14 weeks.
Baseline responses were obtained on admission where feasible. Although there was no significant difference between the treatment groups, the ORIF group showed a significantly greater deterioration from the baseline than the INFIX group, suggesting INFIX better maintains pre-injury function.
29% of patients experienced LCNT palsy whilst the INFIX was in situ. 6 patients in the INFIX group experienced some form of metal work failure (3 required surgical removal), compared with 7 ORIF patients (4 required removal).
Conclusions
Pelvic INFIX achieves bony stabilisation of unstable pelvic fractures, and should be considered for rotational or vertically unstable fractures requiring operative intervention. Despite higher ISS scores, INFIX patients performance in joint specific and global health functioning scores was not significantly different from ORIF patients. We do not use INFIX for pelvic fractures with symphyseal disruption.
Introduction
Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation.
Methods
185 cases of infected non-union of long bones from Jan 2002 to Jan 2009 were treated in this hospital. 46 females and 139 males, age varied from 17–65 years (Avg. 40). Tibia was the commonest bone to be affected, followed by femur & humerus. The control of infection was by debridement, antibiotic cement impregnated K-nail (ACIN) insertion with or without Ilizarov ring fixator application, second stage treatment by definitive internal fixation and bone grafting was done if required. Average duration of follow up, was 26 months (14–58 months). Main outcome measurements were assessment of bone healing, functional outcome, healing time and complications.
Acetabular fractures are amongst the most complex fractures to treat. It has been suggested that pre-contouring the fixation plates may save intra-operative time, blood loss, reduce intra-operative fluoroscopy and improve the reduction. The purpose of this study was to assess if the contouring could be done reliably using the mirror image of the uninjured hemipelvis.
Using the CT data of 12 specimens with no bony abnormality 3D models were reconstructed. Using computer software (AMIRA, Visage Imaging) the mirror image of the left hemipelvis and the right hemipelvis were superimposed based on landmarks. The distances between the surfaces were then calculated.
The results were collected in the form of mean distance and colour maps. The mean difference between surfaces ranged from 1.76mm and 8.47mm. The colour maps demonstrated that for the areas around were acetabular fixation plated would be placed the differences were small. For the anterior column plate 6 (50%) of the specimens had differences of less than 1mm, which based on the work of Letournel and Judet would represent an anatomical reduction. (None had a difference of more than 6mm.) For the posterior column plate 7 (58%) had differences of less than 1mm. (None had a difference of more than 3mm.
This study demonstrates that there is considerable symmetry between both hemipelvises and that precontouring on the mirror image of the uninjured side is an accurate, quick and reliable method for precontouring. However the symmetry is not exact and the operating surgeon needs to be aware that fine-contouring may be required intra-operatively.
Background
There is increasing interest in the use of Total Hip Replacement (THR) for reconstruction in patients who have suffered displaced intracapsular hip fractures. Patient selection is important for good outcomes but criteria have only recently been clearly defined in the form of national guidelines. This study aims to investigate patient reported outcomes and satisfaction after Total Hip Replacement (THR) undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis in order to assess the safety and effectiveness of national clinical guidelines.
Methods
100 patients were selected for treatment of displaced hip fractures using THR between 1 January 2007 and 31 December 2009. These patients were selected using national guidelines and were matched for age and gender with 300 patients who underwent contemporaneous THR as an elective procedure for osteoarthritis.
Background
Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients.
Methods
This is a prospective study with retrospective analysis of all the patients who were admitted to the Northern General Hospital between August 2009 and March 2011. 2 consultants using same technique and peri-operative regime carried out all procedures. All patients were administered prophylactic enoxaparin and those who were admitted via another hospital had a pre-operative Doppler scan. Post-operatively all patients were commenced on warfarin, or low molecular weight heparin (enoxaprin) if warfarin was contra-indicated, and was continued for three months after discharge.
Introduction
Intracapsular hip fractures in young adults are treated with internal fixation, often as a surgical emergency to reduce the vascular insult to the femoral head. Avascular necrosis and non-union often require revision surgery.
Methods
A prospective trauma database was retrospectively searched from 1st August 2008 to 31st December 2010. Intracapsular hip fracture admissions to the Regional Trauma Centre, in adults under sixty-five years, were studied.
Ninety-eight intracapsular fractures internally fixed with sliding hip screw underwent radiographic review for quality of fixation, and evidence of complications at a mean of thirteen months. Co-morbid medical conditions and quality of fixation were assessed for association with revision rates.
Introduction
Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients.
Methods
Complete data were available for 566 patients treated over a 27-month period. All patients had urea and creatinine checked on admission, and at 24–48 hours after surgery. Post-operative analgesia, fluid therapy, transfusion protocols and orthogeriatric reviews were standardised. Generalised Linear Models and correlation matrices were used. Cox-proportional hazards analyses investigated the association between serum concentrations of urea and creatinine on admission and length of stay and mortality after surgery.
Introduction
Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario.
Materials and methods
Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported.
Patients presenting with a fractured neck of femur are a fragile group with multiple co-morbidities who are at risk of post-operative complications. As many as 52% of patients are reported to suffer a urinary tract infection post hip fracture surgery. There are little data surrounding the effects of post-operative urinary tract infections on mortality and deep prosthetic infection.
We prospectively investigated the impact of post-operative urinary tract infection (UTI) in 9168 patients admitted to our institution with a diagnosis of proximal femoral fracture over an eleven year period in a prospective population study. We examined the effects of post operative UTI on the incidence of deep infection, survivorship and length of stay.
Post-operative UTI occurred in 6.1% (n=561) and deep infection in 0.89% (n=82). Deep infection was significantly more common in patients complicated with a UTI (3.2% vs 0.74% p< 0.001) with a relative risk of 3.7:1. In 58% of patients the same organisms was cultured in the urine and hip samples. A postoperative UTI did not adversely effect 90 day survival, however was associated with an increased length of stay (ROC analysis AUC=0.79). Delays to surgery and age were not predictive of a post operative UTI.
Recognition of the risks posed by post operative UTI, the risk factors for development of infection and early treatment is essential to reduce the risks of increased subsequent periprosthetic infection.
Certain acetabular fractures involve impaction of the weight-bearing dome and medialisation of the femoral head. Intra-operative fracture reduction is made easier by traction on the limb, ideally in line with the femoral neck (lateral traction). However, holding this lateral traction throughout surgery is very difficult for a tiring assistant.
We detail a previously undescribed technique of providing intra-operative lateral femoral head traction via a pelvic reduction frame, to aid fixation of difficult acetabular fractures. The first 10 consecutive cases are reviewed (Group 1) and compared with a retrospective control (Group 2, n=18) of case-matched patients, treated prior to introducing the technique. The post-operative X-rays and CT scans were assessed to identify quality of fracture reduction according to the criteria of Tornetta and Matta. Operative time, blood loss and early complication rates were also compared.
All cases in both groups were acute injuries with medial and/or superior migration of the femoral head. The majority were either associated both column or anterior column posterior hemi-transverse. There was no statistical difference between the groups in age, time to surgery, BMI or ASA grade.
Fracture reduction was assessed as excellent in seven, good in three and poor in one. This was not significantly different from the control group (p=0.093). The mean operative time was 232 minutes in Group 1 and 332.78 minutes in Group 2 (p = 0.0015). There was no difference between the groups for blood loss or complication rates.
We conclude that this new technique is at least equivalent to using manual traction and early results suggest it reduces operative time and technical difficulty in treating these complex acetabular fractures.
Introduction
National Institute for Health and Clinical Excellence (NICE) guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractured neck of femur (NOF) in cognitively intact patients who were independently mobile prior to the injury. The National Joint Registry for England and Wales (NJR) has collected data on THRs performed since 2003. This retrospective cohort study explores risk factors independently associated with implant failure and perioperative mortality.
Methods
NJR data recording a THR performed for acute fractured NOF between 2003 and 2010 were analysed. Cox proportional hazards models were used to analyse the extent to which risk of implant revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting 90-day perioperative mortality. Significance was taken as p< 0.01.
Introduction
When treating a patient admitted with hip fracture it is useful to have a simple scoring system to predict outcomes, based on admission clerking and routine investigations. The Nottingham Hip Fracture Score (NHFS) is one such measure. Its use has been described by Wiles et al (Br J. Anaes. Jan. 2001) for risk stratification in predicting 30-day and 1-year mortality.
Objective
Our aim was to use the hip fracture database at Peterborough City Hospital, UK to conduct an independent validation study of the NHFS stratification system.
Introduction
Pelvic fractures are indicators of severe trauma and high energy absorption. They are associated with multiple local or distant concomitant injuries, which explain their high mortality and morbidity. The aim of this study is to investigate the late sequel of traumatic-pelvic-fractures (PFX) focusing on quality-of-life and sexual-function.
Methods
From a database of prospectively documented data, patients who had suffered a PFX and had been treated operatively in our institution from January 2008–2009 were recruited. Exclusion criteria were patients less than one-year post-injury, pathological-fractures, patients < 18 or >65, and patients with co-morbidities linked to sexual dysfunction. Demographics, injury-mechanisms, fracture-patterns (Young-Burgess classification), injury-severity-score (AIS/05-ISS), urogenital injuries and clinical outcome were recorded and analysed. Health-related-quality-of-life was assessed using the (EuroQol-5D) and sexual-function using the international-index-of-erectile-function and the female-sexual-function-index. The minimum follow-up was 12 months (12–30).
A randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercial dressings. The Flexor Carpi Ulnaris of anaesthetised New Zealand rabbits was exposed to high-energy trauma using computer-controlled jig and inoculated with 106
Clinical observations and haematology were performed during the study. Histopathological assessment of post-mortem muscle specimens included image analysis of digitally scanned haematoxylin and eosin stained tissue sections and subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy to determine the presence of bacteria and biofilm formation within the injured muscle. Non-parametric data were compared using Kruskal-Wallis.
There were no bacteraemias, significantly raised white cell counts, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. All injured muscle specimens showed evidence of haemorrhage, inflammatory cell infiltration and fibrosis. All ipsilateral axillary lymph nodes were activated. There were no significant differences in the amount of muscle loss, size of the activated lymph nodes or in subjective semi-quantitative scoring criteria for muscle injury or lymph node activation. There was no evidence of bacterial penetration or biofilm formation.
This study demonstrated statistically significant reductions in
The poor outcome of large head metal on metal total hip replacements (LHMOMTHR) in the absence of abnormal wear at the articulating surfaces has focussed attention on the trunnion/taper interface. The RedLux ultra-precision 3D form profiler provides a novel indirect optical method to detect small changes in form and surface finish of the head taper as well as a quantitative assessment of wear volume. This study aimed to assess and compare qualitatively the tapers from small diameter with LHMOMTHR's. 3 groups of retrieval tapers were analysed (Group 1: 28mm CoCr heads from MOMTHRs (n=5); Group 2: Large diameter CoCr heads from LHMOMTHRs (n=5); Group 3: 28mm heads from metal on polyethylene (MOP) THRs; n=3). Clinical data on the retrievals was collated. Both bearing surfaces and head tapers were measured for wear using the Redlux profiling non contact measurement system. Measurements included taper angle and 3D surface maps. Taper angles obtained with the Redlux method were compared to those obtained using CMM measurement on 3 parts. The Redlux profiling, including imprints, was also repeated 3 times to gauge potential errors. There was no difference in mean 12/14 taper angles between groups. There was no difference in volumetric and linear wear at the bearing surface between groups. Only the LHMOMs showed transfer of pattern from the stem to the internal head taper, with clear demarcation of the contact and damaged area between head taper and stem trunnion. 3D surface mapping demonstrated wear patterns compatible with motion or deformations between taper and trunnion in the LHMOM group alone. Discussion: Differences in appearance of the taper surface between LHMOMTHRs and MOP or MOM small diameter devices highlight an area of concern and potential contributor to the mode of early failure. Further work is required to fully qualify the Redlux method capabilities.
Introduction
It has been speculated that impact deformation of thin 1-piece cups used for modern metal-on-metal hip replacement may contribute to early failure. The purpose of this study was to reproduce typical impact deformation and quantify the effect of this on the frictional torque generated at the hip.
Methods
We tested nine hip couples of three designs (the ASR, BHR and Durom) and three sizes (42mm, 46mm and 50mm). A custom compression device was designed to replicate the in vivo forces and impact deformation of 1-piece metal cups reported in the literature. Each cup was mounted in the device, which itself was mounted on a mechanical testing machine. The cups were compressed with incremental loads up to a maximum of 2000N. At each increment we measured cup deformation, and then the head component was seated into the cup. The hip was lubricated and the head component rotated 60 degrees axially within the cup and the axial torque was measured.
Aim
Computer assisted total knee arthroplasty may have advantages over conventional surgery with respect to component positioning. Femoral component mal-rotation has been shown to be associated with poor outcomes, and may be related to posterior referencing jigs. We aimed to determine the variation between the transepicondylar axis (TEA) and posterior condylar axis (PCA) in a series of knees undergoing navigated total knee arthroplasty (TKA), and to determine the correlation between final intra-operative and post-operative coronal alignment.
Method
A review of 184 consecutive patients undergoing primary TKA between June 2007 and August 2010, using Precision navigation and Triathlon implants (Stryker). The difference between the TEA and PCA was measured as was the initial and final coronal alignment. A standing four foot alignment radiograph was obtained 6 weeks after surgery to determine the weight-bearing mechanical axis.
Introduction
Edge loading is a common wear mechanism in Metal-on-Metal (MOM) hip resurfacing and is associated with higher wear rates and the incidence of pseudotumour. The purpose of this study was to develop a method to investigate the contributions of patient, surgical and implant design variables on the risk of edge loading.
Method
We created a mathematical model to calculate the distance from the head-cup contact patch to the rim of the cup and used this to investigate the effect of component position, specific design features and patient activity on the risk of edge loading. We then used this method to calculate the contact patch to rim distance (CPRD) for 160 patients having undergone revision of their MOM hip resurfacing in order to identify any possible associations.
Background
Lateral column lengthening combining bony and soft tissue procedures has been described for symptom relief and deformity correction in the planovalgus foot. There are relatively few reports on its outcomes in childhood. We present our medium term outcomes using this technique in children.
Methods
Twenty-five symptomatic mobile planovalgus feet in fifteen patients were operated upon between 2005 and 2008. The mean age at surgery was 12 years 6 months. Ten patients had idiopathic pes planovalgus, two had overcorrected congenital talipes equinovarus, and one had skewfoot deformity. The surgery included one or more bony elements - lengthening calcaneal osteotomy, heel shift, medial cuneiform osteotomy - iliac crest tricortical bone graft harvest and one or more soft tissue procedures - peroneus brevis/peroneus longus transfer, plantar fascia release and tibialis posterior advancement. The extent of surgery was decided per-operatively in an a la carte fashion. The Visual Analogue Score for Foot and Ankle (VAS FA) and American Foot and Ankle Association (AOFAS) ankle-hindfoot and midfoot scores were measured. Clinical findings and complications were recorded.
Background
Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children.
Aim
The main objective of this study was to confirm whether bilateral 8-plates achieve an epiphysiodesis or not?
Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique.
Method
Prospective study of 40 feet in 28 patients who underwent an Achilles tenotomy and calcaneal pulldown technique. The indications for this method were resistant equinus and problems with casting. Feet scored with the Pirani method. Under a general anaesthetic, a standard Achilles tenotomy was performed. The equinus deformity corrected by traction of the calcaneum with a “catspaw” retractor and dorsiflexion of the forefoot. Further treatment was performed according to the Ponseti method. The Ponseti clubfoot brace was used to maintain correction.
Results
28 patients 40 feet. Mean preoperative Pirani score:3.0 (left 3.0, right 3.1 range 1.5–6). Mean preoperative Hindfoot Pirani score:2.5 (left 2.55, right 2.5 Range 1.5–3). Mean post operative Pirani score:2.0(left 2.0, right 2.0 Range 0.5–6). Mean postoperative Hindfoot pirani score:1.45. Three patients had severe arthrogryphosis, of whom 2 did not correct requiring open surgery. All idiopathic CTEV feet corrected with a range of 5–20 degrees of dorsiflexion at last follow up. The mean follow up was 43.64 months (range 7–96 months).
Introduction
Through the paediatric LCP Hip plating system, the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to paediatrics. The purpose of this study was to review the outcome of the paediatric LCP Hip plate use in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications.
Materials and methods
We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Hip Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications.
Aim
To assess the results of Castles procedure performed at our hospital compared with those available in literature.
Introduction
Fifteen patients (19 hips) with severe disability and hip subluxation/dislocation underwent proximal femoral resection arthroplasty (Castles procedure) over a 10 year period under the care of 2 paediatric orthopaedic surgeons. We conducted a retrospective study of case series whether the surgery (Castles procedure) improved the pain levels, sitting tolerance, ability to use commode/nappy change, ease of dressing and the carers overall satisfaction with the procedure.
Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results.
Distal radius fractures are common, yet the long-term functional outcome of these patients is unknown. This study investigated the long-term functional outcomes after distal radius fracture (DRF) in adult patients 16–23 years following injury. Secondary aims were to establish morbidity, mortality and function related to pattern of injury and patient demographics.
Methods
622 consented adult patients with a DRF were enrolled in the study. Prospective data was recorded; patient age, mechanism of injury and fracture pattern. Patients were assessed 16–23 years post-injury. 275 patients were deceased. 194 patients were able to complete a Quick Dash (QD) validated upper limb pain and function Patient-Reported Outcome Measure (PROM). Five patients declined follow-up. Socioeconomic status was assessed using the Scottish Index of Multiple Deprivation (SIMD) 2009.
Results
The mean age at injury was 41 years for men and 64 for women in the initial cohort. 146 women and 48 men completed final follow-up. The mean age at QD assessment was 57 years for men and 76 for women; mean and median SIMD deciles were 6.7 and 7, respectively, for both genders. The mean QD score was 10.35 for all patients, with no significant gender difference (p=0.63). 85.6% (n=166) reported no or at most, mild limitation.
High socioeconomic status, absence of other injuries at DRF and age under 85 years old at follow-up was associated with better long-term function. Early function and pain predicted long-term function; comminution pattern, treatment modality as chosen by surgeon, and early complications did not. Mortality data was analysed for the deceased (n=275). The mean patient survival from DRF to death was 11 years 5 months, with no significant gender difference (p=0.43); survival was predicted by age at injury, post-treatment dorsal angulation and early function. Respiratory, cardiovascular causes and malignancy were the three most common primary causes of death.
Aim
Treatment for distal third shaft fractures of humerus is very challenging especially if its comminuted and bone is osteopenic. They are commonly treated with plating. Plating has complications of iatrogenic radial nerve palsy. We report our case series of distal third fractures of humerus treated with retrograde Halder Humeral Nail.
Materials and methods
Since 1994 to 2010 we have 576 fractures of humerus treated with retrograde Halder Humeral nail. Of these 45 were distal third extra articular fractures of humerus. Average age of patients at the time of surgery was 30.4 years (Range 15–82 years, Median 33 years). Of 45 patients 26 were females and 19 males.3 out of 45 had non union at the time of presentation. The nail was locked distally with one or two screws and proximally with a screw and tripwire. The entry point of the nail was roof of olecranon fossa (contrary to standard retrograde nails where it is an inch above olecranon fossa) This design of nail allows it be used for even very distal fractures. All patients were followed till clinical and radiological signs of union. 1 patient was lost to follow up.
Background
During cephalomedullary nail stabilisation of subtrochanteric femoral fractures, damage to the distal anterior femoral cortex by the nail is a recognised cause of periprosthetic fracture. Currently available cephalomedullary devices vary widely in anteroposterior curvature, though all are less curved than the mean anatomic human femur. This study tests the hypothesis that a cephalomedullary device with greater anteroposterior curvature will achieve a more favourable position in the distal femur, with greater distance of the nail tip from the anterior cortex, and therefore lower risk of cortical damage.
Methods
Retrospective analysis of postoperative radiographs from patients undergoing subtrochanteric femoral fracture stabilisation with either a)Stryker Long Gamma Nail (radius of curvature 2.0m, 19 patients) or Synthes long PFNα (1.5m, 19 patients) was performed. Distance from the anterior femoral cortex to the anterior part of the distal nail was measured, using the known diameter of the nail as a radiographic size marker.
Percutaneous plating of the distal tibia via a limited incision is an accepted technique of osteosynthesis for extra-articular and simple intra-articular distal tibia fractures. In this study we identify structures are risk during this approach.
Method
Thirteen unpaired adult lower limbs were used for this study. Thirteen, 16-hole synthes®LCP anterolateral distal tibial plates were percutaneously inserted according to the manufacturer instructions and confirmed by xray. Dissection was performed around the plate to examine the relation of nerves and soft tissue.
Results
The neurovascular bundle was under the plate in one case. Over the horizontal limb of the plate, typically the superficial peroneal nerve had a variable course over all four screw holes. The anterior tibial artery coursed over hole number 3 and the Extensor hallucis longistendon was positioned over hole 3 or 4. The Anterior tibialis tendon skirted hole 4 in 12 cases. Over the vertical limb of the plate, the neurovascular bundle coursed over holes, 5 to 7, the superficial peroneal nerve over holes 5 to 7.
Introduction
Posterior malleolar fractures are present in up to 44% of all ankle fractures. Those involving > 25% of the articular surface have a higher rate of posterior ankle instability which may predispose to post traumatic arthritis. The posterolateral approach to the distal tibia allows direct reduction and stabilization of the posterior malleolus and concomitant lateral malleolus fractures. An anatomical study was performed to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels in this uncommon approach.
Methods
26 unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia as described by Tornetta et al. The peroneal artery was identified coursing through the intraosseous membrane on deep dissestion as the flexor hallucis longus muscle was reflected medially. The level of its bifurcation was also noted over the tibia. Perpendicular measurements were made from the tibial plafond to these variable anatomical locations.
Techniques for fixation 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 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 AAOS 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.
Hypothesis
This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial shear fractures.
Postero-medial shear fractures are under-appreciated and their clinical relevance have recently been characterised. Less invasive surgery and indirect reduction techniques are inadequate for treating these postero-medial coronal plane fractures.
Methods
The approach includes an inverted ‘L’ shaped incision and reflection of the medial head of gastrocnemius, while protecting the neurovascular structures. This is a more extensile exposure than described by Trickey (1968). Our case series includes 8 females and 8 males. The average age is 53.1 years. The mechanism of injury included 7 RTAs, 5 fall from height, 1 industrial accident and 3 valgus injuries. All patients' schatzker grade 4, or above, fractures with a posteromedial split depression. Two were open, two had vascular compromise and one had neurological injury.
The Fixion expandable nailing system provides an intramedullary fracture fixation solution without the need for locking screws. Proponents of this system have demonstrated shorter surgery times with rapid fracture healing, but several centres have reported suboptimal results with loss of fixation. This is the largest comparative series to be reported to date.
We compared outcomes between 50 consecutive diaphyseal tibial fractures treated with a Fixion device at our institution to an age, sex and fracture configuration matched series of 57 fractures at a neighbouring hospital treated with a conventional interlocked intramedullary nail. Minimum follow up time was 2 years.
Operating time was significantly reduced in the Fixion group (mean 61 minutes, range 20–99) compared to the interlocked group (88 minutes, 52–93), p< 0.00001. The union rate was no different between the Fixion group (93.9%) and the interlocked group (96.5%), p=0.527. Time to clinical and radiological union was significantly faster in the Fixion group (median 85 days, range 42–243) compared to the interlocked group (119, 70–362), p< 0.0001. The overall reoperation rate was lower in the Fixion series (24.5% vs 38.6%, p=0.121), although the majority of reoperations in the interlocked group were more minor, for screw removal. 3 Fixion nails were revised for fixation failure and 2 manipulations were required for rotational deformities after falls; all of these patients were non-compliant with post-operative instructions. There were no fixation failures in the interlocked group. 3 fractures were noted to propagate during inflation of Fixion nails.
The Fixion nail is faster to implant and allows more physiological loading of the fracture, with a faster union time. However, these advantages are offset by a reduction in construct stability. Our results have demonstrated a learning curve with a reduction in complications as our indications were narrowed, avoiding osteoporotic, multifragmentary, unstable fractures and non-compliant patients
Currently the debate continues in definitive fixation method for complex tibial plateau fractures. The aim of surgical management remains prevention of further damage to the articular cartilage, whilst avoiding iatrogenic risks - Low Risk Surgery (LRS). The purpose of this study was to determine the functional impact, clinical radiological outcome following tibial plateau fractures treated with either external fixation or internal fixation.
124 Schatzker IV-VI tibial plateau fractures were reviewed following surgical fixation. Fractures analysed included 24 type IV, 20 type V and 80 type VI tibial plateau fractures. The majority of Schatzker IV fractures were treated with internal fixation, but 67 of 80 Schatzker VI fractures were treated with the Ilizarov method. The average IOWA knee score, was 86 (16 to 100) and the average range of motion was 133 degrees (60 to 150). There were no differences between the circular fixator group and the internal fixation group in terms of range of motion or IOWA scores. There were comparable functional outcomes and complication rates between both groups.
In summary patients with high energy tibial plateau fracture treated with internal or external fixation, have a good chance of achieving satisfactory long term knee function.
Background
A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures.
Aims
We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports.
In acute orthopedic trauma care rapid communication between the resident and consultant surgeon is important. Teleradiology and internet facilities have been explained for transferring the x-ray images. Advanced technology found to be impractical for many countries like Sri Lanka.
Objective
To determine the applicability of mobile phone multimedia message system (MMS) in acute trauma care to transfer the X-ray images and identify the practical issues related to it.
Methodology
A cross sectional survey was done for a period of 01 yr. Digital photos of X-ray images were taken by using a phone camera and communicated between the senior resident and the consultant. MMS images were analyzed in relevant to the, adequacy of MMS images, quality of the MMS image and relevant area of visualization to reach a radiological diagnosis to decide the acute management plan of the patient. Analyzed the issues related to the processing and transmission of MMS Images.
Objective
The aim of the study was to evaluate inter observer reliability and intra observer reproducibility between the three column classification using 3D CT reconstruction models and schatzker classification systems using 2D CT models.
Materials and methods
Fifty two consecutive patients with tibial plateau fractures were evaluated by two orthopaedic surgeons. All patients were classified into Schatzker and three column classification systems using CTimages. The Images were evaluated in a randomised and blind fashion. Demographics of the patient were blinded to reduce observer bias. The inter observer reliability was measured for both classfications in round one. In round two the process was repeated after two weeks and the intra observer reproducibility was measured using cohen kappa coefficient and level of agreement based on Landis and Koch.
Aim
To review the results of patients who underwent fixation of complex proximal femur fractures using the Proximal Femur Locking Plates (PFP) and analyse causes of failure of PFP.
Methods
Retrospective review of radiographs and case notes of PFP fixations in two hospitals between February 2008 and June 2011. Primary outcome was union at six months. Secondary outcome included post-operative complications, and need for further surgical intervention.
Background
The purpose of this retrospective study was to examine the functional outcomes of patients treated for isolated fracture of the greater tuberosity (GT) and to determine how their outcomes were affected by fracture pattern, treatment choices, associated shoulder injuries, the post fixation displacement of GT fragment and the time delay between injury and fixation.
Methods
Forty-eight (28 male and 20 female) patients (mean age 45 years) treated at our institution between 1999–2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 conservatively. Functional outcome was assessed using Oxford scores (OS), University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow surgeons (ASES). The outpatient follow up time required and the presence of other shoulder injuries, time delay to surgery and the time off work were also recorded.
Introduction
The incidence of distal femoral fractures amongst elderly patients is likely to rise due to increased life expectancy. This study reports on the outcome of a series of distal femoral fractures treated by retrograde femoral nailing and then to compare the results for these patients with a series of patients with a proximal femoral fracture.
Materials and/Methods
In this longitudinal cohort study, 36 patients with extra-articular distal femoral fractures were treated with a solid retrograde femoral nail. Data was collected prospectively and then compared to proximal femoral fractures (2426) treated by the same surgeon treated over the same time period.
Introduction
Acute renal dysfunction (ARD) following orthopaedic surgery is known to increase morbidity, mortality, and length of hospital stay. The aim of this study was to compare the incidence of new acute post-operative renal dysfunction between two cohorts of elective orthopaedic surgical patients receiving either cefuroxime or a combination of gentamicin and flucloxacillin as prophylactic antibiotic regimes. The study was initiated following a change in antibiotic prophylaxis within our unit from cefuroxime to gentamicin and flucloxacillin.
Method
Using a standardised data collection tool we retrospectively reviewed medical records of 238 patients who had received 1.5g of cefuroxime (TKR: n = 128; THR: n=110). This data was compared to prospectively collected data from 254 patients (TKR=117 THR=137) who had received Flucloxacillin 2g and Gentamicin (with the dose based on height). Primary outcome measure for the study was the RIFLE criteria which grades renal impairment: 0-Nil, 1-Risk, 2-Injury, 3-Renal failure.
Our Trust's prophylactic antibiotic regime for elective hip and knee replacements recently changed, following the publication of Department of Health guidelines aimed at reducing the incidence of Clostridium Difficile associated diarrhoea (CDAD). We aimed to assess whether this change has reduced the incidence of post-operative CDAD.
We reviewed all primary and revision total hip and knee replacements performed in Gloucestershire Royal Hospital between April 2007 and March 2010. Up to August 2008, patients received prophylaxis with cefuroxime (Group A). This subsequently changed to flucloxacillin and gentamicin (Group B). All patients who developed CDAD within one month of surgery were identified and their case-notes were reviewed for the presence of CDAD risk factors, such as concomitant use of broad-spectrum antibiotics.
3117 patients were included and 15 developed CDAD (0.48%); 12 patients (0.77%) from Group A and 3 from Group B (0.19%), representing a four-fold decrease. Analysis of a 2×2 contingency table with Fisher's exact test showed that the difference between the two groups was statistically significant (P=0.0347).
Case-note analysis revealed that 8/12 patients in Group A and 1/3 patients in Group B had other risk factors for developing CDAD. Excluding these patients, the difference between the two groups was not statistically significant (P=0.218).
CDAD is exceedingly rare following total joint replacement surgery, especially when the only antibiotics given are prophylactic. Our figures are in line with a general decline in CDAD nationally from 2007. This decline is most likely due to multiple factors, such as hand-washing, barrier nursing and restrictive antibiotic policies. The effect of the change in prophylaxis is therefore difficult to quantify. Choice of prophylactic antibiotics should be based upon their efficacy alone, not their potential to reduce CDAD.
Introduction
Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days.
Methods
We prospectively studied 1223 patients (age- and sex-matched) who underwent lower-limb arthroplasty enrolled in our ERP between March 2010 and December 2011; 454 patients (Group 1) received enoxaparin, 769 patients (Group 2) received rivaroxiban. Patients wore thrombo-embolic stockings for six weeks post surgery. Patients were monitored for thrombo-embolic events and wound-related complications for 42 days post-operatively.
Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial
Introduction
New generation oral anticoagulants (dabigatran/rivaroxaban) have recently become available for the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty. Traditional therapies (warfarin/low molecular weight heparins) are less costly, but have several limitations.
The aim of this study was to evaluate the financial impact of substituting enoxaparin and warfarin with newer therapies dabigatran and rivaroxaban. A secondary objective was to investigate patient satisfaction with these treatments.
Methods
A randomised prospective study was conducted over a 12 month period. Patients with a history of VTE undergoing hip or knee replacement were randomised to receive one of four anticoagulants for five weeks post surgery. Information was gathered during the hospital stay and then post discharge, by telephone, for five weeks(35 days)to determine costs. The costs included cost of drug, nursing time, blood monitoring and transport costs. The patients were also asked to complete the Duke Anticoagulation Satisfaction Scale (DASS). The DASS is a 26 item questionnaire which has 7 responses for each question.
Introduction
Osteoarthritis continues to be a major cause of pain and disability. The pathological processes leading to the end-stage of joint degeneration remain poorly understood. Advances in radiological imaging have the potential to improve understanding of the structural and functional changes observed in OA. The aim of this study was to describe the microarchitecture of the femoral head in osteoarthritis.
Methods
Twenty osteoarthritic femoral heads underwent micro-computed tomography scanning at 30µm. Four parameters of micro-architecture and structure were determined: bone volume ratio (BV:TV), trabecular thickness, structural model index and degree of anisotropy. The femoral head was divided into 27 cubic volumes of interest. Analysis of variance (ANOVA) was used to assess differences between regions. Cystic and sclerotic changes were assessed qualitatively.
Background
Spondylolysis (SL) of the lower lumbar spine is frequently associated with spina bifida occulta (SBO). There has not been any study that has demonstrated biomechanical or genetic predispositions to explain the coexistence of these two pathologies.
Purpose
To test the hypothesis that fatigue failure limits will be exceeded in the case of a bifid arch, but not in the intact case, when the segment is subjected to complex loading corresponding to normal sporting activities.
Introduction
Tendon injuries remain challenging, secondary healing and prolonged immobilisation result in suboptimal outcome. Previous study by our group showed that demineralised bone matrix (DBM) can result in faster healing of a tendon enthesis. The aim of this study is to test different ways augmenting tendon with DBM to enhance tendon repair and regeneration.
Methods
DBM strips were prepared from tibias of mature ewes. Patella, patellar tendon and tibias were dissected and the distal 1 cm of the patellar tendon was excised.
4 models were designed;
Model-1, DBM strip was used to bridge the gap between the tendon and the tibial tuberosity. The DBM strip was stitched to the tendon using one bone anchor.
Model-2, similar to model 1 with the use of 2 anchors.
Model-3, similar to model 2, construct was off loaded by continuous thread looped twice through bony tunnels sited in the patella and in the tibial tuberosity.
Model-4, similar to model 3 with 3 threads as off loading loop.
All models were tested for pullout force and mode of failure.
Introduction
Demineralised Bone Matrix (DBM) is widely used in Orthopaedics and dentistry as a bone graft substitute and may be used to augment bone formation in load bearing applications.
In this study we examine the effect of gamma irradiation and freeze drying on the tensile strength of Demineralised Cortical Bone (DCB).
Methods
Tibias were harvested from mature ewes and cut into bony strips. Demineralisation was done using 0.6M HCL and confirmed by X-ray. Specimens were washed until a pH of 7.0 +/_ 0.2 was achieved in the washing solutions.
Specimens were allocated into 4 groups; group (A) non freeze dried non gamma irradiated, group (B) freeze dried non gamma irradiated, group (C) non freeze dried gamma irradiated mention the level of gamma irradiation and group (D) freeze dried and gamma irradiated. The maximum tensile force and stress were measured. Statistical analysis using the Mann-Whitney U test was carried out.
Objective
The aim of this study was to investigate PDGF release in the peripheral circulation following trauma and to correlate it with the numbers of MSCs in iliac crest bone marrow (BM) aspirate.
Methods
Trauma patients with lower extremity fractures (n=18, age 21–64 years) were recruited prospectively. Peripheral blood was obtained on admission, and at 1, 3, 5 and 7 days following admission. The serum was collected and PDGF was measured using ELISA. Iliac crest (BM) aspirate (20ml) was obtained on days 0–9 following admission. MSCs were enumerated using standard colony-forming unit fibroblasts (CFU-F) assay.
Background
Bioresorbable materials offer the potential of developing fracture fixation plates with similar mechanical properties to bone thereby minimizing stress shielding and obviating the need for implant removal.
Aim
To determine the in vivo degradation profile of a novel phosphate glass fibre composite bioresorbable plate and effects on the underlying bone.
Purpose
Handgrip dynamometry has previously been used to detect pre - operative malnutrition and predict the likelihood of post - operative complications. This study explored whether a relationship exists between pre-operative pinch and power grip strength and length of hospital stay in patients undergoing hip and knee arthroplasty. We investigated whether handgrip dynamometry could be used pre - operatively to identify patients at greater risk of longer inpatient stays.
Methods
164 patients (64 male, 100 female) due to undergo lower limb arthroplasty (83 Total Knee Replacement, 81 Total Hip Replacement) were assessed in pre - admission clinic. Average measurements of pinch grip and power grip were taken from each patient using the Jamar hydraulic dynamometer (Jamar, USA). Duration of each inpatient stay was recorded. Patients with painful or disabling conditions involving the upper limb were excluded. Other clinical variables such as age and ASA grade were investigated as potential confounders of the relationship of interest and adjusted for.
Introduction
Surgeons are often confronted with large amounts of bone loss during the revision of total hip prostheses. Regularly, porous metals are applied to reconstruct the missing bone. Rapid and extensive bone infiltration into the implant's pores is essential to obtain strong and durable biological fixation. Today, specialised layered manufacturing techniques provide the flexibility to produce custom-made metallic implants with a personalized external shape and a well-controlled internal network of interconnected pores. In this study, bone ingrowth in porous titanium structures that were manufactured by selective laser melting (SLM) was evaluated in an in vivo goat model.
Methods
Cylindrical Ti6Al4V constructs (Ø8mm × 14mm, porosity 75%) with or without hydroxyapatite coating were implanted in six Saanen goats. Three holes were drilled in the subchondral bone of each tibia and femur. Constructs were inserted into the holes in a press-fit manner. Resonance frequency analysis was used to measure construct stability. At 3, 6 and 9 weeks after surgery, fluorochrome labels were injected. After 6 and 12 weeks, samples were explanted. Some samples were scanned with micro-CT and subsequently sectioned for histological analysis. The others were used for pull-out tests.
Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission.
Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE.
The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort.
Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.
Traditionally sequential medial soft tissue release is performed for balancing in total knee arthroplasty for varus knees. Its effects on kinematics have been described in extension and 90° flexion in coronal plane. This is the first study to describe its effects on kinematics throughout flexion. 12 cadaveric knees were studied using a computer navigation system to assess kinematics. Femoro-Tibial-Mechanical-Angle(FTMA) was studied in extension, 0°, 5°, 30°,45°,60°,90° and maximum flexion. Sequential medial release was performed in 7 steps, described by Luring et al(Ref). At each step FTMA was measured without and with stressing. A 10 Newton Meter moment arm was applied for varus and valgus stress. Most of the initial release steps had little effect on FTMA without force applied, especially in the initial 60° of flexion. Application of varus force demonstrated very small changes. Application of valgus force demonstrated little change in initial arc of flexion until step 5 was reached (Table 1). Our study concludes the present sequence of medial release may not be correct and should be further investigated to modify the sequence for soft tissue balancing in TKR surgery.
Purpose
Platelet-Rich Plasma (PRP), an autologous derivative of whole blood that contains a supraphysiological concentration of platelets and growth factors. Most published studies have investigated the effect of PRP-conditioned media on cell cultures. We are not aware of any study that has investigated whole PRP with its cellular components on human tissue cultures. This study aims to investigate the effect of PRP on cell migration from human Achilles tendon explants, and the subsequent cellular proliferative effects in culture.
Methods
This is an
Background
Cauda equina syndrome (CES) is a physical process. There is compression of the cauda equina resulting in arrest of the electrochemical signal from the central nervous system. Previous studies have demonstrated that anthropomorphic features influence nerve conduction properties.
Aim
We therefore sought to if there was an association between biophysical parameters and CES.
Introduction
The correction of paediatric scoliosis is a surgical procedure in which substantial bleeding occurs, and which historically has been associated with high levels of blood transfusion. Transfusions are associated with risks of infection, allergic reactions, volume overload and immunosuppression.
The purpose of our study was to evaluate the efficacy of a care pathway implemented at St Thomas' hospital over ten years with a focus on minimising the need for blood transfusions. A Spinal Surgery Care Pathway was developed including: nurse-led clinics facilitating pre-operative haemoglobin optimisation; intra operative cell-salvage, the use of tranexamic acid, and a transfusion criteria awareness programme.
Methods
We reviewed the records of all patients 18 years of age or younger undergoing spinal corrective surgery between 2000 and 2010. Collating data from the surgical records and haematology laboratory, we identified the proportion of patients requiring transfusion and the respective volume of blood or blood products transfused.
Introduction and aims
Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre.
Method and Materials
Data on 80 patients who had received caudal epidural (n=36), nerve root block (n=28) and facet joint injections (n=16) form August 2010 to October 2011 consented to be in the study. 40 patients in each group completed Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) before and 6 weeks after the procedure and patient satisfaction questionnaire investigating their experience and any complications related to the spinal injection retrospectively. The study included 32 males and 48 females. Mean age 57 years, range 21–88. [Consultant group M:17, F:23 mean age: 55, range 21–81. ASP group M:15, F:25 mean age 59, range 22–88]. Measures of patient satisfaction and outcome were obtained; using 2 tailed independent samples
Introduction
Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery.
Methods
Our institutional neurophysiology database was analysed between 1st October 2005 and 31st March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team.
Objective
Pyogenic spinal infection (PSI) is an increasingly common presentation to spinal units in the UK. Its investigation and diagnosis is often delayed. The purpose of this study was to determine the prognostic significance of the inflammatory marker levels on admission on achieving a positive microbiological diagnosis in patients with PSI.
Study design
Retrospective case series review of all patients presenting with PSI to our unit.
Background
In 2009, NICE CG 88 guideline on the management of non-specific low back pain was published. We looked at whether the introduction of these guidelines has had an impact on the management of back pain within primary care.
Methods
Patients with non-specific low back pain (> 6 weeks but < 12 months) attending spinal outpatient clinic in UHL between 2008 and 2011 were asked to complete questionnaires. Two groups were studied, the first prior to the publication of NICE guidelines, and the second afterwards. Patients with radicular, stenotic and red flag symptoms were excluded. Key audited treatment standards assessed included manual therapy, acupuncture, focused structured back exercise program, supervised group exercise program and lastly referral to a combined physical and psychological treatment program. Compliance with not using X-ray or MRI and treatment modalities such as injections, laser therapy, ultrasound therapy, lumbar supports, traction and TENS therapy was assessed. Secondary outcomes included VAS (back, leg pain), Oswestry Disability Index, MSP and MZD. Primary outcomes analyzed using 1-sided Fisher's exact test and secondary outcomes using two sample t tests.
Introduction
Spondylodiscitis is a combination of discitis and spondylitis. It is very rare to have an isolated discitis without associated vertebral osteomyelitis. It is relatively uncommon in developed nations. However, this disease can lead to severe disability and even death if left untreated. Antibiotics is the mainstay of treatment but cases with neurological compromise would need prompt surgical decompression and stabilisation. Recovery in serious cases is often a lengthy process, requiring long hospital stay. Our unit conducted a review as it is noted spondylodiscitis is becoming more common in elderly and immunocompromised groups.
Patients and methods
Retrospective study of spondylodiscitis presented to our unit over the last three years is conducted. Medical records and charts are reviewed, with a focus on disease presentation, risk factors, causative organisms and when surgery becomes necessary.
Introduction
There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.
Materials and methods
It is a retrospective study of consecutive series of 62 patients with thoracic adolescent idiopathic scoliosis surgically treated by single surgeon between 2007 and 2008 at a tertiary referral Orthopaedic Spinal unit. Posterior spinal fusion and thoracoplasty (n=32, all but one girls) were compared with 30 without thoracoplasty (all but one girls). Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 3-months, 1 year and/or 2-year follow-up, and comparisons were made between two groups. The minimum follow-up was one year.
Introduction
Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections.
Materials & methods
Sheffield Spinal Infection Database collects data prospectively from regularly held Spinal infection MDTs. We accrued 125 spinal infections between September 2008 and October 2010. The medical records, blood results, radiology and bacteriology results of all patients identified were reviewed. In patients with negative first biopsy, second biopsy is contemplated and parenteral broad spectrum antibiotic treatment initiated.
We reviewed the current screening protocol for MRSA detection in patients admitted for elective lower limb arthroplasty as we thought it may not be cost effective and there is no evidence base for validity of MRSA screening swabs.
The laboratory cost for these screening swabs was £9,027. Given the low prevalence rate of MRSA and low conversion rate at 6 weeks, there is a role for accepting a single-swab screening protocol. This would also result in significant cost savings of around £ 4,500.
There is however no evidence in literature about the time period of validity of MRSA screening swabs.
The NW Advancing Quality programme is a regional one aimed at improving the delivery of evidence based care. Hip and knee replacement has been one of 5 clinical areas. Over a 3 year period performance at all 24 NW trusts has been measured. For hip and knee replacement patients the evidence based care has been delivery of antibiotic and thromboembolic prophylaxis. Robust data has been collected on the choice and timeliness of prophylaxis and readmission rates for each trust. The programme included financial and reputational (public reporting) rewards for top performing units. Sharing of data and collaborative working has been put in place to improve overall performance
Over the 3 years of the programme data has been collected on 47,825 patients. Across the region delivery of the measures has improved from 88 to 96%. Patients achieving all measures and avoiding readmission has improved from 64 to 85%. There has been reduced variation in performance. The biggest improvement in performance has occurred in the initially poorer perfoming trusts (year 1 range 54–97%, year 3 range 86–99%). All cause readmission within 28 days of discharge has fallen from 9 to 7%.
The progamme has demonstrated that it is possible to improve delivery of evidence based care and clinical outcomes on a regional basis. It has evolved from a stand alone programme to continue as a regional CQUIN. The programme has had wider benefits. Units report a change of culture producing improved delivery of other protocols. The collaboraive working has created a multidisciplinary network with improvement initiatives widened to include comparing PROMS data, Enhanced Recovery and Shared Decision Making. Challenges have included obtaining consensus regarding the initial and now soon to be introduced updated thromboembolic measures
Using general practitioner records, hospital medical notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with an overall mean age of 71.8 years (34.3–93.2). A total of 319 (79.4%; 95% confidence interval, 75.4%–83.3%) reported complications were confirmed to be correct. Very high rates of correct reporting were demonstrated for infection (94.5%) and further surgery (100%), whereas the rates of reporting deep venous thrombosis (DVT), pulmonary embolism, myocardial infarct and stroke were lower (75%–84.2%). Dislocation, periprosthetic fractures and nerve palsy were associated with modest rates of correct reporting (36%–57.1%). More patients who had had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations in accuracy, it appears that post-operative complications may form part of a larger patient-reported outcome programme for monitoring outcome after elective joint replacement surgery.
Aim
A new multidisciplinary hip fracture pathway, based on national BOA and NICE guidance, was introduced in our institution to facilitate rapid preoperative medical optimisation and early surgery for patients with hip fractures. The aim of this audit was to assess its impact on patient care and outcomes.
Method
A prospective audit of 161 patients admitted with a fractured neck of femur was conducted in the six months before (92 patients) and after (69 patients) implementation of the new pathway. Data included: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; and inpatient mortality rate. Significance was tested using Chi Squared, Fisher's exact and unpaired Student t-Tests.
Introduction
Entry into orthopaedic higher surgical training remains extremely competitive, however little evidence exists regarding the validity of short-listing and interviewing for selection. This paper assesses the relative correlations of short-listing and interview scores in predicting subsequent performance as an orthopaedic trainee.
Methods
We compared data from the selection process (short-listing and interview scores) to subsequent performance during training (academic output and an annual assessment score by Programme Director). Data was prospectively collected from 115 trainees on the South West Thames region of the U.K. during 2000–2010.
Introduction
Fractures of the distal radius are one of the most common extremity fractures encountered in A&E departments and general adult fracture clinics. Over the last 10 years the rate of operation for distal radial fractures has been steadily increasing. Staff within our unit felt that formal teaching, particularly of new medical staff, with regards to fracture reduction and appropriate cast application could result in a reduction in operation rates.
Methods
Retrospective data was extracted from FORD (Fracture Outcome and Research Database). Data included: the number of fractures in a 6 month period, number of fractures undergoing ORIF in that period, fracture configuration, patient demographics, and mechanism of injury. All patients undergoing ORIF had their radiographs assessed by 2 separate reviewers. Information regarding adequate fracture reduction, adequate cast application (using Gap Index calculation), and appropriate plaster cast moulding was recorded. Formal teaching was then given to the next group of medical staff rotating through the unit, and the same data was collected prospectively for that 6 month period. Exclusion criteria included bilateral injuries, and polytrauma patients.
Background
Arthroplasty requires an interdisciplinary multimodal approach with anaesthetists playing a key role; providing stable intra-operative conditions, allowing rapid patient recovery, optimising analgeisa and minimizing side-effects. The incidence of post-operative urinary retention (POUR) varies significantly in joint arthroplasty (10–84%). Current literature quotes lower doses of opioids have been shown to reduce POUR, however studies consistently show spinal opioids influence bladder function causing urinary retention. Existing literature fails to comment upon the rate of POUR following joint arthroplasty comparing intrathecal diamorphine against intrathecal local anaesthetic (ITLA) within a modern fast track arthroplasty system (FTA).
Methods
A two-year (2009–11) retrospective analysis was conducted encompassing a multi-surgeon duel-centre review. Rates of POUR were compared when utilising ITLA and multimodal analgesia including local anaesthetic infiltration (LIA) (site A) against ITLA in combination with intrathecal diamorphine (site B) for joint arthroplasty under spinal analgesia. Outcomes were analysed using 30-day POUR rates coding data and cross-referenced against patient records. Information was collected on patient co-morbidity, age, gender, surgery duration and renal function. Patients were excluded for previous POUR, prostate pathology, postoperative PCA, and conversion to general anaesthetic.
Oxford hip and knee scores are being used by many heath care commissioners to determine whether individual patients are eligible for joint replacement surgery. Oxford scores were not designed for use in deciding whether patients are suitable for surgery and they are not validated as a triage tool. The aim of this study was to assess what effect these predetermined threshold Oxford Scores would have on a contemporary patient cohort.
An analysis was undertaken of 4254 pre-operative Oxford scores in patients who had already undergone either hip resurfacing, a total hip, total knee or unicompartmental knee replacement surgery at our institution between 2008 and 2011. We assessed how these scores would affect the decision making pathway determining which patients would be eligible for joint replacement surgery. We also evaluated the effects this would have on patients undergoing surgery in terms of gender, sex, age and type of arthroplasty.
22.4% hip resurfacings, 10.0% of total hip replacements, 7.5% total knee replacements and 11.0% unicompartmental knee replacements would have been declined on the Oxford Scores system. The selection criteria as set by the health care commissioners was found to be ageist as there was a bias against older patients obtaining surgery. There was a bias against different forms of arthroplasty, particularly those patients suitable for resurfacing or unicompartmental knee replacement. It was also sexist as it selectively excluded male patients from surgery.
Rather than using pre-operative Oxford scores to discern which patients are eligible for surgery, evaluation of patient factors which are reported to adversely affect the outcome of hip and knee replacement surgery, may offer a better solution to improving quality of care. Oxford scores are undertaken to benchmark a providers performance and not to decide on an individual's suitability for surgery.
Introduction
Procedure Based Assessments (PBAs) were recently introduced for orthopaedic trainees and play an increasing role in assessment. The study aims to describe the attitudes of trainees to the educational benefit of PBAs and the factors which underlie these attitudes.
Methodology
A link to an online questionnaire was sent via the eLogbook email system to all orthopaedic trainees in the UK with a National Training Number (NTN). The questions were attitude statements with Likert-type scaled responses, free text responses and closed questions.
Background
Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty.
Purpose
To audit all centres performing revision knee procedures in England and Wales over a 2-year period. All centres were audited against two pre-defined standards linked to hospital volume Operative volume should be greater than 10 revisions per year; More than 2.5 revisions should be performed for every 100 primary arthroplasties implanted.
Introduction
Motion analysis is a validated method of assessing technical dexterity within surgical skills centers. A more accessible and cost-effective method of skills assessment is to use a global rating scale (GRS). We aimed to perform a validation experiment to compare an arthroscopic GRS against motion analysis for monitoring orthopaedic trainees learning simulated arthroscopic meniscal repairs.
Methods
An arthroscopic meniscal repair task on a knee simulator was set up in a bioskills laboratory. Nineteen orthopaedic trainees with no experience of meniscal repair were recruited and their performance assessed whilst undertaking a standardized meniscal repair on 12 occasions. An arthroscopic GRS, assessing parameters such as “depth perception,” “bimanual dexterity,” “instrument handling,” and “final product analysis” was used to evaluate technical skill. Performance was assessed blindly by watching video recordings of the arthroscopic tasks. Dexterity analysis was performed using a motion analysis tracking system which measured “time taken,” “total path length of the subject's hands,” and “number of hand movements”.
Introduction
Restrictions placed on the working hours of doctors have led to increasing time-pressures on surgical training. Consequently, there has been growing interest in developing new techniques to teach and assess technical skills. The primary aim of this study was to determine whether a novel set of visual parameters assessing visuospatial ability, fine motor dexterity and gaze control could objectively distinguish between varying levels of arthroscopic experience. The secondary aim was to evaluate the correlations between these new parameters and previously established technical skill assessment methods.
Methods
27 subjects were divided into a “novice” group (n=7), “trainee” group (n=15) and expert group (n=5) based on previous arthroscopic experience. All subjects performed a diagnostic knee arthroscopy task on a simulator. Their performance was assessed using new simple visual parameters that included “prevalence of instrument loss,” “triangulation time” and “prevalence of look downs”. In addition, performance was also evaluated using previously validated technical skill assessment methods (a global rating scale and motion analysis).
Introduction
The Department of Health determined that, from April 2011, Trusts would not be paid for emergency readmissions within 30 days of discharge. The purpose of our project was to identify factors associated with such readmissions and implement plans for improvement.
Methods
A literature search was performed to assess current practice. The case notes of all readmissions were then obtained and analysed. Following consultation on the results, procedures were developed and implemented to ensure that readmissions were correctly defined and avoided where appropriate. The orthopaedic department infrastructure was altered and staff briefed and trained to accommodate the changes.
Introduction
Urinary catheterisation can cause bacteraemia and therefore may be associated with a risk of infection in hip and knee arthroplasty. However postoperative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for postoperative catheterisation in order to help develop a protocol to decide who should be electively catheterised.
Methods
A prospective blinded study of 128 consecutive patients undergoing lower limb arthroplasty was carried out. No patient underwent perioperative catheterisation. Data obtained included sex, age, joint (hip or knee replacement), prostate score (IPSS), previous urinary retention, comorbidities and residual bladder volume after attempted complete voiding measured using an ultrasound bladder scanner. The type of anaesthesia and the requirement for urinary catheterisation postoperatively were recorded. Predictive risk factors were identified using binary logistic regression, and expressed as odds ratios (OR) and 95% confidence intervals (CI).