The aim of this study was to document both the short and long term outcome of isolated displaced olecranon fractures treated with primary non-operative intervention. We identified from our prospective trauma database all patients who were managed non-operatively for a displaced olecranon fracture over a 13-year period. Inclusion criteria included all isolated fractures of the olecranon with >2 mm displacement of the articular surface. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary short-term outcome measure was the Broberg and Morrey Elbow score. The primary long-term outcome measure was the DASH score.

There were 43 patients in the study cohort with a mean age of 76 yrs (40–98). A low energy fall from standing height accounted for 84% of all injuries, with ≥1 co-morbidities documented in 38 (88%) patients. At a mean of 4 months (range, 1.5–10) following injury the mean Broberg and Morrey score was 83 (48–100), with 72% achieving an excellent or good short-term outcome. Long-term follow-up was available in 53% (n=21) patients, with the remainder deceased. At a mean of six years (2–15) post injury, the mean DASH score was 2.9 (0–33.9), the mean Oxford Elbow Score was 47 (42–48) and overall patient satisfaction was 91% (n=21).

We have reported satisfactory short-term and longer-term outcomes following the non-operative management of isolated displaced olecranon fractures in older lower demand patients. Further work is needed to directly compare operative and non-operative management in this patient group.

Conventional computer navigation systems using bone fixation have been validated in measuring anteroposterior (AP) translation of the tibia. Recent developments in non-invasive skin-mounted systems may allow quantification of AP laxity in the out-patient setting.

We tested cadaveric lower limbs (n=12) with a commercial image free navigation system using passive trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° knee flexion and 100N of force applied perpendicular to the tibial tuberosity using a secured dynamometer. Repeatability coefficient was calculated both to reflect precision within each system, and demonstrate agreement between the two systems at each flexion interval. An acceptable repeatability coefficient of ≤3mm was set based on diagnostic criteria for ACL insufficiency when using other mechanical devices to measure AP tibial translation.

Precision within the individual invasive and non-invasive systems measuring AP translation of the tibia was acceptable throughout the range of flexion tested (repeatability coefficient ≤1.6 mm). Agreement between the two systems was acceptable when measuring AP laxity between full extension and 40° knee flexion (repeatability coefficient ≤2.1 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (repeatability coefficient >3 mm).

These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard invasive system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative follow-up of ACL pathology.

The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction.

We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage.

This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD.

Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded.

During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line.

Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity.

Two knee arthroplasty implants with very different design principles were previously available in our region. Kinemax is PCL retaining with a fixed bearing and cemented components. LCS is PCL sacrificing, fully uncemented and incorporates a rotating bearing. The aim of this study was to compare the outcome of these two radically different knee designs.

Between 1994 and 2004, 300 consecutive patients were recruited and underwent a knee replacement performed by the senior author. Each patient was randomised via sealed envelopes to receive either LCS or Kinemax implants. All patients were followed up by an audit nurse and patient satisfaction and Knee Society Scores (KSSs) were recorded.

By 2012, 135 patients had complete data at a minimum of 10-years of follow-up. The remaining 165 had either died before 10-year review or had not reached the 10-year mark. No patient was lost to follow-up. There were 69 patients in the Kinemax group and 68 in the LCS group. The pre-operative demographics were not significantly different between the two groups.

At 10-years of follow-up, each implant design demonstrated significant improvements in the KSS (p=0.001 kinemax, p=0.001 LCS) over pre-operative values. No significant difference could be identified between the two designs at 10 years. There were only two revisions in the whole study population and both were for kinemax implants at less than five years post-operatively.

In conclusion, there was no statistically significant difference in outcome between the two radically different knee designs at ten years with both designs performing equally well.

Radiation exposure is a hazard to orthopaedic surgeons, theatre staff and patients intra-operatively. Obesity is becoming a more prevalent problem worldwide and there is little evidence how a patient's body habitus correlates with the radiation doses required to penetrate the soft tissues for adequate imaging.

We aimed to identify if there was a correlation between Body Mass Index (BMI) and radiation exposure intra-operatively.

We performed a retrospective review of 75 patients who underwent sliding hip screw fixation for femoral neck fractures in one year. We recorded Body Mass Index (BMI), screening time, dose area product (DAP), American Society of Anesthesiologists (ASA) grade, seniority of surgeon and complexity of the fracture configuration. We analysed the data using statistical tests.

We found that there was a statistically significant correlation between dose area product and patient's BMI. There was no statistically significant relationship between screening time and BMI. There was no statistical difference between ASA grade, seniority of surgeon, or complexity of fracture configuration and dose area product.

Obese patients are exposed to increased doses of radiation regardless of length of screening time. Surgeons and theatre staff should be aware of the increased radiation exposure during fixation of fractures in obese patients and, along with radiographers, ensure steps are taken to minimise these risks.

Open or closed fracture of the tibial shaft is a common injury. There is no long-term outcome data of patients after tibial shaft fracture utilising modern treatment methods. This study assessed pain and function of 1509 consecutive patients with a tibial shaft fracture at 12–22 years following injury. Secondary outcomes included: effect on employment, effect of social deprivation, necessity for hardware removal and comparative morbidity following fasciotomy.

Prospective study of 1509 consecutive adult patients with a tibial shaft fracture (1990–1999) at a high-volume trauma unit. 1034 were male, and the mean age at injury was 40 years. Fractures were classified according to AO, and open fractures graded after Gustillo and Anderson. Time to fracture union, complication rate, hardware removal and incidence of anterior knee pain were recorded. Employment and assessment of social deprivation were detailed. Function was assessed at 12 to 22 years post injury using the Short Musculoskeletal Functional Assessment and Short Form 12 questionnaires.

87% of fractures united without further intervention. Social deprivation was associated with higher incidence of fracture and poorer functional and economic outcomes. 11.5% patients underwent fasciotomy which correlated with poorer long-term outcome. Tibial shaft fracture had high mortality in the elderly. At long-term follow-up 25% of patients have anterior knee pain and 20% ankle discomfort after IM nailing.

This is the largest and longest study assessing functional and economic outcomes of tibial shaft fracture. This is the first paper to describe ankle pain following tibial IM nailing at long-term follow-up.

Vancouver B fractures around a cemented polished tapered stem (CTPS) are often treated with revision arthroplasty. Results of osteosynthesis in these fractures are poor as per current literature. However, the available literature does not distinguish between fractures around CTPS from those around other stems.

The aim of our study was to assess the clinical and radiological outcome of open reduction and internal fixation in Vancouver B fractures around CTPS using a broad non-locking plate.

Patients treated with osteosynthesis between January 1997 and July 2011 were retrospectively reviewed. All underwent direct reduction and stabilisation using cerclage wires before definitive fixation with a broad DCP. Bicortical screw fixation was obtained in the proximal and distal fragments. We defined failure of treatment as revision for any cause.

101 patients (42 men and 59 women, mean age 79) were included. 70 had minimum follow-up of 6 months. 63 of these went on to clinical and radiological union. Three developed infected non-union. 7 had failure of fixation. Lack of anatomical reduction was the commonest predictor of failure followed by inadequate proximal fragment fixation and infection. 14 patients dropped at least 1 mobility grade from their preoperative status.

This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Patients who develop these fractures are often frail and “high risk” for major revision surgery. We recommend osteosynthesis for patients with Vancouver B periprosthetic fractures around CTPS provided these fractures can be anatomically reduced and adequately fixed.

Open reduction and internal fixation (ORIF) of ankle fractures is associated with well known complications including wound dehiscence and infection, construct failure and symptomatic metalwork. A technique of intramedullary fibular nailing has been developed that requires only minimal incisions, is biomechanically stronger than ORIF and has low-profile hardware. We hypothesized that fibular nailing would result in a rate of reduction and union comparable to ORIF, with a reduced rate of wound and hardware problems.

100 patients over the age of 65 years with unstable ankle fractures requiring fixation were randomised to undergo fibular nailing or ORIF. Outcome measures assessed over the 12 postoperative months were wound complications, accuracy of reduction, Olerud and Molander score (OMS), and total cost of treatment.

The mean age was 74 years (range 65–93) and 75 patients were women, all had some form of comorbidity. Significantly fewer wound infections occurred in the fibular nail group (p=0.002). Eight patients (16%) in the ORIF group developed lateral-sided wound infections, two of these developed a wound dehiscence requiring further surgical intervention. No infections or wound problems occurred in the fibular nail group and at 1 year patients were significantly happier with the condition of their scar (p=0.02), and had slightly better OMS scores (p=ns). The overall cost of treatment in the fibular nail group was less despite the higher initial cost of the implant.

The fibular nail allows accurate reduction and secure fixation of ankle fractures with a significantly reduced rate of soft-tissue complications when compared with ORIF.

The Ponseti method has been proven to be the gold standard of treatment for clubfoot. The question however remains about the treatment of atypical and complex feet with this method. The Ponseti technique has been used to treat all clubfeet at the our institution for the past 10 years.

We interviewed 70 patients (114 affected feet) ages 5–9 regarding the current state of their clubfoot using the 10 item Disease Specific Instrument (DSI) developed by Roye et al. Of these, 16 patients had a complex foot defined by a transverse medial crease. The DSI scores from all patients were transformed onto a 100 point scale and compared based on overall score as well as functional outcome and satisfaction.

There was no significant difference in the overall scores with a mean of 76.43 (sd= 21.1) in patients who did not have a complex deformity compared to a mean of 79.17 (sd= 19.4) in those who did have a complex foot (p=0.644). On the functional subscale the mean scores were 74.07 (sd=27.1) and 89.58 (sd=25.9) for patients who had non-complex and complex feet, respectively (p=0.474). Regarding satisfaction, the non-complex group had a mean score of 79.51 (sd=19.7) compared to the mean of 78.75 (sd=16.7) in the complex group (p=0.888).

Primary treatment with the Ponseti method achieves very successful correction of the clubfoot deformity with good outcome scores. Furthermore, even in patients with a complex deformity, the Ponseti method still achieves equally successful outcomes.

Tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is a common salvage procedure for a range of indications. Previous work has suggested subtalar joint preparation is unnecessary to achieve satisfactory results. We examine the incidence of symptomatic subtalar nonunion following tibiotalocalcaneal fusion in a series of patients, all of whom had full preparation of the subtalar joint, and consider the possible contributing factors.

We performed a retrospective review of all patients who underwent TTC arthrodesis from 2004–2010. All fusions were performed by the same surgeon with full preparation of both tibiotalar and subtalar joints.

61 TTC arthrodeses were performed in 55 patients (mean age = 59 years) using an intramedullary retrograde nail. Mean follow-up was 18 months (6–48 months). Fifty-six ankles (92%) achieved satisfactory union. Five patients (8%) had symptomatic non-union: 4 patients of the subtalar joint - with 3 patients undergoing revision subtalar arthrodesis and 1 patient of the tibiotalar joint. Nine patients required removal of the calcaneal screw (16%) – all had evidence of isolated subtalar nonunion prior to metalwork failure. Eight of these patients achieved asymptomatic union following screw removal.

Subtalar nonunion following TTC fusion has resulted in recent changes to nail design to increase stability across the subtalar joint. Our results demonstrate a favourable overall nonunion rate with isolated subtalar nonunion making up the majority of cases. We also observed a significant rate of distal screw loosening, also associated with subtalar nonunion prior to screw removal, the significance of which merits further investigation.

The longitudinal midline and medial-parapatellar incision are commonly used in Total Knee Arthroplasty (TKA). Medial-parapatellar incision n offers a smaller wound, avoids creation of thin skin flaps and easier exposure in obese patients. This incision creates a lateral skin flap which may be subject to poor blood supply and delayed wound healing.

We undertook a Randomised Controlled Trial (n=20) comparing midline and medial-parapatellar incisions. Cutaneous blood-flow was measured using a Doppler Imager. Interstitial fluid measurements for lactate, pyruvate, lactate/pyruvate ratio and glucose were obtained from subcutaneous microdialysis catheters. Wound cosmesis was graded and skin sensation tested.

Immediately post-op there was no significant difference in subcutaneous blood flow, but by day 3 patients with medial-parapatellar incisions showed greater bloodflow than midline incisions, particularly on the medial side (387 vs 278units p=0.148). At both day 1 and 3 post-op the lateral flap of the medial parapatellar incision showed decreased blood flow compared to the medial side, though these failed to reach significance. In contrast the midline incision showed no discernable difference in blood flow between the medial and lateral flaps. Concentrations of subcutaneous glucose increased from 4 hours post-op in the midline group, returning to baseline by 24hours. In contrast, the parapatellar group remained at base line throughout. Lactate concentrations increased over time in both groups peaking at 12hours post-op. No difference was noted between incision types with regard to wound cosmesis.

We conclude that the use of a medial-parapatellar incision results in only minimal biochemical changes, which are unlikely to alter wound healing. Medial-parapatellar incision is therefore a safe alternative to a midline incision and can be utilised in appropriate complex cases to aid surgical exposure.

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery.

From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified.

55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33).

There has been recent interest in the treatment of Dupuytren's disease by minimally invasive techniques such as needle fasciotomy and collagenase injection, but only few studies have reported the outcomes following open fasciotomy. This study attempts to address this gap, with a retrospective analysis of a large series of patients who underwent an open fasciotomy by a single surgeon over a five-year period. The aim of the study was to determine the requirement for re-operation in the cohort and to analyse the revisionary procedures performed.

Theatre coding data was used to identify a consecutive series of patients who underwent open fasciotomy over a five-year period between 2000 and 2005. Within this group medical records were obtained for those patients who underwent a secondary procedure for recurrence. All procedures were carried out by a single surgeon in a regional hand unit using an unmodified open technique.

A total of 1077 patients underwent open fasciotomy for Dupuytren's disease. Of these, 865 (80.3%) were male and 212 (19.7%) were female. The mean age at initial surgery was 64.4 years (range 21.7 to 93.7 years) for males and 68.3 (range 43.6 to 89.8 years) for females. Of the 1077 patients who underwent open fasciotomy, 143 patients (13.3%) subsequently underwent a second procedure for recurrence.

The medical records were available for 97 patients. The median time to re-operation in this group of patients was 42.0 months (95% CI, 8.3 to 98.0 months). The most common revision procedure being dermofasciectomy (54.2%), followed by fasciectomy (32.6%) and re-do open fasciotomy (13.2%). Mean pre-operative total extension deficit was 88 degrees (range 30–180 degrees) with intra-operative correction to a mean of 9.5 degrees (range 0–45 degrees).

There is no standard definition for recurrence after Dupuytren's surgery. We have looked at the rate of revision surgery after open fasciotomy, in a relatively fixed population serviced over a 5-year period by a single hand surgeon. A low re-operation rate has been identified, with good intra-operative correction achieved by secondary surgery.

There is a high rate of forearm deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients acquire a dislocated radial head due to disproportionate ulnar shortening.

One-hundred and six patients with HME aged 15 years or older were identified from a prospective database. Flexion and extension of the elbow and wrist, and supination and pronation of the forearm was measured. The number of exostoses affecting the proximal and distal radius and ulna were recorded. Proportional ulna length was calculated as a percentage of the patients measured height ([ulna length/height] × 100).

More than 70% of patients were affected by exostoses of the forearm, of which the distal radius was the commonest site to be affected (73%). One in seven patients had a dislocated radial head, which was associated with proportional ulna shortening (p<0.001). Both radial head dislocation (p<0.001) and proportional ulna shortening (p<0.001) were confirmed to be independent predictors of forearm motion on multivariable regression analysis. In conjunction with other predictors these could be used to calculate ROM of the forearm. In addition proportional ulna length was also an independent predictor of radial head dislocation (p<0.001).

Proportional ulna length could be used as a tool to identify patients at risk of diminished forearm motion and radial head dislocation during childhood, who could be monitored clinically and radiographically, and surgical intervention could be offered before deterioration in function and dislocation of the radial head occurs.