Aims

The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture.

Introduction

The application of artificial intelligence (A.I) using patient reported outcomes (PROs) to predict benefits, risks, benefits and likelihood of improvement following surgery presents a new frontier in shared decision-making. The purpose of this study was to assess the impact of an A.I-enabled decision aid versus patient education alone on decision quality in patients with knee OA considering total knee replacement (TKR). Secondarily we assess impact on shared decision-making, patient satisfaction, functional outcomes, consultation time, TKR rates and treatment concordance.

Aim

To review the natural history of upper limb osteochondromas and assess their functional effect.

Aim

This pilot study aimed to identify the important symptomatic, functional and psychosocial aspects of hip disorders from the perspective of adolescent patients and their families in order to begin developing a patient-focused instrument (Bridging Adolescent Self-Reported Hip – BASH - score).

Introduction

The number of revision hip arthroplasty procedures is rising annually with 7852 such operations performed in the UK in 2010. These are expensive procedures due to pre-operative investigation, surgical implants and instrumentation, protracted hospital stay, and pharmacological costs. There is a paucity of robust literature on the costs associated with the common indications for this surgery.

Introduction: The proximal femoral nail antirotation (PFNA) system is a cephalomedullary device originally designed to contend with the challenge of unstable tro-chanteric femoral fractures with the novel helical blade component aimed at limiting femoral head limiting cutout. We demonstrate its use in a variety of cases.

Methods: This is a prospective study of 370 consecutive patients treated with short and long PFNA systems at a single center with 1-year follow-up. The device was used for unstable trochanteric femoral fractures (AO-classification 31. A.2 and A.3), prophylactic and definitive fixation of pathological fractures and high energy femoral fractures for a wide age range (19–101 years). Clinical outcome involved assessment of general mobility & function, operative and post-operative parameters & complications. Radiological outcome involved assessment of blade tip-apex distance, nail tip-femoral scar distance and distal locking configurations.

Results: 17% died within the follow-up period. 72% achieved their pre-trauma mobility status and nearly all fractures healed within 6 months including those in over 85 years. Of 18 problematic cases, serious complications included deep infection, loss of proximal reduction, ipsilateral femoral shaft fracture and periprosthetic supra-condylar fracture. There were no cases of acetabular penetration or blade cut-out. Short PFNA was associated with the majority of femoral shaft fractures and the only significant finding regarding instrumentation.

Discussion: This study supports long PFNA design theory demonstrating adequate purchase in the femoral head-neck zone, shown by lack of cut-out. Positive results have been demonstrated in a variety of cases making it a useful option in fractures in all ages and indications alongside unstable trochanteric configurations.

Juvenile idiopathic arthritis (JIA) affecting the hip can cause debilitating pain and walking disability in children. Total hip replacement offers the potential of a pain free joint and a significant improvement in function. There remains the concern regarding the high rates of aseptic loosening of cemented total hip replacements in this group of patients, and there is evidence that younger patients have higher failure rates.

The aim of this study was to look at the results of uncemented total hip replacement in children with Juvenile Idiopathic Arthritis and in particular to assess any problems associated with performing this surgery in the presence of open growth plates in the acetabular and trochanteric regions.

Between 1995 and 2005, 56 uncemented total hip replacements were carried out in 37 children with JIA with a mean follow up of 7.5 years (range 3 to 12.5). 25 of the hips had ceramic on ceramic bearings. The mean age at surgery was 13.9 years (range 11–16). 19 patients underwent bilateral procedures. All patients showed a significant improvement in their HSS Hip scores (p< 0.01). Two CAD CAM femoral stems were revised for gross subsidence and three acetabular components were revised for loosening. Four polyethylene liners were exchanged due to wear. 51 of 53 (96%) femoral stems and 50 (94%) acetabular components remain well fixed at latest follow up with no signs of loosening. There were no dislocations or infections.

Uncemented fixation appears to work well in this challenging group of patients even in the presence of open growth plates. Implant choice is important to avoid problems of subsidence and loosening. Ceramic bearings available for small implant sizes give promise of improved performance compared to polyethylene over the long term.

Background: The phenomenon of heterotopic ossification (HO) is a well-known complication of joint replacement surgery. However, the clinical associations and effects of HO in cervical arthroplasty are unclear. This study investigates the incidence of HO in cervical disc replacement, identifies potential associated risk factors, and assesses the relationship of HO with clinical outcomes.

Method: The patient population (n=90; 39 men, 51 women; mean age 45 years; range 26–79 yr; standard deviation, 9.8 yr) was acquired from the original multi-center, prospective, observational Bryan Disc Study by the European Consortium. The presence of HO was defined in accordance with the McAfee classification based on cervical lateral x-rays at 12 months post surgery and interpreted by an independent neurosurgeon and a radiologist. Secondary outcome measurements included Odom’s criteria and the Medical Outcomes Study Short-Form 36-Item Health Survey.

Results: 16 out of the total 90 patients (17.8%) experienced HO. 6 patients (6.7%) experienced Grade 3 and 4 HO. 10 patients’ (11%) artificial discs demonstrated movement of less than 2 degrees on flexion and extension cervical x-ray at 12 months post-operatively. 4 of these patients had HO of Grade 3 or 4. Male sex ([chi]² = 4.1; P = 0.0407) and older patients (P = 0.023; odds ratio = 1.10; 95% confidence interval = 1.01–1.19) were associated with development of HO.

Discussion: HO is known to restrict movement of large joint and lumbar disc replacements. Our study demonstrates male sex and older age as potential risk factors in development of HO after cervical disc arthroplasty. There is a strong association between HO and subsequent loss of movement of implanted cervical artificial discs. Failure to preserve motion may expedite the onset of symptomatic adjacent segment level disease making this an important complication requiring further investigation. Grade 3 or 4 HO limited movement in 4.4% of patients.

Background: There is conflicting evidence of correlation between clinical outcome and severity of thoracolumbar spine fractures in neurologically intact patients1. Kalyan et al2 presented the results of their prospective study of thoracolumbar spinal fractures and concluded that the clinical outcome was consistently better predicted by the severity of disc injury than that of the bony fracture. They suggested that if severe disc injury was present, treatment of the disc injury may result in a better short term clinical outcome. The aim of this study was to detail the incidence and type of disc injury in patients with thoracolumbar spinal fractures with intact neurology.

Methods: Retrospective analysis of a prospectively collected spinal injury database at a regional spinal injuries unit. Only patients with a thoracolumbar spinal fracture and intact neurology were included. Retrospective analysis of magnetic resonance imaging (MRI) findings. One hundred and thirty nine neurologically intact patients (89M:50F, mean age 36 years, range 15 – 77yrs) with a thoracolumbar (T11 –L5) spinal fracture were admitted to our spinal unit over the last 11 years (1994 – 2004). Patient data was collected prospectively onto a spinal injuries database. All of these patients had an MRI scan on admission. All types of thoracolumbar fracture were included in this study and the presence or absence of an associated disc injury was recorded retrospectively from the MRI study. The type of disc injury was also recorded.

Results: The incidence of severe disc injury adjacent to a thoracolumbar spinal fracture in our cohort of patients was 43% (60 patients). Disc prolapse or extradural herniation was seen in 16 patients (11%). Intraosseous disc herniation into an adjacent vertebral body was seen in 20 patients (14%). Internal disc disruption was seen in 24 patients (17%). Disc injury was found at more than one level in 21 patients (15%).

Conclusion: The incidence of severe disc injury in our study of neurologically intact patients with a thoracolumbar fracture was considerable (43%). Kalyan et al² suggested that treatment directed at addressing the disc injury in these patients may promote earlier pain relief and also earlier return to pre-morbid activities. If this is the case, then the decision making regarding operative versus non-operative management, in a patient with a thoracolumbar fracture and intact neurology, should be based on the severity of the disc injury as well as the bony injury.