Introduction

Trauma is the leading cause of death and disability in children. Pelvic fractures although rare, with a reported incidence of one per 100,000 children per year are 2^nd only to skull fractures with respect to morbidity. The objectives of this study were to improve understanding of paediatric pelvic fractures through a concise review of all aspects of these fractures and associated injuries. Understanding the patterns in which paediatric pelvic fractures and their associated injuries occur and the outcome of treatment is vital to the establishment of effective preventative, diagnostic and therapeutic interventions.

Introduction: Failed surgical treatment of hip fractures typically leads to profound functional disability and pain for the individual, technical challenges for the surgical team, and an increase in the financial burden on society. This study had three purposes:

to determine the reason/s for failure of internal fixation

Methods: Between 1999 and 2005 41 patients (30 women and 11 men) with a mean age of 70 were treated at our institution with a total hip arthroplasty for failed dynamic hip screw fixation of a fracture of the proximal femur. The radiographs and medical charts of all patients were obtained following institutional approval. The quality of the reduction of the fracture achieved was assessed on the basis of displacement and alignment. Screw position was also assessed. Each patient who had undergone salvage arthroplasty (Group 1) was matched with a patient who had undergone total hip arthroplasty for degenerative disease in our unit (Group 2). Patients were matched for age, sex, implant and time since insertion of the implant. All surviving patients form both groups were followed up for a minimum of two years (mean 5 years). Three main outcome measures were compared between the two groups; surgical complications, the Oxford hip score, and radiographic analysis of the femoral component for signs of loosening

Results: Failure to achieve a good reduction and optimal screw placement was evident in 80% of cases of failed fixation. A high incidence of complications was recorded in the perioperative period during conversion to a salvage arthroplasty. Functional outcome was statistically inferior in Group1, this group also had a much higher incidence of complications. Radiographs at 2 years post operatively showed evidence of femoral stem loosening in 16% of the salvage group compared with 3% in the primary hip arthroplasty group.

Conclusion: When undertaking surgical stabilisation of proximal femoral fractures one should make every effort to achieve the best reduction and most accurate fixation possible. Factors such as osteoporosis, compliance with post-operative mobilisation and delay in fracture fixation are to some extent ‘out of the surgeon’s hands’. Conversion to arthroplasty is technically challenging, and is associated with higher complication rate and poorer outcome than primary hip arthroplasty. We recorded a high incidence of femoral stem loosening in patients who had undergone conversion to hip arthroplasty for failed fixation and would recommend more frequent clinical and radiographic follow up of these patients

Background: This study was carried out to record and compare the opinions of junior and senior orthopaedic surgeons with regards to the amount of training necessary to achieve competency in knee arthroscopy.

Methods: At a recent international orthopaedic conference a questionnaire was given to 50 orthopaedic residents and 40 consultants. Consultants were also asked if they performed regular knee arthroscopy (> 50/year). Competency for this study was deWned as the ability to perform the procedure without supervision.

Participants were asked to estimate the number of times a trainee needs to do the following procedures to achieve competency: diagnostic scope, partial medial meniscectomy, partial lateral meniscectomy, and anterior cruciate ligament (ACL) reconstruction.

Results: Participants completed the questionnaire immediately ensuring a 100% response. Of the 40 consultants, 22 performed regular knee arthroscopy. The greatest similarity was between the opinions of the consultants who performed regular knee arthroscopy and the junior surgeons, for both diagnostic and partial medial meniscectomy. There was a substantial diVerence in opinion for partial lateral meniscectomy and ACL reconstruction, with junior surgeons estimating a much greater amount of practice being needed to achieve competency. Consultants who did not perform regular knee arthroscopy consistently estimated approximately half the number of operations when compared to others.

Conclusions: The information presented in this study demonstrates the opinions of both junior and senior surgeons as to how many repetitions of four common arthroscopic procedures are necessary to achieve competency: this information may be useful in designing eVective arthroscopic training programmes.

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Methods: The minimally invasive technique used involves reduction of the fracture by ligamentotaxis with the use of the traction table and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction where necessary was performed using an ankle arthroscope and a probe introduced through stab incisions anteriorly. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. Locking screws were then inserted percutaneously. All significant anterior or posterior distal tibial fragment were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of foot and ankle outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively, by orthopaedic surgeons blinded to the treatment modality. The mean of the two scores was then recorded. It has been previously demonstrated that the functional outcome in pilon fractures improves for approximately 2 years after injury.

Results: We observed a much higher incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5% of the formal open reduction and fixation group.

Conclusion – The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, in the form a medial locking plate with or without additional percutaneously inserted antero-posterior screws represents a valuable method of treating the most complex of closed pilon fractures.

Introduction: The technology available for replacing/resurfacing the hip is constantly evolving. The surgeon can now choose from a wide array of componenets to perform a cemented, hybrid, uncemented total hip arthroplasty (THA) or resurfacing arthroplasty (RSA). The aim of our study was to evaluate and compare the restoration of hip biomechanics following insertion of three different, commonly used constructs.

Methods: We compared the pre and postoperative radiographs from 40 patients who underwent cemented THA, 45 patients who underwent uncemented THA and 40 who underwent RSA. The femoral offset and limb length differences were measured, with reference to the normal contralateral hip.

Results: Resurfacing resulted in a significant reduction in femoral offset, with accurate restoration of limb length. Both cemented and uncemented THA resulted in a significant increase in femoral offset and leg length. Uncemented THA resulted in the greatest degree of leg lengthening.

Discusssion: Restoration of normal hip anatomy optimises biomechanical function and reduces wear of components. The RSA group had the most accurate restoration compared to the two other groups. The reduced femoral offset associated with the RSA group may reduce the lever arm of the abductor muscles however this is unlikely to be clinically important.

Introduction: In September 2007, the Health Service Executive implemented a new employment control policy, due to budgetary constraints. The health ministry and the HSE state that there are no adverse effects on patient care as a result of implementing this policy. In our regional orthopaedic unit, these cutbacks resulted in closure of 12 orthopaedic beds and consequently, a loss of a minimum of 40 joint replacements per month. Most of these patients are having their replacements carried out under the NTPF scheme at a rate, which is three times the local cost.

Aim: The aim of this study was to evaluate the impact of bed closure and consequent reduction in elective orthopaedic workload on a regional orthopaedic unit.

Materials and Methods: A comparative review of elective joint arthroplasty was undertaken with regard to theatre workload, length of time on waiting lists and referrals to the national purchase treatment fund from September 2007 to December 2007. This data was compared with same timeframe in 2006.

Results: Since the implementation of the HSE policy, the elective bed capacity was reduced by 66%. Elective joint replacements performed from September–December 2007 have reduced by 72 patients (109 to 37) compared with the same timeframe in 2006, a reduction in workload of 66%. 107 patients added to waiting list since bed closures, which constitutes a 6-fold increase in time on waiting list.

Conclusion: Following the recent implementation of the HSE policy in September 2007 we have objectively quantified a significant negative impact on elective orthopaedic services in our unit. This false economy also has a negative impact on training opportunities as only more urgent and complex cases are performed in the public sector, while routine cases are carried out in the private sector. Should this trend continue, the impact on surgical and hence future patient care may be detrimental to the public health care system in Ireland.

Introduction: Distal radius metaphyseal fractures in children are not uncommon, but when they occur proximal to the insertion of the pronator quadratus muscle, reduction and maintenance of reduction can be challenging. The deforming forces at the fracture site result in pronation and shortening of the distal fragment. Manual manipulation of this fracture often results in tearing of the dorsal periosteum and hence renders this fracture highly unstable.

Aim: We present a novel easily reproducible mini-open surgical technique and functionally and radiologically evaluate a series of eleven patients who have undergone this technique.

Materials and Methods: The surgical technique consists of a mini-open intrafocal image intensifier guided reduction technique with percutaneous k-wiring fixation. Five males and six females with an average age of 8.8 years (range 5 to 13 years), who sustained a pronator quadratus distal radius fracture and subsequently underwent this surgical technique from 2005 to 2007, were evaluated both radiologically in terms of radial length, radial tilt and volar tilt compared with the contralateral limb and functionally using the Mayo Modified wrist score and the patient related wrist evaluation questionnaire.

Results: Patients were followed up for an average of 18 months (range 2–31 months). All patients achieved clinical and radiological union. No patient required remanipulation for loss of reduction. Radiological outcome measures similar to contralateral limb with good functional scores. No complications were noted. All patients returned to preoperative level of function

Conclusion: This minimally invasive technique has been shown to be technically easy, reliable and reproducible with excellent results and low risk of displacement compared to other techniques used to treat this potentially challenging fracture.

Introduction: The pilon fracture extending from the distal tibial metaphysis into the ankle joint represents one of the most challenging injuries faced by orthopaedic surgeons. Achieving the ideal of anatomic reduction and stable fixation is often impeded by the frequently severe soft tissue injuries associated with these fractures. In June 2004 we began treating intra-articular pilon fractures by minimally invasive techniques.

Materials and Methods: The minimally invasive technique used involved reduction of the fracture by ligamentotaxis and manipulation of the foot to correct rotation, varus/valgus, pro/recurvatum. Any further reduction was performed using an ankle arthroscope and a probe introduced through stab incisions. Following reduction a distal tibial locking plate was applied percutaneously to the medial of the tibia. All significant anterior or posterior distal tibial fragments were fixed separately with an anterior percutaneously inserted interfragmentary compression screw.

We compared all cases of closed intra-articluar fractures (AO types C2 and C3) fixed by the method described above in a one year period (June 2004 – June 2005) – Group 1 (n = 26), with the immediate previous one year period (June 2003 – June 2004) of matched closed fracture pattern fixed by formal open reduction and internal fixation – Group 2 (n = 16).

Mean follow up was 26 months. All bony and soft tissue complications were recorded. A specific assessment of outcome was undertaken using the American Orthopaedic Foot and Ankle Score (AOFAS). Scoring was undertaken on two separate occasions at a mean of 9 and 24 months post operatively.

Results: We observed a far greater incidence of complications in the open reduction group when compared with the minimally invasive group. An excellent AOFAS result was obtained in 83% (20/24) of the patients in the minimally invasive group, the same result was achieved in only 12.5 % of the formal open reduction and fixation group.

Conclusion: The use of the minimally invasive reduction method described here in combination with the insertion of percutaneous fixation, represents a valuable method of treating the most complex of closed pilon fractures.

Introduction: The technology available for replacing/ resurfacing the hip joint is constantly evolving. The practicing surgeon can now choose from a wide array of components to perform a cemented, hybrid, uncemented total hip arthroplasty (THA), or a hip resurfacing. The potential advantages and disadvantages of all have been widely reported in the literature. The choice of implant depends on a number of factors, such as, patient age and level of activity, hip anatomy, and the surgeons’ preference and expertise. The aim of our study was to evaluate and compare the restoration of hip biomechanics following the insertion of three different, commonly used constructs.

Methods: We compared the postoperative anteroposterior radiographs from 40 patients who underwent cemented THA, 45 patients who underwent uncemented THA and 40 who underwent Articular Surface Replacement (ASR). All procedures were carried out by a single consultant orthopaedic surgeon who was experienced in the insertion of all three different implant designs. The acetabular offset and height, and the femoral offset and limb length were measured, with reference to the normal contralateral hip, using accepted methods.

Results – Hip resurfacing resulted in a significant reduction in femoral offset (p < 0.001), with accurate restoration of limb length. Both cemented and uncemented THA resulted in a significant increase in femoral offset, both also resulted in significant leg – lengthening (p< 0.001), this was more marked with uncemented THA’s. Radiological measurements of the acetabular reconstruction were similar in all groups.

Discussion – Restoration of normal hip anatomy optimises biomechanical function and reduces wear of components. The ASR group had the most accurate restoration in comparison to the two other groups. The reduced femoral offset associated with the ASR group may reduce the lever arm of the abductor muscles however this is unlikely to be clinically significant.