Introduction

Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt.

Background

Over 10% of total hip arthroplasty (THA) surgeries performed in England and Wales are revision procedures¹. Malorientation of the acetabular component in THA may contribute to premature failure due to mechanisms such as edge loading and prosthetic impingement. It is known that the pelvis flexes and extends during activities of daily living (ADLs), and excessive pelvic motion can contribute to functional acetabular malorientation. Preoperative radiographs can be performed to measure changes in pelvic tilt during ADLs to identify high risk individuals and inform surgical decision making. However, radiographs require time-consuming radiation exposure, and are unable to provide truly dynamic 3-dimensional analysis. The purpose of this study was to develop and evaluate a motion capture method using inertial measurement units (IMUs). This would provide a rapid, non-invasive analysis of pelvic tilt which could be used to support surgical planning.

Background

Over 10% of total hip arthroplasty (THA) surgeries performed in England and Wales are revision procedures¹. Malorientation of the acetabular component in THA may contribute to premature failure. Yet with increasingly younger populations receiving THA surgery (through higher incidences of obesity) and longer life expectancy in general, the lifetime of an implant needs to increase to avoid a rapid increase in revision surgery in the future.

The Evaluation of X-ray, Acetabular Guides and Computerised Tomography in THA (EXACT) trial is assessing the pelvic tilt of a patient by capturing x-rays from the patient in sitting, standing and step-up positions. It uses this information, along with a CT scan image, to deliver a personalised dynamic simulation that outputs an optimised position for the hip replacement. A clinical trial is currently in place to investigate how the new procedure improves patient outcomes².

Our aim in this project was to assess whether accurate functional assessment of pelvic tilt could be further obtained using inertial measurement units (IMUs). This would provide a rapid, non-invasive triaging method such that only patients with high levels of tilt measured by the sensors would then receive the full assessment with x-rays.

Purpose

Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI.

Introduction

Hoffa fractures are rare, intra-articular fractures of the femoral condyle in the coronal plane and involving the weight-bearing surface of the distal femur. Surgical fixation is warranted to achieve stability, early mobilisation and satisfactory knee function.

We describe a unique type of Hoffa fracture in the coronal plane with sagittal split and intra-articular comminution. There is scant evidence in current literature with regards to surgical approaches, techniques and implants. We report of our case with a review of the literature.

The TL Hex (Orthofix) is a relatively new hexapod frame system that we have been using at our institution since August 2013 to treat acute fractures and correct tibial and femoral deformity. We report our initial experience of 48 completed treatments with this novel system in 46 patients and discuss illustrative cases.

For acute fracture, 30 patients (24 male, 7 female) required framing with a mean age of 43 years (range 19–80). One patient underwent bilateral framing. The tibia was involved in all cases. In two cases, the femur also required framing. Open fractures occurred in 13 cases (43.3%).

For elective limb reconstruction, 16 patients (14 male, two female) required framing with a mean age of 35 years (range 16–67). One patient underwent bilateral framing. The tibia was involved in all but one case, which affected the femur. Surgical indications included congenital deformity in four cases, malunion in eight cases, non-union in three cases and chronic infection in two cases.

For acute fractures, the mean frame time was 164 days (range 63–560) and all but one fracture achieved union. Complications included pin, wire or strut failure requiring adjustment (three patients) and pin site infection (six patients). Three patients are being considered for residual deformity correction or treatment of non-union.

In the elective limb reconstruction group, mean frame time was 220 days (range 140–462). All treatments successfully achieved deformity correction and bone union. Complications included two pin site infections. There was no evidence of recurrence of infection in the two osteomyelitis cases.

In conclusion, the TL Hex frame system appears to be a safe and reliable tool for limb reconstruction. We have observed acceptable frame times, low complication rates and almost 100% bony union.

Aim

To determine the influence of tendo achilles (TA) rupture gap distance and location on clinical outcome managed with accelerated functional rehabilitation.

Background

Bioresorbable materials offer the potential of developing fracture fixation plates with similar properties to bone thereby minimising the “stress shielding” associated with metal plates and obviating the need for implant removal. Phosphate glass fibre reinforced (PGF)-polylactic acid (PLA) composites are bioresorbable and have demonstrated sufficient retention of mechanical properties to enable load bearing applications.

Background

Percutaneous vertebroplasty (PVP) is a well established procedure with respect to improved pain and function following vertebral compression fracture. Currently, there is no consensus on the optimal cement distribution within a treated vertebral body. The aim of this study was to determine the influence of two distinct patterns of cement distribution following PVP on patient reported outcome measures up to 1 year post procedure.

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.

Approximately one-fifth of patients are not satisfied with total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain and psychological disease, which may present as anxiety and depression. It is unclear whether this is constitutional or the result of knee pain. To address this, we explored the association of anxiety and depression with knee disability before and after TKA.

Forty patients undergoing TKA completed Hospital Anxiety and Depression Scale (HADS) and Oxford Knee Scores (OKS) preoperatively and at three and six months postoperatively. Both were elevated preoperatively and improved significantly post-operatively (P<0.001). The severity of preoperative anxiety and depression was associated with worse knee disability (coefficient −0.409, p=0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after three (coefficient −0.459, p=0.003) and six months (coefficient −0.428, p=0.006).

The difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improves with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both.

Long bone fractures are a commonly presented paediatric injury. Whilst the possibility of either accidental or non-accidental aetiology ensures significant forensic relevance, there remain few clinical approaches that assist with this differential diagnosis. The aim of this current study was to generate a reproducible model of spiral fracture in immature bone, allowing investigation of the potential relationship between the rotational speed and the angle of the subsequent spiral fracture.

Seventy bovine metacarpal bones were harvested from 7 day old calves. Sharp dissection ensured removal of the soft tissue, whilst preserving the periosteum. The bones were then distributed evenly before eleven groups, before being aligned along their central axis within a torsional testing machine. Each group of bones were then tested to failure at a different rotational speed (0.5, 1, 15, 20, 30, 40, 45, 60, 75, 80 and 90 degrees s-1). The angle of spiral fracture, relative to the long axis, was then measured, whilst the fracture location, the extent of comminution and periosteal disruption, were all recorded.

Sixty-two out of 70 specimens failed in spiral fracture, with the remaining tests failing at the anchorage site. All bone fractures centred on the narrowest waist diameter, with 5 specimens (all tested at 90 degrees s-1) demonstrating comminution and periosteal disruption. The recorded spiral fracture angles ranged from 30 - 45 degrees, and were dependant on the rotational speed.

This study has established a relationship between the speed of rotation and the angle of spiral fracture in immature bovine bone. It is anticipated that further study will enable investigation of this trend in paediatric bone, ultimately providing an additional diagnostic tool for clinicians trying to verify the proposed mechanism of injury.

Aim

To determine the effects of knee and ankle position on tendo Achilles (TA) gap distance in patients with acute rupture using ultrasound.

Purpose of study: Self reported walking distance is a clinically relevant measure of function. Our aim was to report patient accuracy and understand factors that might influence perceived walking distance.

Method: A prospective cohort study. 103 patients were asked to perform one test of distance estimation and 2 tests of functional distance perception using pre-measured landmarks. Standard spine specific outcomes included the patient reported claudication distance, Oswestry disability index (ODI), Low Back Outcome Score (LBOS), visual analogue score (VAS) for leg and back, and Modified Zung Depression index (MZD).

Results: There are over-estimators and under-estimators. Overall the accuracy to within 10 yards was only 5% for distance estimation and 40% for the two tests of functional distance perception. Distance: Actual distance 121.4 yds; mean response 268yds (95% CI 192.8–344.15), Functional test 1 actual distance 32 yards; mean response 78.4 yds (95% CI 58.6–97.3), Functional test 2 actual distance 21.4yds; mean response 51.9yds (95% CI 38.3–65.5). Surprisingly patients over 60 years of age (n=43) are twice as accurate with each test performed compared to those under 60 (n=60) (average 70% overestimation compared to 140%; p=0.06). Patients in social class I (n=18) were more accurate than those in classes II–V (n= 85) (59% vs 131% p=0.13). There was a positive correlation between poor accuracy and increasing MZD (Pearson’s correlation coefficient 0.250; p=0.012). ODI, LBOS and other parameters measured showed no correlation.

Conclusions: Subjective distance perception and estimation is poor in this population. Patients over 60 and those with a professional background are more accurate.

The purpose of this study was to assess the Interobserver Reliability of the Sauvegrain Skeletal Age Assessment.

Elbow radiographs requested to exclude injury were anonymised. Sixteen examinations were assessed by ten independent orthopaedic specialist registrars or consultants. The Sauvegrain method as modified by Dimeglio was used to score the radiographs. The observations made were then assessed for interobserver reliability by means of a multiple observer Kappa score and the total scores by intra-class correlation coefficient.

Kappa scores for the components of the score were 0.403 for the lateral condyle; 0.492 for the trochlea; 0.354 for the proximal radius and 0.508 for the olecranon. Adding item scores to produce a modified Sauvegrain score had an intraclass reliability of 0.858 (95% CI 0.758 to 0.935).

Methods of identifying skeletal maturation and predicting future growth generally depend on the use of an atlas of hand radiographs. Difficulties with poor interobserver reliability associated with these methods has led to a move towards assessments that do not depend upon bone age estimations. Unfortunately plans based on ratios of growth or average patterns produce errors when unusual types of growth disturbance are present. We conclude that use of a scoring system for maturation assessed by elbow radiographs offers a significant advantage when substituted into the straight line method of growth prediction. The Sauvegrain method as modified by Dimeglio1 has demonstrated an excellent level of inter observer reliability. We have used Sauvegrain scores to improve the accuracy of timing when using the Mosely straight line method.

Objective: To determine if there was any difference in standard spine outcome measures for single level degenerative lumbar spondylolisthesis treated by decompression and intertransverse fusion alone or with pedicle screw instrumentation.

Methods: A prospective longitudinal cohort study was undertaken looking at 23 patients undergoing surgery for L4/5 degenerative spondylolisthesis with symptomatic spinal stenosis. Clinical outcome was assessed through specific outcome measures of walking distance(yards), Oswestry disability index (ODI), Back Functional Assessment (BFA) and Visual analogue score for pain(VAS).

Results: Follow up was achieved in 21 patients (91%) and the mean length of follow up was 29 months (range 12–60 months). The mean age at operation was 66 years. In the uninstrumented group (n=12), the mean pre and post operative outcome scores were: walking distance (pre-122, post-950), ODI (pre-45, post-29), BFA (pre-23, post-31) and VAS (pre-83, post 49). In the instrumented group (n=11), the mean pre- and post operative outcome scores were: walking distance (pre-143, post-763), ODI (pre-54, post-33), BFA (pre-14, post 33) and VAS (pre-77, post-49). There was no statistically significant difference in improvement in each outcome measure between the two groups.

Conclusion: Surgical decompression in degenerative spondylolisthesis aims to relieve symptoms of radicular pain and neurogenic claudication. However, the indications for instrumentation are controversial. Previous studies have shown an improved fusion rate with instrumentation but no difference in subjective patient satisfaction scores. We have used validated patient based outcome measures to assess clinical outcome. Our results show no statistically significant difference between single level L4/5 degenerative spondylolisthesis treated with decompression with or without instrumentation.

There is still much debate on the appropriateness of taking post operative radiographs especially in the presence of high quality radiography that image intensifiers now provide. The aim of this study was to determine current UK practice regarding the use of check radiographs and to compare this practice with the implant related complications.

A postal performa was sent to 450 randomly chosen UK Trauma and Orthopaedic Consultants to assess their practice regarding check radiographs following hip fracture surgery. In addition a case note review of all patients undergoing hip fracture surgery over the three years of 2001 to 2003 at Selly Oak Hospital, was performed. Patients undergoing revision surgery in the same admission were identified. The decision to revise was noted to determine whether check radiograph influenced the decision.

Response rate to the performa was 66.7% (300/450). 96% routinely took postoperative radiographs following Hemiarthroplasty. Of these, 87% allowed the patient to mobilise before checking the radiograph. In the DHS group, 61% took check radiographs. Of these, 75% allowed the patient to mobilise prior to reviewing the radiograph. Following Cannulated screw fixation, 58% routinely performed check radiographs and 67% allowed the patient to mobilise before reviewing the radiograph. 1265 hip fracture surgeries were performed in our unit in three years. Only one decision to revise was based on a problem identified on a routine check radiograph.

We highlight the lack of national consensus on the use of post operative radiographs. We recommend the use of post operative radiographs only when clinically indicated, hence sparing the patient from discomfort, unnecessary exposure to radiation as well as allowing more effective utilisation of radiological and human resources.

Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. We reviewed the cases undertaken in our department, complications, which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12 years period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range [18 to 66]). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. In conclusion this study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although, the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed.

The clinical diagnosis of an acute compartment syndrome is most reliably based on increasing pain and pain on stretching the affected muscle groups. These signs cannot be elicited in the presence of epidural or regional blocks, or if the patient is unconscious. We present a national audit of consultant trauma and orthopaedic surgeons on the use of compartmental pressure monitoring in such patients. The postal questionnaire also asked whether a departmental protocol was in use and whether regional and epidural blocks were withheld in patients at risk of developing an acute compartment syndrome.

17% of consultants had such an agreed protocol, 53% did not have access to a continuous pressure monitoring device, 58% would request for an epidural/regional block to be withheld with only 2% routinely measuring compartment pressures in the presence of such a block.

This study highlights a major deficiency in the clinical approach to a relatively common condition that may result in limb and life threatening complications and supports the recommendation for compartmental monitoring equipment to be made available.

Easier access, organised holidays targeting differing age groups, an ageing population and lower fares have resulted in a varied air-travelling population of all ages. Medical issues surrounding air travel such as thromboembolic events and the so called ‘economy class syndrome’, as well as dramatic medical intervention at 36,000ft do make for equally dramatic headlines in the popular press. As passengers are more aware of the medical vulnerability of air travel, airlines too are conscious of the medical support they can offer to their passengers. The British Medical Association (BMA) has recently raised concerns over training of flight staff and equipment carried during flights. Issues under debate include whether it is correct for airlines to rely on ‘Samaritan’ doctors or nurses that happen to be on board, or whether qualified medical staff should be part of the aircrew.

Our study reports the analysis of medical emergencies occurring on a major international airline over a period of six months. We looked at the nature of the medical complaint, the treatment received and who gave this treatment. This airline ensures cabin crew receive 30 hours of training in first aid and basic life support during their introductory training period that is followed by annual updates. Senior aircrew, usually the purser are trained in the use of an automated defibrillator. The aircraft carries a first aid kit that all cabin crew are trained to use. In addition there is a medical kit that can be used by any doctor, nurse or paramedic who may respond to an assistance call. In addition in-flight advice is available from Medlink, an independent company that will give direct advice including medical diversion and arrange support for patients on landing

Exacerbation of pre-existing medical problems accounted for the majority of in-flight emergencies. Pre-flight advice, screening and an increased vigilance by ground staff may recognise passengers who are medically unfit to fly.

Syncope accounts for 91% of new in-flight emergencies and appear related to a prolonged period of sitting. In-flight advice as part of Deep Venous Thrombosis (DVT) prevention is given on many long haul flights. This advice should also emphasise the importance of an exercise regime prior to getting up from the sitting position to reduce the number of syncopal episodes.

With adequate cabin crew training, in flight telephone support from commercial companies and careful selection of drugs, the need for ‘Samaritan’ medical help can be greatly reduced.