Introduction and Objective

Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective was to compare the analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to weak opioids (WO) in the treatment of moderate to severe, nociceptive, chronic pain in knee osteoarthritis patients.

The clinical guidelines for hip fracture management indicate that indwelling foley catheterization should be avoided when possible. Alternatives to indwelling catheters such as intermittent or condom catheters are recommended. Appropriate catheterization usage is important in hip fracture patients to avoid complications such as urinary tract infections (UTIs) (7–24% of patients) or post-operative urinary retention (POUR) (20–56% of patients). In this study, we aim to, (1) evaluate catheter usage in hip fracture patients at a large tertiary care centre, (2) compare current practices in catheter usage to clinical guidelines, (3) determine the incidence of POUR in hip fracture patients (4) determine the factors that increase one's risk of developing POUR.

We analyzed 584 hip fracture patients between the ages of 18 and 102 admitted between November 2015 and October 2017 at a tertiary Care Hospital. Data collected included patient demographics, fracture pattern, surgical procedure, length of stay, co-morbidities and catheter use. We compared actual catheter usage to suggested guidelines to determine whether recommendations were being followed. We also investigated the incidence of POUR and risk factors associated with developing POUR. Independent samples t-test were used to compare continuous dependent variables in bivariate analyses and a logistic regression was used to determine predictors of developing POUR, catheter usage, and length of stay in multivariate analyses. T

Over three quarters (76.9%) of patients with hip fractures were treated with a catheter during their admission, 63.5% of which were inserted pre-operatively and 36.5% of which were inserted post-operatively. Indwelling catheters accounted for 92.2% of catheters used, while intermittent and catheter condoms accounted for 7.8%. POUR occurred in 98 of 584 cases (16.7%). Age (p = 0.004), gender (p=0.001), and presence of kidney disease (p=0.033) were statistically significant predictors of POUR. Fracture pattern (p=0.825), surgical procedure (p=0.298), diabetes mellitus (p=0.309) and UTI in the past 60 days (p=0.848) or on admission (p=0.999) were not statistically significant predictors of developing POUR. The development of POUR did not significantly increase length of stay (p=0.558). There was no statistically significant correlation between developing POUR and extended post-operative catheter use over 24 hours (p=0.844) or 48 hours (p=0.862). Patients who received a catheter pre-operatively or post-operatively for longer than 24 hours were not significantly more likely to develop POUR (p=0.057).

Catheter use was common for all hip fracture patients and indwelling catheters were used in the overwhelming majority of cases. The high frequency of catheter usage, and specifically indwelling catheter usage, suggests that there is low compliance with the clinical guidelines for hip fracture patients. The incidence of POUR was 17%. Older, male patients were more likely to develop POUR. Although not statistically significant, more appropriate catheter use may decrease urinary complications such as POUR.

Introduction

Periprosthetic fractures of the femur are potentially catastrophic injuries associated with significant morbidity and mortality. Surgical treatment comprises revision arthroplasty or internal fixation. It is well established that a delay in treating patients with hip fracture leads to higher mortality rates, however there is limited evidence regarding mortality rates and the time to surgery in patients with lower limb periprosthetic fractures.

The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS).

A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test.

The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants.

There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached.

The unwell child with an acutely irritable hip poses a diagnostic dilemma. Recent studies indicate that pericapsular myositis may be at least as common as joint infection in the septic child. MRI might therefore be a critical first step to avoid unnecessary hip drainage surgery in the septic child with hip symptoms.

We reviewed our own experience with MR imaging in this setting.

We searched our PACS system to retrieve MRI scans performed for children with suspected hip sepsis from August 2008 to August 2014 using the following terms: hip, septic arthritis, osteomyelitis, mysositis, abscess, femur, acetabulum. 56 cases fulfilled inclusion criteria that included acute presentation with hip symptoms and 2 or more Kocher criteria for septic arthritis. Recent unsuccessful hip washout was not a contra-indication.

56 patients presented with acute infection around the hip. 47 (84%) had MRI scans before any surgical intervention and 9 (16%) had scans promptly following unsatisfactory hip washout with failure to improve.

20 (36%) were found to have pericapsular myositis. In this group, the infection commonly involved the iliopsoas (4), gluteal (4), piriformis (5) or obturator (7) muscles. 15 (27%) children had proximal femoral or acetabular osteomyelitis and 8 (14%) were diagnosed with septic arthritis. The 13 (23%) remaining scans did not show infection around the hip.

This study confirms a high rate of extracapsular foci in septic children presenting with hip irritability. Less than 20% had actual septic arthritis in this series. While drainage of a septic joint should never be delayed in the face of a large joint effusion with debris on US, there is a clear role for MRI scanning in the acute setting when the diagnosis is less certain.

A group of UK paediatric surgeons (the UK SCFE Study Group) convened to design pertinent trials in slipped capital femoral epiphysis (SCFE), twelve centres across the UK reviewed the demographics and management of children with SCFE.

At all contributing centres with digital PACS records, a search for terms relating to SCFE were performed. From the results, radiographs and electronically stored clinic letters were assessed to confirm the diagnosis and ascertain age at presentation, incidence of bilaterality, chronicity, stability, management and complications.

A total of 601 SCFEs presented between 2007 and 2012 to the twelve units. The mean age at presentation was 12.5 years. The left hip was nearly twice as commonly involved compared to the right (R: L = 3.3: 5.1), with bilateral presentation in 22% of patients. The most common mode of presentation was acute-on-chronic. Stable slips were over twice as common as unstable. The most common intervention was percutaneous pinning in situ. Open reduction was required in 24% of cases. The commonest complication was osteonecrosis (10.5%).

This data concurs with earlier smaller audits and highlights current demographics and contemporary management of SCFE throughout the UK and informs the subject and content of potential future randomized control trials.

Involvement in research forms a mandatory part of Trauma & Orthopaedic specialty training. Evidence of publication is a compulsory criterion for attaining Certificate of Completion of Training (CCT). The publishing behaviour of orthopaedic trainees from all four deaneries in Scotland was examined (East, North, South East and West of Scotland).

A literature search was performed for Scottish orthopaedic trainees achieving CCT between July 2005–July 2010 using Knowledge Network and PubMed databases. Data collected included date of publication, article type, journal, publishing institute, number of authors and position of trainee within authors.

There was no significant difference in mean number of publications/trainee prior to specialty training across the four deaneries (EOS 0.18; NOS 0.18; SES 0.25; WOS 0.73). The number of publications/trainee during training was statistically significantly higher in SES (mean 6.31; mode 9; median 4) compared to WOS (2.23;0;1), NOS (2.18;1;2) and EOS (1.72;1;1). However, there was no correlation between a trainee's number of publications during training and post–CCT. There was no significant difference for mean number of authors/trainee publication during training across the four deaneries (range 3.38–3.63), nor mean position of trainee in list of authors (range 1.37–1.67).

This study highlights important differences and notable similarities in publishing behaviour during orthopaedic training across the Scottish deaneries. It suggests that rates of publication relate to factors during training and that publishing during training is not predictive of future behaviour. This research may be of interest to trainees, training committees and orthopaedic departments in future appointments.

Aim

Since 2008 we have been using third generation Fassier Duval (FD) telescopic rods for children with complex and severe osteogenesis imperfecta (sOI). We present our experience with the technique.

Purpose

To compare the early medial open approach (MO) with the anterior approach (AO) performed after the appearance of the ossific nucleus for DDH that has failed closed reduction or presented late.

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.

Background

Injury to the ACL is a significant problem and can cause further damage to the internal structures of the knee. ACL injury is associated with injuries to other structures in the knee such as the meniscus and chondral cartilage. Such intra articular injuries pre-dispose the knee to develop arthritis. This injury is usually seen in young and active people usually related to sporting injuries. There is a paucity of literature on the influence of anthropometric features on the hamstring graft obtained in ACL reconstruction, although there are studies on the sex based differences affecting the hamstring graft. This study was undertaken to assess the influence of anthropometric measurements on the graft thickness obtained at ACL reconstruction surgery within the UK population.

Background

A consecutive series of 76 patients (101 hips) underwent primary open reduction, capsulorrhaphy and innominate osteotomy for late presenting developmental hip dislocation. They were aged 1.5 to 5 years at the time of surgery between 1958 and 1965. This study was designed to review their outcome into middle age.

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study. Standardised, well-centered anteroposterior standing hip radiographs were obtained and using the validated method of Hefti (1995), anterior and posterior acetabular coverage and contact area were measured. From this we were able to extrapalate the acetabular version.

Ten operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks.

Twenty-six hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. 21 further age and sex matched AP pelvis radiographs were taken from the PACS system at random. All of which had been reported as normal by a consultant musculoskeletal radiologist, these formed group C.

The Kruskal Wallis test was used to compare the 4 outcomes, in the 3 groups.

A significant difference between the groups was found for contact area (p< 0.001). There was no significant difference between the other 3 outcomes. Anterior coverage (p=0.509), posterior coverage (p = 0.135) and antirversion (p= 0.845).

Conclusion: Acetabular coverage and anteversion in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. The early osteoarthritic changes seen in these hips may be related to a decreased contact area compared to the normal population. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Introduction: A criticism of innominate osteotomy (IO) is that it causes relative acetabular retroversion, predisposing to OA. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients 45 years after they had undergone open reduction and innominate osteotomy for late presenting DDH. Using the validated method of Hefti (1995) we measured anterior and posterior acetabular coverage, contact area and version.

Results: Group 1 – 26 Post-op hips, Group 2 – 20 Contralateral hips, Group 3 – 21 Normal hips. Anterior coverage was 10.8% in group 1, 11.0% in group 2 and 12.0% in group 3. Posterior coverage was 18.8% in group 1, 18.9% in group 2 and 21.0% in group 3. Contact area was 16.1 cm2 in group 1, 13.9 cm2 in group 2, and 22.1 cm2 in group 3. Version was 7.20 in group 1, 7.10 in group 2, and 7.70 in group 3.

A significant difference was found for contact area (p< 0.001). There was no significant difference in version (p = 0.845).

Conclusion: Early OA may be related to contact area. Any abnormal (retro)version grows out. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Introduction: Fibular hemimelia (FH) is a congenital limb reduction deficiency characterised by partial or complete absence of the fibula and a spectrum of associated anomalies. For children with a major anticipated limb length discrepancy and severe foot deformity, management (amputation or limb reconstruction) is controversial.

Materials and Methods: 8 children who are now adults (average age 28 years) underwent limb reconstruction as children in one of two UK centres for severe fibular hemimelia. All 8 participants were recalled to our institution for instrumented gait analysis. The SF-36 and lower limb domains of the Toronto Extremity Salvage Score (TESS) questionnaires were also administered.

Results: Partcipants scored well for general health but had functional limitations reflected in lower TESS scores. Kinematic analysis revealed decreased sagittal knee motion and valgus knee alignment. Also ubiquitous were anterior pelvic tilt and obliquity with incomplete hip extension and reduced range of hip abduction. Kinetic analysis showed reduced peak plantar flexion moment with reduced push-off power and an internal hip adduction moment in late stance. These parameters are compared to control data for below knee amputees.

Discussion and conclusions: Although the number of participants is small, this is the first study to use instrumented gait analysis for severe fibular hemimelia managed with limb reconstruction. The results add objective data to the debate over limb reconstruction or amputation in this group of children.

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study on the long term outcome of this protocol. Standardised, well-centered anteroposterior standing hip radiographs had been obtained. We used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage and contact area. All measurements were made by a single independent investigator.

Results: 10 operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks. 26 hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B.

Discussion: We were unable to assess operated hips which had gone on to replacement or severe osteoarthritis. This is a flaw as those hips with better radiographs have been selected out for study. Nonetheless this was a unique opportunity to assess the effect of innominate osteotomy on acetabular development in good numbers of hips with a variety of evolved outcomes.

Conclusion: Acetabular coverage and load area in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

This study was undertaken to assess the influence of anthropometric measurements on the graft thickness obtained at anterior cruciate ligament reconstruction surgery.

Data from fifty one consecutive patients who had undergone ACL reconstruction by the same surgeon using double loop hamstring grafts were analysed. The body mass index, height and weight of these patients were correlated with the graft thickness obtained during surgery using non parametric tests (Spearman’s correlating coefficient).

There was a statistically significant positive correlation between the body weight and graft thickness (r = 0.32, p=0.02, n= 51). There was however, no correlation between the body mass index and height with the graft thickness.

Anthropometric measurements do not have as much influence on the thickness of the graft as would have been assumed, in ACL reconstruction surgery. Although the body weight has a positive correlation, the body mass index and height do not seem to have any appreciable influence on graft thickness.

Aim: This study was undertaken to assess the incidents of Deep Vein Thrombosis (DVT) and/or Pulmonary Embolus (PE) in orthopaedics outpatients who were immobilised in lower limb casts.

Materials and Methods: We retrospectively analysed the incidents of DVT/PE in a district general hospital over a one year period in orthopaedic outpatients who had their lower limb immobilised. Only patients who were no already on anti-coagulants were included and patients with co-morbidity associated with a higher risk of thrombosis were excluded. The diagnosis of DVT was made by ultrasound scan and PE confirmed with a CT pulmonary angiogram. The details of patients who were found to have a clot were cross checked with the outpatient plaster room register. The relevant case notes were then studied.

Results: There were three hundred and eighty patients who had lower limb casts, six of whom developed a blood clot during the period of immobilisation. All patients were male -and four patients presented with a DVT and two patients presented with a pulmonary embolism, all patients survived.

There were two smokers and one patient was very overweight.

Discussion: Incidents of DVT among patients with lower limb casts are low. At present there is no guideline on the use of DVT prophylaxis in orthopaedic outpatients. Our results show that even though the number of proven DVTs is low, the potential of developing a fatal pulmonary embolus in these patients is present.

Conclusion: DVT prophylaxis could be considered for orthopaedic outpatients who are treated with lower limb casts and who have additional risk factors. A larger prospective survey is required before guidelines regarding prophylaxis can be drawn up.

The aim of the study is to assess the humero radial plica which could be a factor in causing lateral elbow pain. The cause of lateral elbow pain has been an enigma for the orthopaedic surgeons over the years. The synovial fold of the humeroradial joint has been well documented and considered as a meniscus between the articulation. They can also present as symptoms suggesting intra articular loose bodies causing pain in these patients. Our study included 117 consecutive elbow arthroscopies performed by two surgeons for a period of 18 months. All patients were initially treated non-operatively as a ‘tennis elbow’ before undergoing arthroscopy. Conservative treatment included rest, activity modification, physiotherapy including ultrasound bracing, nsaids and local corticosteroid injection. All patients were assessed using the Mayo clinic performance index for elbows both pre and post operatively. Radial head plica was found in 21(18%) out of 117 elbow arthroscopies and was resected using a soft tissue resector. There were 16 (76%) men and 5(24%) women in this affected group and all of whom were young and active with a mean age 38 years. Of the 21 patients 16(76%) had a post operative score of 90 or more (excellent) and 5(24%) had a score 75–89(good). This study addresses the fact that cause of lateral elbow pain can be due to various pathologies in the elbow and in the cases of ‘resistant tennis elbows’ we recommend that the existence of a radial head synovial plica should be considered and if present treatment should be directed at this. Our study demonstrates that by resecting the synovial plical fold, pain will be relieved and these patients regained elbow function. Since this was noted in the young active age group this could reduce the morbidity and the time for rehabilitation required especially for those involved in active sports. A similar series has not been cited in English literature

Aim: To assess the outcome of open release of the common extensor origin in the management of tennis elbow after the failure of non operative treatment methods.

Methods: 18 patients (24 elbows) between the age group of 38 to 59 who underwent open release of the common extensor origin by the same team after a mean waiting time of 23 months from the onset of pain and a trial of failed non operative methods like analgesics/nsaids, physiotherapy, local steroid injections were contacted and asked to score the effectiveness of surgery after a gap of six months. Since the predominant troubling symptom for all patients was pain they were asked to score the pain relief correlating with the surgery.

Results: In 15 patients (83%) excellent pain relief (defined as an 8 or more out of 10 improvement) was achieved and they regained normal use of the limb. One patient (5%) had moderate improvement (score between 6 and 7 out of 10) and two further (11%) patients gained minimal benefit with persistent symptoms (score 5 out of 10). None of the patients suffered deterioration as a result of surgery.

Conclusion: This study proves that despite new advances in the treatment of tennis elbow, release of the extensor origin by the open method which is a simple and economical day case procedure, still remains an excellent option in cases where trial of non operative management has failed.