At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience. Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction. 77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’. The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences

Implant removal is necessary in up to 25% of patients with plate osteosynthesis after proximal humeral fracture. Our new technique of arthroscopic implant removal offers all advantages of minimal invasive surgery. Additionally treatment of concomitant intraarticular lesions is possible. This study outlines the first results after arthroscopic implant removal in comparison with those of open implant removal. A prospective series of 40 consecutive treated patients had implant removal and arthrolysis after plate osteosynthesis of proximal humeral fracture. Implant removal was carried out due to limitation in range of movement, secondary implant dislocation and implant impingement. 30 patients (median age 63 (30–82) years) had arthroscopic, ten patients (median age 53 (34–76) years) had open implant removal. Median 10 months after implant removal subjective patient satisfaction, Constant Murley Score (CMS) and Simple Shoulder Test were determined. Arthroscopic implant removal showed comparable first results as open implant removal. There was no significant difference between CMS of both groups. The active shoulder abduction, flexion and external rotation improved significantly after arthroscopic and open implant removal. The simple shoulder test outlined advantages for the arthroscopic technique. After arthroscopic implant removal patients showed higher subjective satisfaction as well as faster pain reduction and mobilization. Analysis of perioperative data showed less blood loss in the group with arthroscopic implant removal. In 85% of patients with arthroscopic implant removal concomitant intraarticular lesions were observed and treated. The arthroscopic implant removal after plate osteosynthesis of proximal humeral fractures offers all advantages of minimal invasive surgery and comparable first results as the open implant removal. The subjective and objective satisfaction of patients is high. The technique can be applied and established by all arthroscopic trained shoulder surgeons

Introduction. Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure. Methods and materials. We identified 299 consecutive patients who underwent circular frame fixation for fracture or deformity correction in our unit from our prospective database. All 247 patients who followed the staged frame removal protocol were included in this study. We reviewed the electronic clinical record and radiographs of each patient to record demographics, risk factors for treatment failure and outcome following frame removal. We defined failure of the protocol as a re-fracture or change in bony alignment within 12 weeks of frame removal. Results underwent statistical analysis using Chi square analysis. Results. Of the 247 patients, 196 were trauma patients, of which 56 were open fractures and 48 were elective cases. There were 92 Ilizarov frames and 155 hexapods. 93 patients were smokers. The protocol failed to prevent mechanical failure after frame removal in 10 patients, of which four had refracture and six had an increase in deformity. The average increase in deformity was 7.7 in the frontal plane and 3.8 in the lateral plane. We identified risk factors for mechanical failure in eight of the ten; four were smokers, two were on steroids and two had hypophosphataemic rickets. Of the ten patients, four were for elective indications, six for trauma. Two of the six trauma patients had been treated for open fractures. ‘The type of frame and smoking history showed no statistical association with mechanical failure. Four patients went to have another frame, five were managed with plaster and one patient refused further treatment. Conclusion. Our staged reloading protocol may delay frame removal however it is a simple and effective way to confirm the timing of frame removal

Aims. Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Methods. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively. Results. A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS. Conclusion. ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157–167

Background:. Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service. Objective:. Review Belfast Regional Limb Reconstruction frame removal practice, introduce changes aimed at improving care and evaluate effects. Methods:. 1 year retrospective review of Ilizarov frame removal. Evaluation of service prior to and following provision of a new patient information leaflet, alongside a test wire removal technique. Subsequent service evaluation supplemented via patient reported feedback questionnaire. Results:. Retrospectively 85% Ilizarov frames removed in clinic, 54% required Entonox. Annual cost £19000. 46% patients unaware of process, gathering information from unprofessional sources. General anaesthetic and analgesic requirements related to psychosocial influences; no correlation between fracture configuration, elective reconstructive cases and operative techniques. Prospectively 96% patients found information leaflet educational and beneficial. 87% Ilizarov frames removed in clinic. 100% patients who had outpatient removal recommend this method. Entonox use reduced to 15% with average pain score 4.6/10 without analgesia. Patients felt happier. Projected annual cost savings £3000. 100% rated service excellent. Discussion:. Professional education and a standardised outpatient removal process for Ilizarov frames, delivered by a dedicated specialist team, reduces morbidity and positively impacts service provision

Our aim was to compare the one-year post-operative outcomes following retention or removal of syndesmotic screws in adult patients with a fracture of the ankle that was treated surgically. A total of 51 patients (35 males, 16 females), with a mean age of 33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic screw fixation, were randomly allocated to retention of the syndesmotic screw or removal at three months post-operatively. The two groups were comparable at baseline. . One year post-operatively, there was no significant difference in the mean Olerud–Molander ankle score (82.4 retention vs 86.7 removal, p = 0.367), the mean American Orthopedic Foot and Ankle Society ankle-hindfoot score (88.6 vs 90.1, p = 0.688), the mean American Academy of Orthopedic Surgeons foot and ankle score (96.3 vs 94.0, p = 0.250), the mean visual analogue pain score (1.0 vs 0.7, p = 0.237), the mean active dorsiflexion (10.2° vs 13.0°, p = 0.194) and plantar flexion (33.6° vs 31.3°, p = 0.503) of the ankle, or the mean radiological tibiofibular clear space (5.0 mm vs 5.3 mm, p = 0.276) between the two groups. A total of 19 patients (76%) in the retention group had a loose and/or broken screw one year post-operatively. . We conclude that removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle. Cite this article: Bone Joint J 2014;96-B:1699–1705

Background. Many patients undergo frame removal in the outpatient setting and nitrous oxide is frequently used, but has varying effects. The aim of the study was to ascertain whether pain levels during frame removal are improved with local infiltration of local anaesthetic (LA) and to assess the effect of LA and nitrous oxide compared to nitrous oxide alone. Methodology. This was a small single centre study using patient reported questions to assess pain levels during frame removal. The test group received 5–20ml 2% lidocaine infiltrated into tissues surrounding half pins and olive wire exit sites. All patients were asked to complete a questionnaire to assess pain levels and patient satisfaction following the procedure. Patients were asked to mark their pain level on a 100mm visual analogue scale giving a final pain score out of 100. Results. There were twenty three patients in the LA group but due to observed levels of increased distress without LA, the control group was restricted to 7 patients. Patient satisfaction was high and there were no complications across both groups. The LA group (N=23) had a mean pain score of 35, which was significantly lower than the mean of 62 in the N=7 control patients (unpaired t-test: p=0.010). Conclusion. Frame removal in clinic has been shown to be a safe and well tolerated procedure and this study has shown that LA does improve pain levels during frame removal. Further work to compare pain levels and patient satisfaction with alternative frame removal methods at other centres is being carried out

We report four patients who sustained secondary fractures of the posterior wall of the tibial shaft during the removal of one pattern of intramedullary nail after fracture healing. The cause of this complication is discussed

Aims. Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy. Methods. Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year. Results. A total of 116 (97%) of 120 enrolled participants commenced treatment. Of those, 21 were lost to follow-up, resulting in 30 participants in the advice leaflet, 32 in the advice video, and 33 face-to-face therapy arms, respectively at six weeks of follow-up. There was no significant difference between the treatment groups in the DASH at six weeks (advice leaflet vs face-to-face therapy, p = 0.69; advice video vs face-to-face therapy, p = 0.56; advice leaflet vs advice video, p = 0.37; advice leaflet vs advice video vs face-to-face therapy, p = 0.63). At six weeks, there were no differences in any secondary outcome measures except for the DASH work subscale, where face-to-face therapy conferred benefit over advice leaflet (p = 0.01). Conclusion. Following cast removal for nonoperatively treated distal radius fractures, offering an advice leaflet or advice video for rehabilitation gives equivalent patient-reported outcomes to a course of face-to-face therapy. Cite this article: Bone Joint J 2021;103-B(6):1033–1039

Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were also noted in time taken to complete and distance covered in metres, of the simulated exercises on repeat performance (p<0.05). Conclusion. Overall, with only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

Introduction. Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. Methods. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

MOXIMED KineSpring® Knee Implant System is an Orthopaedic device designed for younger or highly active patients with osteoarthritis. The device is placed under the skin, is attached to the tibia and femur, and contains springs which help limit some of the forces that are transmitted through the knee during activities such as walking or running and thereby relieve pain that may be experienced by patients with early arthritis of the knee. The aim of this study is to determine the long term safety and efficacy of the KineSpring knee implant system. This is a prospective case series involving two centres in Glasgow. 29 patients (mean age of 45.1 years and range 18-65 years) were recruited into the study between 2011 and 2016. The Primary outcome measure was Oxford knee score (OKS) at 2, 5 and 10 years post-operatively. Secondary outcome measures include device related complications and survival, patient reported functional outcome measures, patient satisfaction, pain levels and change in radiographic classification of osteoarthritis. At 2-year follow-up, 7 implants were removed (74.1% survival). Complications include deep infection, requiring removal in 1 patient, 2 implant failures requiring removal and one spring breakage. In comparison to pre-operative measures there was an improvement in the pain (3.58 vs. 5.20, p=0.02), stiffness (4.16 vs. 4.47, p=0.6) and OKS (32.4 vs. 36.9, p=0.03). The KineSpring improves overall pain, stiffness and functional outcome at 2 years following surgery, however there was a high rate of removal and further long-term follow up analysis is required regarding its effectiveness

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures. Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded. There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001). This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR. From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD). The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05). This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures

The aim was to report operative complications, radiographic and patient-reported outcomes following lateral tibial plateau fracture fixation augmented with calcium phosphate cement (CPC). From 2007–2018, 187 patients (median age 57yrs [range 22–88], 63% female [n=118/187]) with a Schatzker II/III fracture were retrospectively identified. There were 103 (55%) ORIF and 84 (45%) percutaneous fixation procedures. Complications and radiographic outcomes were determined from outpatient records and radiographs. Long-term follow-up was via telephone interview. At a median of 6 months (range 0.1–138) postoperatively, complications included superficial peroneal nerve injury (0.5%, n=1/187), infection (6.4%, n=12/187), prominent metalwork (10.2%, n=19/187) and post-traumatic osteoarthritis (PTOA; 5.3%, n=10/187). The median postoperative medial proximal tibial angle was 89o (range 82–107) and posterior proximal tibial angle 82o (range 45–95). Three patients (1.6%) underwent debridement for infection and 27 (14.4%) required metalwork removal. Seven patients (4.2%) underwent total knee replacement for PTOA. Sixty percent of available patients (n=97/163) completed telephone follow-up at a median of 6yrs (range 1–13). The median Oxford Knee Score was 42 (range 3–48), Knee injury and Osteoarthritis Outcome Score 88 (range 10–100), EuroQol 5-Dimension score 0.812 (range −0.349–1.000) and Visual Analogue Scale 75 (range 10–100). There were no significant differences between ORIF and percutaneous fixation in patient-reported outcome (all p>0.05). Fixation augmented with CPC is safe and effective for lateral tibial plateau fractures, with a low complication rate and good long-term knee function and health-related quality of life. Percutaneous fixation offers a viable alternative to ORIF with no detriment to patient-reported outcome

Aims. The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis. Patients and Methods. A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame. Results. There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p = 0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042). Conclusion. LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. . Cite this article: Bone Joint J 2017;99-B:494–502

Aims

Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

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Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

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The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

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Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.