Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.

Acute syndesmotic ankle injuries continue to impose a diagnostic dilemma and it remains unclear whether weighbearing or external rotation should be exerted rotation during the imaging process. Therefore, we aimed to implement both axial load (weightbearing) and external rotation in the assessment of a clinical cohort of patients with syndesmotic ankle injuries syndesmotic using weightbearing CT imaging. In this retrospective comparative cohort study, patients with an acute syndesmotic ankle injury were analyzed using a WBCT (N= 20; Mean age= 31,64 years; SD= 14,07. Inclusion criteria were an MRI confirmed syndesmotic ankle injury imaged by a bilateral WBCT of the ankle during weightbearing and combined weightbearing-external rotation. Exclusion criteria consisted of fracture associated syndesmotic ankle injuries. Three-dimensional (3D) models were generated from the CT slices. Tibiofibular displacement and Talar Rotation was quantified using automated3D measurements (Anterior TibioFibular Distance (ATFD), Alpha Angle, Posterior TibioFibular Distance (PTFD) and Talar Rotation (TR) Angle) in comparison to a cohort of non-injured ankles. Results. The difference in neutral-stressed Alpha° and ATFD showed a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.046 and P = 0.039, respectively) The difference in neutral-stressed PTFD and TR° did not show a significant difference between patients with a syndesmotic ankle lesion and healthy ankles (P = 0.492; P = 0.152, respectively). Conclusion. Application of combined weightbearing-external rotation reveals a dynamic anterior tibiofibular widening in patients with syndesmotic ankle injuries. This study provides the first insights based on 3D measurements to support the potential relevance of applying external rotation during WBCT imaging. However, to what extent certain displacement patterns are associated with syndesmotic instability and thus require operative treatment strategies has yet to be determined in future studies

Lisfranc injuries are uncommon and can be challenging to manage. There is considerable variation in opinion regarding the mode of operative treatment of these injuries, with some studies preferring primary arthrodesis over traditional open reduction and internal fixation (ORIF). We aim to assess the clinical and radiological outcomes of the patients treated with ORIF in our unit. This is a retrospective study, in which all 27 consecutive patients treated with ORIF between June 2013 and October 2018 by one surgeon were included with an average follow-up of 2.4 years. All patients underwent ORIF with joint-sparing surgery by a dorsal bridging plate (DBP) for the second and third tarsometatarsal (TMT) joint, and the first TMT joint was fixed with trans-articular screws. Patients had clinical examination and radiological assessment, and completed American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Foot Function Index (FFI) questionnaires. Our early results of 22 patients (5 lost to follow-up) showed that 16 (72%) patients were pain free, walking normally without aids, and wearing normal shoes and 68% were able to run or play sports. The mean AOFAS midfoot score was 78.1 (63–100) and the average FFI was 19.5 (0.6–34). Radiological assessment confirmed that only three patients had progression to posttraumatic arthritis at the TMT joints though only one of these was clinically symptomatic. Good clinical and radiological outcomes can be achieved by ORIF in Lisfranc injuries with joint-sparing surgery using DBP

Abstract. Objectives. Our study evaluates financial impact to the Best Practice Tariff (BPT) of hip fracture patients on Novel Oral Anti-Coagulant (NOAC) medication. Since their approval by NICE for the prevention of stroke and systemic embolism in non-valvular atrial fibrillation, the incidence of hip fracture patients admitted to hospitals on NOAC medication (e.g. rivaroxiban, apixaban) has been increasing. BPT for hip fractures has two components: a base tariff and a conditional top-up tariff of £1,335 per patient (applied to patients of 60 years of age). For the top-up tariff, six criteria must be met, of which time-to-surgery within 36 hours is one. Our department currently recommends withholding NOAC medication and delaying surgery for at least 48 hours as per our Trust's haematology guidelines to reduce intra-operative bleeding risk. Therefore, the conditional top-up tariff cannot be claimed for these patients. Method. A retrospective review of our Trust hip fracture patients over 60 years of age admitted during 2019 on NOAC medication using National Hip Fracture Database (NHFD). Results. 545 hip fracture patients had operative treatment at our Trust during the one-year period of 2019. 31 of these patients were admitted on NOAC medication, and therefore had to stop the NOAC and wait for at least 48 hours before having surgery. This translates to a potential hip fracture BPT loss of £41,385 in 2019, as the conditional top-up tariff could not be claimed. Conclusion. This study illustrates the large financial impact to BPT that hip fracture patients admitted on NOAC medications has at our Trust. It raises the argument as to whether the BPT should allow for an increased length of time until surgery for such patients, to allow safe surgical treatment with reduced bleeding risk. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Transverse patella fractures are commonly encountered in trauma surgery, open reduction and internal fixation are considered the gold standard treatment modality that could permit early knee motion and immediate rehabilitation. Many fixation methods had been defined and compared to each other's in many clinical and biomechanical studies. The aim of this study was to assess the safety and stability of our novel anatomical patella plate and to compare its stability with tension band-wire technique. A total of 12 cadaveric preserved knees (six right and six left patellae) with close patellar size were chosen to form two groups of six samples. Each group received either plate or tension band-wiring fixation for an experimentally created patella fracture. Cyclic load of an average of 350 N was applied for all specimens and after accomplishing 50 cycles the displacements of all fracture edges were recorded. After completing 50 cycles in each group, the average fracture edges displacement measured in the plate group was 1.98 ± 0.299 mm, whereas the average fracture edges displacement measured in the tension band-wire group was 2.85 ± 0.768 mm (p = 0.016). In the operative treatment of displaced transverse patellar fractures, the strength of fixation obtained by titanium curved plates is highly stronger when compared to the fixation with a tension band-wire technique. Fixation with titanium curved plates provides satisfactory stability at the fracture site which allow withstanding the cyclic loads during the postoperative rehabilitation

Last decade, a shift towards operative treatment of midshaft clavicle fractures has been observed [T. Huttunen et al., Injury, 2013]. Current fracture fixation plates are however suboptimal, leading to reoperation rates up to 53% [J. G. Wijdicks et al., Arch. Orthop. Trauma Surg, 2012]. Plate irritation, potentially caused by a bad geometric fit and plate prominence, has been found to be the most important factor for reoperation [B. D. Ashman et a.l, Injury, 2014]. Therefore, thin plate implants that do not interfere with muscle attachment sites (MAS) would be beneficial in reducing plate irritation. However, little is known about the clavicle MAS variation. The goal of this study was therefore to assess their variability by morphing the MAS to an average clavicle. 14 Cadaveric clavicles were dissected by a medical doctor (MH), laser scanned (Nikon, LC60dx) and a photogrammetry was created with Agisoft photoscan (Agisoft, Russia). Subsequently a CT-scan of these bones was acquired and segmented in Mimics (Materialise, Belgium). The segmented bone was aligned with the laser scan and MAS were indicated in 3-matic (Materialise, Belgium). Next, a statistical shape model (SSM) of the 14 segmented clavicles was created. The average clavicle from the SSM was then registered to all original clavicle meshes. This registration assures correspondences between source and target mesh. Hence, MAS of individual muscles of all 14 bones were indicated on the average clavicle. Mean area is 602 mm. 2. ± 137 mm. 2. for the deltoid muscle, 1022 mm. 2. ±207 mm. 2. for the trapezius muscle, and 683 mm. 2. ± 132 mm. 2. for the pectoralis major muscle. The sternocleidomastoid muscle has a mean area of 513 mm. 2. ± 190 mm. 2. and the subclavius muscle had the smallest mean area of 451 mm. 2. ± 162 mm. 2. Visualization of all MAS on the average clavicle resulted in 72% coverage of the surface, visualizing only each muscle's largest MAS led to 52% coverage. The large differences in MAS surface areas, as shown by the standard deviation, already indicate their variability. Difference between coverage by all MAS and only the largest, shows that MAS location varies strongly as well. Therefore, design of generic plates that do not interfere with individual MAS is challenging. Hence, patient-specific clavicle fracture fixation plates should be considered to minimally interfere with MAS

Background and Aims. Many orthopaedic patients admitted to hospital who require urgent surgery are also on Warfarin. Patients with an INR>2 have an increased risk of bleeding complications during surgery; however delay to surgery due to a high INR has both clinical and financial implications. This audit evaluates whether the appropriate management for correction of INR is employed as per local guidelines and, if not, whether this results in significant delay to operative treatment. Methods. A retrospective and prospective audit was performed analysing all Orthopaedic trauma admissions admitted to University Hospital Aintree in a 5 month period. Only those solely on warfarin, who were not acutely bleeding and required surgery in <24 hours were included. Results. A sample of 17 patients was obtained of which only 35.3% had correct INR reversal as per local guidelines. Errors that occurred included 81.1% not being given further Vitamin K at reassessment, 18.2% given too much Vitamin K, 9.1% given too little Vitamin K, 18.2% given Octaplex incorrectly and 9.1% not given Octaplex when indicated. Only 1 patient had a delay to their surgery directly resulting from incorrect INR reversal (total time to surgery − 33 hours 45 minutes). Conclusion. Better education for clinical staff on the local policy for INR reversal in patients requiring urgent orthopaedic surgery is needed. Local policy guidelines have since been redesigned in light of these results and a completion audit cycle has been performed showing significant improvement with 50% of the patient sample given correct INR reversal

Background. Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. Methods. 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. Results. Mean age was 77 years (range 50–99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0–9) and 75.5 (0–100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. Conclusions. This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and further research is in progress. Level of evidence. 2b. Ethics. Local approval was obtained

A consensus regarding management of calcaneal fractures eludes orthopaedic surgeons. While operative treatment has gained more acceptance, surgical morbidity remains high. We undertook a retrospective review of early complications and radiological outcomes following internal fixation of calcaneal fractures in our unit over 15 months. A consecutive series of 33 patients who underwent fixation of the Calcaneus was selected. Patient records, X-rays and scans were reviewed. 37 fractures in 33 patients underwent fixation. 81 % were male. Mean age at surgery was 37yrs (19 -59yrs). 35 % were operated within 1 wk of injury and 13% after 2 wks of injury. 43% were Sanders' type III, 18% type II and 13% tuberosity avulsion fractures. 63% had a reversed/zero Bohler's angle. Mean post-op Bohler's angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury. Males over 40yrs and smokers seem to be at most risk of wound complications. Time to surgery/delay in surgery up to 2 wks did not seem to have any adverse consequences. Complications increase with fracture complexity and avulsion fractures have highest risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most

The operative treatment of fractures of the proximal humerus can be complicated by poor bone quality. Our aim was to evaluate a new method which allows prediction of the bone quality of the proximal humerus from radiographs. Anteroposterior radiographs were taken of 19 human cadaver humeri. The cortical thickness was measured at two levels of the proximal humeral diaphysis. The bone mineral density (BMD) was determined for the humeral head (HH), the surgical neck (SN), the greater tuberosity (GT) and lesser tuberosity (LT) using dual-energy x-ray absorptiometry. The mean cortical thickness was 4.4 ± 1.0 mm. Specimens aged 70 years or less had a significantly higher cortical thickness than those aged over 70 years. A significant positive correlation was found between cortical thickness and the BMD for each region of interest. The cortical thickness of the proximal diaphysis is a reliable predictor of the bone quality of the proximal humerus

Objectives

Vancomycin and fosfomycin are antibiotics commonly used to treat methicillin-resistant Staphylococcus aureus (MRSA) infection. This study compares the in vitro inhibitory effects against MRSA of articulating cement spacers impregnated with either vancomycin or fosfomycin.

The establishment of a suitable animal model of repair of the rotator cuff is difficult since the presence of a true rotator cuff anatomically appears to be restricted almost exclusively to advanced primates. Our observational study describes the healing process after repair of the cuff in a primate model. Lesions were prepared and repaired in eight ‘middle-aged’ baboons. Two each were killed at four, eight, 12 and 15 weeks post-operatively. The bone-tendon repair zones were assessed macroscopically and histologically.

Healing of the baboon supraspinatus involved a sequence of stages resulting in the reestablishment of the bone-tendon junction. It was not uniform and occurred more rapidly at the sites of suture fixation than between them. Four weeks after repair the bone-tendon healing was immature. Whereas macroscopically the repair appeared to be healed at eight weeks, the Sharpey fibres holding the repair together did not appear in any considerable number before 12 weeks. By 15 weeks, the bone-tendon junction was almost, but not quite mature.

Our results support the use of a post-operative rehabilitation programme in man which protects the surgical repair for at least 12 to 15 weeks in order to allow maturation of tendon-to-bone healing.

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5° (11° to 23°) and the mean anterior deviation 4.5° (1° to 14°). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value.

We report the effects of local administration of osteogenic protein-1 on the biomechanical properties of the overstretched anterior cruciate ligament in an animal model. An injury in the anterior cruciate ligament was created in 45 rabbits. They were divided into three equal groups. In group 1, no treatment was applied, in group II, phosphate-buffered saline was applied around the injured ligament, and in group III, 12.5 μg of osteogenic protein-1 mixed with phosphate-buffered saline was applied around the injured ligament. A control group of 15 rabbits was assembled from randomly-selected injured knees from among the first three groups. Each rabbit was killed at 12 weeks.

The maximum load and stiffness of the anterior cruciate ligament was found to be significantly greater in group III than either group 1 (p = 0.002, p = 0.014) or group II (p = 0.032, p = 0.025). The tensile strength and the tangent modulus of fascicles from the ligament were also significantly greater in group III than either group I (p = 0.002, p = 0.0174) or II (p = 0.005, p = 0.022).

The application of osteogenic protein-1 enhanced the healing in the injured anterior cruciate ligament, but compared with the control group the treated ligament remained lengthened. The administration of osteogenic protein-1 may have a therapeutic role in treating the overstretched anterior cruciate ligament.