Objective

We aimed to analyse the clinical outcomes and survivorship of anatomic total shoulder arthroplasty using a stemless humeral component with cemented pegged polyethylene glenoid performed with the technique of eccentric reaming to partially correct retroversion. These results were then compared with TSA using the same implant for end-stage shoulder arthritis with a normal version of the native glenoid.

Technological advancements in orthopaedic surgery have mainly focused on increasing precision during the operation however, there have been few developments in post-operative physiotherapy. We have developed a computer vision program using machine learning that can virtually measure the range of movement of a joint to track progress after surgery. This data can be used by physiotherapists to change patients’ exercise regimes with more objectively and help patients visualise the progress that they have made. In this study, we tested our program's reliability and validity to find a benchmark for future use on patients.

We compared 150 shoulder joint angles, measured using a goniometer, and those calculated by our program called ArmTracking in a group of 10 participants (5 males and 5 females). Reliability was tested using adjusted R squared and validity was tested using 95% limits of agreement. Our clinically acceptable limit of agreement was ± 10° for ArmTracking to be used interchangeably with goniometry.

ArmTracking showed excellent overall reliability of 97.1% when all shoulder movements were combined but there were lower scores for some movements like shoulder extension at 75.8%. There was moderate validity shown when all shoulder movements were combined at 9.6° overestimation and 18.3° underestimation.

Computer vision programs have a great potential to be used in telerehabilitation to collect useful information as patients carry out prescribed exercises at home. However, they need to be trained well for precise joint detections to reduce the range of errors in readings.

Abstract

Aims

We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis.

Lateral Epicondylitis is a common condition caused by angiofibroblastic hyperplasia of the tendinous insertion. Its treatment is varied and includes rest, physiotherapy, corticosteroid injection and surgical release. Of late, the role of Platelet Rich Plasma (PRP) injections have been explored, with positive results.

We prospectively assessed the outcomes of lateral epicondylitis treated with PRP injections and compared the outcomes of ultrasound guided and ‘blind’ injection.

This was a single centre prospective cohort study. Patient were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) Score. PRP was injected into and around the common extensor origin either with or without ultrasound guidance. The primary outcome measure was DASH score at 3 months.

45 (23F:22M) patients were recruited. The mean age was 50 years (range 35 to 79). The mean duration of follow-up was 106 days. The average pre-injection DASH score for both groups combined was 45.5 (11.7–87.5). The mean DASH score at 3 months follow-up was 27.7. The ultrasound guided injection group had a mean improvement in DASH score from 45.5 to 31.2. The “blind” injection group had a mean improvement in DASH from 44.4 to 27.7. No complications were noted. There was no statistically significant difference in improvement in DASH score between the two groups.

Our study provides further evidence to support of the use of PRP injections in the treatment of epicondylitis of the elbow. Interestingly, however, we found that the use of Ultrasound guidance does not appear to improve patient outcomes.

The best surgical treatment of lateral epicondylitis remains uncertain. Recently radiofrequency microtenotomy (RFMT) has been proposed as a suitable surgical treatment. We aim to compare open release with RFMT and present the results of our randomised controlled trial.

Patients with symptoms of tennis elbow for at least 6 months who had failed to respond to conservative management were included in the trial. They were randomised to open release or RFMT. Outcome measures included grip strength, pain and DASH scores.

41 patients were randomised, 23 to RFMT and 18 to open release, 2 patients withdrew from the study. Our results show that both treatments give a significant benefit at all time points for DASH and pain scores, but only open release gives a significant improvement in grip strength. Comparing the two treatments the only significant difference is the open group have better pain scores at 6 weeks, but this is not seen at later follow up.

In conclusion both groups have shown benefit from the treatments, but one is not shown to be clearly superior.

The upper age limit for Paediatric Orthopaedic referrals and admissions has recently been increased from 14 to 16 years. This has many benefits but will change the volume of cases as well as influencing both case mix and the resources required. We analysed the operations and admissions in our department for the year preceding and succeeding the change in age limit in order to evaluate the impact on the service. Our outcome measures were number of trauma and elective cases treated, time spent operating, case mix and cost to the service.

Admission and operative logs for the aforementioned years were analysed to obtain number of admissions, length of stay and operative intervention as well as time in theatre. National reference data from Information Services Division Scotland was used in order to get accurate costs for theatre time and inpatient stays in our hospital.

Results showed an increase in total number of cases from 438 per year to 499. Trauma cases increased from 133 (30.4%) to 202 (40.5%). Of these, 35 (17.3%) were over 14 years. The number of children over 14 years which had an operation, doubled from 51 to 102. Hours spent operating increased from 681.25 to 830.25. The percentage time operating on those aged over 14 increased from 13.2% to 23.8%. Theatre costs increased by £148005 (21.9%) to £822442.50.

The change in age limit has significantly increased case variety and numbers. This has significant financial implications and as such needs adequately resourced to ensure high quality clinical care.

Frozen shoulder is a common condition that affects the working population. The longevity and severity of symptoms often results in great economic burden to health services and absence from work. This prospective cohort study aimed to investigate whether early intervention with arthroscopic capsular release resulted in improvement of symptoms and any potential economic benefit to society.

Patients were recruited prospectively. Data was gathered by way of questionnaire to ascertain demographics, previous primary care treatment and absence from work. Oxford Shoulder Score (OSS) was also calculated. Arthroscopic capsular release was performed and further data gathered at four week post-operative follow up. Economic impact of delay to treatment and cost of intervention was calculated using government data from the national tariff which costs different forms of treatment. Statistical analysis was then performed on the results.

Twenty five patients enrolled. Mean pre-operative OSS: 37.4 (range 27–58, SD 7.4). Mean post-operative OSS: 15.9 (range 12–22, SD 2.3). P<0.01. Mean improvement in OSS: 21.5 (range 12–38, SD 7.1)

The cost of non-operative treatment per patient was £3954. The cost of arthroscopic capsular release per patient was £1861, a difference of £2093. There were no complications

Arthroscopic capsular release improved shoulder function on OSS within four weeks. The cost of arthroscopic capsular release is significantly less than the cost of treating the patients non-operatively. Early surgical intervention may improve symptoms quickly and reduce economic burden of the disease. A randomised controlled trial comparing timings of intervention would further elucidate potential benefits.

The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction.

We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage.

This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD.

Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded.

During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line.

Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity.

Objective

The purpose of this study was to compare outcome of arthroscopic stabilization of the shoulder using knotted and knotless anchors and two rehabilitation regimes.

The administration of prophylactic antibiotics is essential in the prevention of surgical site infection, particularly when metalwork is implanted. Intravenous Cefuroxime has been the antibiotic of choice for prophylaxis in our unit over the last few years. Unfortunately this has been linked to an increased rate of Clostridium Difficile infection. Our departmental antibiotic prophylaxis guidelines, based on the Scottish Intercollegiate Guidelines Network (SIGN), were therefore revised, such that intravenous Flucloxacillin and Gentamicin became the first line agents.

We primarily aimed to assess whether prophylactic antibiotics were being administered according to our revised local guidelines. Steps were then taken to improve adherence to the guidelines, and the audit repeated.

Data was collected prospectively between 1^st November 2010 and 28^th November 2010 (cycle 1). Demographic data, type of surgery, details of choice, dose and timing of antibiotic administration were compiled. The quality of documentation was also reviewed. Interventions to improve adherence to the guidelines were commenced between 1^st January 2011 and 28^th February 2011. This included a departmental presentation, supplementary distribution of the guidelines and email communication to all orthopaedic surgeons and anaesthetists to increase awareness. A repeat audit cycle was performed between 1^st March 2011 and 28^th March 2011 (cycle 2). All data was stored and statistically analysed using SPSS for Windows 17.0.

A total of 130 patients were included, with 65 patients in each cycle. Demographic data and type of surgery were reasonably similar in both cycles. Intravenous antibiotics, when required, were administered within 30 minutes of the surgical incision in most cases in both cycles of the audit. In the first cycle of the audit only 9 out of 65 patients (14%) received the correct antibiotics as suggested by our updated guidelines. This improved significantly to 46 out of 57 patients (81%) in the second cycle. Documentation of antibiotic prescribing in the anaesthetic record, operation note and drug charts also improved in the second cycle.

We observed poor initial adherence to our updated guidelines as most patients received incorrect antibiotic prophylaxis. However, following our audit interventions to increase awareness of the new guidelines, we witnessed a significant improvement in compliance. Our next step will be to ensure that the new policy of using intravenous Flucloxacillin and Gentamicin does indeed reduce the rate of Clostridium Difficile infection while maintaining a low rate of deep and superficial wound infection.

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria.

We sought to measure the rate of progress of Dupuytren's contracture.

All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively.

Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits.

Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers.

This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk.

Aims: To investigate the clinical and radiological (MRI) effectiveness of Nuclear Magnetic Resonance Therapy (NMRT) on mild to moderate degenerative knee osteo-arthrosis (OA).

Methods: A double blind randomised control mono-centric study of 100 volunteer patients with mild to moderated knee OA. All patients underwent clinical examination, pain was recorded on visual analog scale (VAS) and Oxford knee score and WOMAC osteoarthritis index at baseline and at follow up intervals (1 week, 1 month, 3 months and 6 months). The treatment group (n=50) received five sessions of one hour NMRT on five consecutive days. Radiological assessment included baseline standing plain radiograph of the knee joint (AP and Lateral views) and positional MRI scan which was repeated at 3 months. Cartilage thickness in weight bearing areas and bone and cartilage MRI score (BAC-MS) were used to assess response of the cartilage to NMRT. Data was analysed using SPSS 16.0 software and non-parametric tests.

Results: Ninety six patients completed six months follow-up. The treatment and placebo groups were comparable except that the male: female ration was 1:1 and 1:2 respectively. No adverse effect was reported during the study. The treatment group showed mean increase of 4° in the range of movement at 6 six months, which was statistically significant (p=0.01). There was no difference in other outcome variables at any time interval between the two groups.

Radiologically, BAC-MS and cartilage thickness at three months had no significant difference between treatment and placebo groups (p-value = 0.81 and 0.88 respectively). The change in BAC-MS and cartilage thickness at 3 months was also not significant (p-value = 0.09 and 0.41 respectively).

Conclusion: Five 1 hour sessions of NMRT is a safe mode of treatment, but has no radiological (at 3 months) and clinical (6 months) beneficial effect on mild to moderate Knee Joint Osteoathrosis.

Purpose: To see if the symptoms of mild to moderate degenerative knee osteoarthrosis are improved clinically by magnetic resonance therapy (MRT).

Method: This a double blind randamised control mono-centric study involving 100 volunteer patients recruited form the outpatient clinics who met the set inclusion and exclusion criteria of mild to moderate Osteoarthrosis of the knee joint. AD Elektronik GmbH, Wetzlar, Germany supplied the devices for giving MRT, which involved five sessions of one hour each on five consecutive days. These devices work with a coded chip card and only half of the 100 cards were coded to provide MRT. Base line assessment and follow up at 1 week, 1 month, 3 month and 6 months included clinical examination and Oxford and WOMAC Knee scores. Radiological assessment included baseline plain radiographs of the knee joint in standing position (AP and Lateral views) and positional MRI scan. At three months MRI scan was repeated. Data was analysed using SPSS 16.0 software and Mann-Whitney and Chi–square Tests were used.

Results: No adverse effects were reported during the study. The treatment and the placebo groups were comparable except that the male: female ratio was 1: 2. Placebo group had statistically significant improvement in the WOMAC Pain OA index at 3 months (p=0.017). There was statistically significant improvement in the range of movements at 6 months (p=0.010), but this was clinically not significant as the mean increase in Range of Movement was 4°. At the end of 6 months there was not difference between the two groups.

Conclusion: This study has found that five 1 hour sessions of MRT is a safe mode of treatment, but fails to support that it has a beneficial effect on Knee Joint Osteoathrosis.

Introduction: Between 1 and 4 per 1000 births worldwide are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations and folate metabolism may be affected by polymorphisms in the MTHFR gene.

Methods: Using a case-parent triad design, we investigated whether the MTHFR C677T polymorphism, and maternal peri-conceptional folic acid supplement use, influenced risk of isolated clubfoot. 375 case-parent triads took part.

Results: Among children there was a significant trend of decreasing clubfoot risk with increasing number of Talleles: relative risk (RR ) CT vs CC=0.75 (95% CI: 0.57,0.97); RR TT vs CC=0.57 (95% CI: 0.37,0.91); p trend=0.006. This association was not modified by maternal folic acid use.

Conclusion: Maternal MTHFR genotype did not influence risk of clubfoot in the offspring overall, although a possible interaction with folic acid use was found. This is the first report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood and the folate metabolism pathway is complex. Further research is needed to elucidate these relationships.

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors.

Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases.

Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these.

Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder.

Aim: Congenital Talipes Equinovarus (CTEV) is managed in a variety of ways, with little agreement on how best to assess outcome. Some authors advocate patient based subjective assessments, while others use a variety of objective measures. Without agreement, it is impossible to evaluate different management methods. We have therefore evaluated a number of objective parameters compared to a subjective assessment following management of CTEV. Methods: 216 children and their families consented to participate in the study. The children had been managed in a number of hospitals across Scotland, and in a variety of ways. Outcome was assessed by a researcher not involved in the management of the children. Subjective assessment consisted of a postal questionnaire. Objective assessment consisted of a number of anthropometric measures. Results: A strong correlation was seen between subjective assessment, and several objective outcome measures including foot length discrepancy, calf muscle wasting, and range of movement at the ankle. Conclusions: Objective assessment using several parameters correlates well with subjective assessment. Using these objective measures, it is possible to evaluate and compare different management protocols in CTEV.