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Bone & Joint Open
Vol. 4, Issue 8 | Pages 612 - 620
21 Aug 2023
Martin J Johnson NA Shepherd J Dias J

Aims

There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method.

Methods

The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress.


The Bone & Joint Journal
Vol. 104-B, Issue 11 | Pages 1225 - 1233
1 Nov 2022
Png ME Petrou S Achten J Ooms A Lamb SE Hedley H Dias J Costa ML

Aims

The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting.

Methods

An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves.


Bone & Joint Open
Vol. 3, Issue 10 | Pages 777 - 785
10 Oct 2022
Kulkarni K Shah R Mangwani J Dias J

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Methods

Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_13 | Pages 51 - 51
1 Nov 2021
Santhosh S Dias J Brealey S Leighton P
Full Access

Introduction and Objective

Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity.

Materials and Methods

A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this.


Bone & Joint Open
Vol. 2, Issue 9 | Pages 773 - 784
1 Sep 2021
Rex SS Kottam L McDaid C Brealey S Dias J Hewitt CE Keding A Lamb SE Wright K Rangan A

Aims

This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI.

Methods

MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.


Bone & Joint Open
Vol. 2, Issue 8 | Pages 583 - 593
2 Aug 2021
Kulkarni K Shah R Armaou M Leighton P Mangwani J Dias J

Aims

COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.

Methods

A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory.


The Bone & Joint Journal
Vol. 99-B, Issue 3 | Pages 351 - 357
1 Mar 2017
Sousa R Serrano P Gomes Dias J Oliveira JC Oliveira A

Aims

The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin.

Patients and Methods

Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis.

The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_23 | Pages 86 - 86
1 Dec 2016
Serrano P Silva MS Dias J Oliveira JC Oliveira A Sousa R
Full Access

Aim

Our goal is to increase diagnostic accuracy of synovial fluid testing in differentiating prosthetic joint infection(PJI) by more exhaustively studying simple and inexpensive biomarkers. For that purpose, we sought to determine: 1) if synovial fluid C-reactive protein(CRP), alpha-2-macrogloblulin(A2M), procalcitonin and adenosine deaminase(ADA) concentrations are different between infected and aseptic cases; 2) performance and optimal cutoff values of each marker; 3) whether any such test may help improve diagnostic performance of traditional leukocyte count.

Method

Between January/2013 and December/2015 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples as well as the implant for sonication were gathered for microbiological study. Definitive diagnosis was classified as infection or aseptic on the basis of the recent International Consensus Meeting definition of PJI. Using receiver operating characteristic curves, we determined cutoff values as well as sensitivity and specificity for each marker.


The Bone & Joint Journal
Vol. 98-B, Issue 8 | Pages 1069 - 1073
1 Aug 2016
Stirling E Jeffery J Johnson N Dias J

Aims

The degree of displacement of a fracture of the distal radius is an important factor which can be assessed using simple radiographic measurements. Our aim was to investigate the reliability and reproducibility of these measurements and to determine if they should be used clinically.

Patients and Methods

A 10% sample was randomly generated from 3670 consecutive adult patients who had presented to University Hospitals of Leicester NHS Trust between 2007 and 2010 with a fracture of the distal radius. Radiographs of the 367 patients were assessed by two independent reviewers. Four measurements of displacement of the fracture were recorded and the inter-observer correlation assessed using the intra-class correlation coefficient.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_14 | Pages 20 - 20
1 Jul 2016
Kannan S Ghosh A Dias J Singh H
Full Access

Our aim was to compare the biomechanical strength modified side-to-side repair with modified pulvertaft technique keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar.

In our study, we have used turkey tendons. Two investigators performed 34 repairs during one summer month. All mechanical testing was carried out using the tensile load testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, and tensile stress. The statistical comparison was carried by Levene's test and T test for means.

The mean maximum load tolerated by modified side-to-side repair was 50.3N(S.D13.7) and that by modified pulvertaft 46.96N(S.D: 16.4), overall it was 48.29 N (S.D: 14.57). The tensile stress at maximum load for modified pulvertaft and modified side-to-side repair was 4.2MPa(S.D: 3.1) and 4.7 MPa (S.D: 3.8) respectively {Overall 4.3MPa(S.D: 3.5)}. The tensile stress at yield was 4.01 MPa (S.D: 3.1) and 5.5 MPa (S.D: 3.7) respectively for modified pulvertaft and modified side-to-side repair {overall 4.44 MPa (S.D: 3.45)}. The tensile strain at maximum load respectively for side-to-side and modified pulvertaft repair was 7.87%(S.D: 33.3) and 7.84%(S.D: 34.02) respectively.

We found no statistical difference between 2 repairs in terms of strength, load to first failure, and maximum load to failure. The suture cut through was the commonest mode of failure.

Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 84 - 84
1 Jan 2013
Singh H Brinkhorst M Slijper H Hovius S Dias J
Full Access

The aim of this study was to

describe the measurements of range of circumduction in normal volunteers and develop summaries of the data,

develop the rate and rhythm of circumduction of the wrist with the use of Biometric electrogoniometer,

reproducibility, reliability and accuracy of these measures of circumduction.

Forty healthy subjects with a mean age of 42.6 years were assessed with flexible biaxial electrogoniometry in standard 90° pronated position of wrist for kinematic assessment of movement in orthogonal planes. Functional range of flexion-extension, ulnar-radial deviation and circumduction was measured and analysis of the digital output produced a visual display of the results as Lissajous's figures. This also allowed measurement of the total range of circumduction as two-dimensional area under the curve measurement. The rate and rhythm of movements were mathematically calculated and displayed over the two dimensional circumduction curves. The average arc of uniplanar flexion and extension is greater than the flexion and extension component of the circumduction curve but mean uniplanar radial ulnar deviation arc is similar to the radial-ulnar deviation component of the circumduction curve. The area of circumduction and circumference of the circumduction curve was used to measure the total range of circumduction. The four quadrants for the velocity of circumduction showed that the rate was faster in the deviation components as compared to flexion and extension. Quadrant analysis showed the changes in the rhythm was less in the deviation components compared to flexion and extension. The accuracy for measuring uniplanar movements showed a standard deviation of 6°. The accuracy for measuring circumduction showed a standard deviation of 347 °° (7%). Accuracy for measuring velocity of circumduction showed a standard deviation of 17°/s. This technique was found to be accurate and reliable in measuring the rate, range and rhythm of wrist circumduction.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 85 - 85
1 Jan 2013
Salman A Singh H Dias J
Full Access

Both intrinsic and extrinsic hand muscles contribute to finger flexion; however there are different ways in which individuals can flex their fingers. Due to different muscle insertions, it is possible to distinguish the mechanical effect of intrinsic muscles from extrinsic muscles. The aim of this observational study was to investigate the degree to which individuals in the population rely on either their intrinsic or extrinsic hand muscles. A high frequency camera was used to record the hands of 31 healthy participants, aged between 18 to 40, while they made a fist repeatedly. The hands were placed on a horizontal plane and the video was taken from the ulnar side, aligned horizontally with the hand. The maximum vertical distance between the fingertip and the distal palmer creases (XY) was recorded using WIN analyze 3D software. Three examiners independently analysed the videos and classified them into intrinsic dominant, extrinsic dominant or a mixed pattern. A t-test was performed on the XY values for the three different categories. The XY height difference between the intrinsic and extrinsic groups were statistically significant (P=0.001). The XY of mixed and intrinsic was also statistically significant (p=0.012) but not for mixed and extrinsic (p=0.46). Assessment of time when movement starts at each individual joint showed significant difference with intrinsic predominant moving the MCPJ before IPJ and extrinsic dominant individual moving their IPJ before MCPJ. This study shows that there is a difference in hand muscle dominance between individuals. More importantly it shows that there are individuals who rely on their intrinsic hand muscles more than their extrinsic muscles.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 9 | Pages 1170 - 1175
1 Sep 2012
Palan J Roberts V Bloch B Kulkarni A Bhowal B Dias J

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club.

The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions.

It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 137 - 137
1 Sep 2012
Singh H Taub N Dias J
Full Access

Background

Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast.

Methods

Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 226 - 226
1 Sep 2012
Shyamsundar S Jeyapalan K Dias J
Full Access

Aim

This study reviewed the efficacy of a CT arthrogram in clinical decision making for wrist disorders.

Methods

Sixty four consecutive CT arthrograms done in a three year period at Glenfield Hospital were selected. All patients were referred by hand consultants at the Glenfield Hospital and all investigations were performed by a single senior musculoskeletal radiologist. CT arthrograms focussed on the following areas: scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), peripheral and central triangular fibrocartilage complex (TFCC) tears, and articular surface disorders. Referral and clinic letters for all patients were obtained. We collected patient demographic detail, prescan diagnosis and clinical plan, CT arthrogram findings, postscan diagnosis and clinical plan and the final outcome. A decision was made whether the scan helped in the clinician's management plan and if so how it helped.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 140 - 140
1 Mar 2012
Dhukaram V Brewer J Tafazal S Lee P Dias J Jones M Gaur A
Full Access

Introduction

Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent.

Objectives

To assess whether patients can be safely discharged from hospital before the brachial plexus block has worn off and record any complications and concerns.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 546 - 546
1 Nov 2011
Ibrahim T Aswad MG Dias J Esler C Brown A
Full Access

Introduction: To report the 11-year follow-up of patients of contaminated femoral heads donated at primary total hip replacement from a cohort study published in 2004.

Methods: Of the 440 donors, 266 patients (61%) were still alive at a mean of 11.7 years post primary total hip replacement and 170 patients (64%) agreed to review. The patients had either a positive or negative culture from their donated femoral head at primary total hip replacement. The Oxford hip score, European Quality of Life (EuroQOL) questionnaire, rates of complication and revision surgery were used as outcome measures.

Results: At long-term follow-up, the Oxford hip score was not different between the positive (mean = 36, standard deviation = 12.3) and sterile (mean = 39, standard deviation = 10.9) groups (p = 0.40). The EuroQOL questionnaire was also not different between the positive and sterile groups. There was no statistically significant difference in the rate of complications (p = 0.93) and revision surgery (p = 0.11) of the age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Discussion: The results of this 11-year follow-up of contaminated donated femoral heads cohort study were similar to those at short-term follow-up. Culture results of donated femoral heads play no significant role in predicting failure of primary total hip replacement in the donor at long-term follow-up.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 295 - 295
1 Jul 2011
Isaac S Dias J Gaur A
Full Access

Introduction: Diabetes mellitus is a systemic disease affecting peripheral nerves and the use of regional anaesthesia in diabetic patients undergoing surgery could be unpredictable. We investigated the efficacy of brachial plexus block in diabetic patients undergoing upper limb surgery compared to normal individuals.

Method: Four hundred and fifty-two patients had a brachial plexus block performed under ultra-sound guidance by senior anaesthetists. There were 221 males and 231 females. Fifty-five patients were diabetic (mean age of 61 years, SD 12), 24 with type 1 and 31 with type 2 diabetes. Mean age of non-diabetic patients was 55 years (SD 15). A mixture of 0.5% Bupivacaine and 1% Prilocaine was used for the block. Post-operative proximal and distal motor and sensory functions were assessed. The assessment was conducted at a mean of 4.6 hours (SD 2.2 hours) post-operatively. MRC grading system was used to asses motor function while sensory function was assessed subjectively using a graded scale between 0, absent sensation, 1, altered sensation and 2, normal sensation.

Results: Brachial plexus block was as efficient in diabetic patients proximally for motor and sensory functions compared to non-diabetic patients. There was significant difference in the efficacy of the block distally between diabetic and non-diabetic patients in both motor (P< 001) and sensory function (P< 0001). Furthermore, in diabetic patients the response to the block between type 1 and type 2 was statistically significant (P< 001).

Conclusion: In diabetes, the efficacy of brachial plexus block is different compared to normal individuals. This study showed that brachial plexus block can be used efficiently in shoulder surgery in patients with diabetes. In more distal surgery, orthopaedic surgeons as well as anaesthetists should be prepared to either reinforce the block by using a local anaesthetic or to convert to general anaesthesia, if necessary, in diabetic patients.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 302 - 302
1 Jul 2011
Hajipour L Gulihar A Dias J
Full Access

Introduction: Treatment of a partial laceration in zone 2 of a flexor tendon is controversial. Although the intact part of a partially lacerated tendon is sufficient to sustain normal physiological forces, conservative management can lead to triggering, entrapment and rupture. Surgical repair is advocated for lacerations deeper than 60%. The Silfverskiold and Halsted techniques for peripheral repair use more suture material and have been shown to be stronger than a simple running suture. Currently there are no comparison of gliding resistance between different circumferential suture techniques, which is more important than tensile strength for partial lacerations.

Aim: The purpose of this study was to compare friction coefficient and gliding resistance at the flexor tendon – A2 pulley interface using three different circumferential repair techniques.

Method: Thirty long flexor tendons from long digit of turkey foot, along with the equivalent of A2 pulley were harvested. The tendons were lacerated to 50% and ten each were subjected to a Silfverskiold, Halsted or a running suture. All experiments were carried out for intact and lacerated tendon at 30, 50 and 70 degrees of flexion and two load settings of 2 N and 4 N. Gliding resistance was measured as the difference between forces recorded at the two ends of the tendon and the friction coefficient was measured using this formula, μ = Ln[(F2/F1)]/Ø.

Results: The Halsted repair was associated with a 100% increase in gliding resistance and friction coefficient relative to the intact tendon, compared to 80% for the Sil-fverskiold repair and 60% for a running suture (p=0.05). The running suture was technically the easiest.

Conclusion: We recommend a simple running suture for peripheral repair of partial flexor tendon lacerations, where surgical repair is advocated.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 296 - 296
1 Jul 2011
Gulihar A Williams S Dias J Harper W
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Background: Musculo-skeletal conditions account for at least 10% of General Practice consultations yet the average time spent by UK medical students in orthopaedic and trauma surgery is only 2.7 weeks.

Aim: This study assessed whether a seven-week undergraduate musculoskeletal teaching program introduced in 2006 improved performance.

Methods: This seven week program combined Orthopaedic and Trauma Surgery with Rheumatology and allied specialities. Its main elements were weekly plenary sessions, specialist clinics, a task-based workbook, regular assessments and traditional firm based teaching. The performance of 139 students who attended the new curriculum in its first year of introduction was assessed using multiple choice questions just before their final examinations in 2008 and was compared to that of a control group of students assessed in 2005 prior to program introduction.

Results: The 2008 students showed a 6% improvement in MCQ scores (p< 0.001) over the 2005 graduates. There was no difference between the 2005 students and a second control group of 46 students from 2008, who did not attend the new teaching program.

Conclusion: The program improved performance by providing more focused musculoskeletal training using available resources and by increasing the program duration.