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Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and

15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_3 | Pages 36 - 36
1 Feb 2017
Bayers-Thering M Brown M Matthews J Phillips M Krackow K
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Abstract

A number of postoperative complications of navigated total knee arthroplasty have been discussed in the literature, including tracker pin site infection and fracture. In this paper we discuss the low postoperative complication rate in a series of 3100 navigated total knee arthroplasties and the overall complication rate in a systematic analysis of the literature.

Methods

3100 consecutive patients with navigated total knee arthroplasties from 2001 to 2016 were retrospectively evaluated for complications specific to navigation. We discuss the two cases of postoperative fracture through tracker pin sites that we experienced and compare this systematically to the literature.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_6 | Pages 6 - 6
1 Feb 2016
Toomey E Matthews J Hurley D
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Purpose and background:

Implementation fidelity (IF) is the extent to which an intervention is implemented as intended by its developers, and increases confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. The aim of this study was to evaluate the IF within a behaviour-change self-management intervention for people with chronic low back pain and/or osteoarthritis, consisting of six weekly sessions (SOLAS ISRCTN49875385).

Methods:

In a sample of data, the intervention was delivered by physiotherapists (n=9) in seven sites. IF was assessed using self-report (by physiotherapists) of all sessions (n=60), direct observations (by the research team) of 40% of the sessions (n=24) and audio-recorded observations (by the research team) of all sessions (n=60) using checklists. Data were analysed in SPSSv20 to assess % agreement between methods and fidelity scores.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_1 | Pages 50 - 50
1 Jan 2016
Borus T Roberts D Fairchild P Christopher J Conditt M Branch S Matthews J Pirtle K Baer M
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Introduction

Unicompartmental Knee Arthroplasty (UKA) has been offered as a tissue sparing alternative to total knee arthroplasty (TKA) for treatment of early to mid-stage osteoarthritis (OA). While the spared tissue and retention of cruciate ligaments may result in faster recovery, smaller incision, less bone resection, decreased pain and blood loss and more normal kinematics and function, UKA has shown unpredictable results in practice, which may be due to variations in surgical techniques1. Recently a robotic-assisted technique has been introduced as a means to provide more consistent and reproducible surgical results. In this study, the early return to function was measured to determine proposed benefits between UKA and TKA.

Methods

Patients requiring either UKA or TKA were prospectively enrolled in this IRB approved study. Each patient received pre-operative education regarding their expected physical therapy (PT) regimen, which was uniform for all patients. PT was determined to be concluded when each patient reached an achievable functional endpoint with each of the following 5 criteria: range of motion from 5 to 115 degrees, recovery of flexion and extension strength to 4/5 of pre-operative strength, gait with minimal limp and without an assistive device for 250 feet and ability to ascend and descend a flight of stairs with step over gait and good control. The number of PT visits to reach each functional goal was recorded.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_2 | Pages 29 - 29
1 Feb 2015
Keogh A Matthews J Hurley D
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Background

Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA.

Methods

A two phase search strategy of electronic databases was used to identify systematic reviews and studies relevant to this area. Articles were coded independently for their use of behaviour change theory, and the number of behaviour change techniques (BCTs) was identified using a 93 item taxonomy, Taxonomy (v1).


Background

Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important in increasing confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. Growing demands on healthcare services mean that multiple condition interventions involving highly prevalent musculoskeletal pain conditions such as chronic low back pain (CLBP) and/or osteoarthritis (OA) are of increasing clinical interest. This is the first in-depth review of implementation fidelity within self-management interventions for any musculoskeletal pain condition.

Methods

Structured self-management interventions delivered by health-care professionals (including at least one physiotherapist) in a group format involving adults with OA of the lumbar spine, hip or knee and/or CLBP were eligible for inclusion. The National Institutes of Health Behaviour Change Consortium Treatment Fidelity checklist was used by two independent reviewers to assess fidelity.


Background

Osteoarthritis (OA) and chronic low back pain (CLBP > 12 weeks duration) are two of the most common and costly chronic musculoskeletal conditions globally. Healthcare service demands mean that group-based multiple condition interventions are of increasing clinical interest and a priority for research, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions concurrently. Rapid review methodologies are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions.

Methods

The electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Register of Controlled Trials were searched from the earliest date possible to August 26th 2013. Structured group-based interventions that aimed to promote self-management and that were delivered by health-care professionals (including at least one physiotherapist) involving adults with OA and/or CLBP were eligible for inclusion. The screening and selection of studies, data extraction and risk of bias assessment were conducted independently by two reviewers.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_4 | Pages 36 - 36
1 Feb 2014
Matthews J Hall A Lonsdale C Hernon M Murray A Taylor I Jackson B Toner J Guerin S Hurley DA
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Purpose of the study and background

The CONNECT trial evaluated a theory-based intervention to increase low back pain patients' adherence to treatment recommendations through physiotherapists' communication behaviour. Bridging the gap between evidence and evidence-based practice, we aimed to develop an implementation intervention to support physiotherapists in translating the CONNECT communication training into practice.

Methods and results

A systematic approach was used to develop this intervention. 1. Focus groups underpinned by the Theoretical Domains Framework were conducted to assess CONNECT trained physiotherapists' (n = 9) perceptions of the barriers and enablers to implementing these strategies in practice; the results of which yielded four main domains; two related to factors outside the individual (i.e. social influences and environmental resources), and two related to individuals' motivation and capabilities (i.e. self –efficacy and behavioural regulation). 2. Intervention components (i.e., behavior change techniques (BCT) and mode of delivery) were chosen. BCTs were mapped to the identified domains (e.g., the BCT of self-monitoring mapped to the self-efficacy domain) and audit and feedback focused coaching was selected as the main mode of delivery based on empirical evidence and feasibility. 3. Outcome measures were selected to evaluate the proposed changes in physiotherapist practice (i.e., Health Care Climate Questionnaire). This intervention was trialed with physiotherapists (n = 2) using a case-study design. Results from patient consultation audio-recordings and follow-up interviews revealed this intervention supported the translation of evidence-based training into practice and is considered feasible and acceptable to physiotherapists.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXII | Pages 3 - 3
1 Jul 2012
Bonner T Eardley W Newell N Masouros S Gibb I Matthews J Clasper J
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Circumferential pelvic binders have been developed to allow rapid closure of the pelvic ring in unstable fracture patterns. Despite evidence to support the use of pelvic binders, there is a paucity of clinical data regarding the effect of binder position on symphyseal diastasis reduction.

All patients presenting to the UK's military hospital in Afghanistan who survived and underwent pelvic radiography were reviewed. Cases were identified by retrospective assessment of all digital plain pelvic radiographs performed between January 2008 and July 2010. All radiographs and CT images were assessed to identify the presence of any pelvic fracture. Patients were grouped into three categories according to the vertical level of the buckle: superior to the trochanters (high), inferior to the trochanters (low) and at the level of the trochanters (troch). Diastasis reduction was measured in patients with Anterior-Posterior Compression (APC) grades II and III, or Combined Mechanical Injuries(CMI). Comparison of diastasis reduction between the high and troch groups was assessed by an independent samples Student's t-test.

We identified 172 radiographs where the metallic springs in the buckle of a SAM Pelvic Sling were clearly visible. The binders were positioned at the trochanteric level in 50% of radiographs. A high position was the commonest site of inaccurate placement (37%). In the patients with fractures and an open diastasis, the mean pelvic diastasis gap was 2.75 times greater in the high group compared to the trochanteric level (mean difference 22 mm) (p < 0.01).

Application of pelvic binders superior to the greater trochanters is commonplace and associated with inadequate fracture reduction, which is likely to delay cardiovascular recovery in these significantly injured casualties.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 315 - 315
1 Jul 2011
James A Dean B Matthews J Price A Stubbs D Whitwell D Gibbons M
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Introduction: Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations.

Methods: Between 2003 and 2008 twenty one patients presented with complex trauma related problems and underwent EPR at a specialist tertiary referral centre. The mean age was 71 years (range 44–87) and the median number of previous surgical procedures was 3 (range 0–11). Eight patients presented following failed internal fixation of proximal femoral fractures. Nine patients had periprosthetic fractures around joint arthroplasties, seven relating to total knee replacements (TKRs) and two to total hip replacements (THRs). One case of periprosthetic fracture around THR had undergone failed internal fixation. Two patients had distal femoral fractures, of which one was infected and had undergone failed internal fixation, while the other was unrecon-structable. Two patients had proximal tibia fractures which had both undergone failed internal fixation.

Results: The mean Harris Hip Score was 89.5 (range 64–85) at a mean follow up period of 8 months (minimum 4 months). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75) at a mean follow up period of 6 months (minimum 2 months). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout.

Discussion: Modular EPR in the lower limb is a durable reconstructive option in complex trauma problems, particularly in the elderly and those patients with significant bone loss. Preliminary functional results indicate very satisfactory results.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 135 - 135
1 May 2011
Dean B Matthews J Price A Stubbs D Whitwell D Gibbons C
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Introduction: Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The objective of this study was to evaluate the success of endoprosthetic replacement (EPR) in patients who had undergone limb salvage following complex trauma presentations.

Materials and Methods: Between 2003 and 2008 twenty one patients presented with complex trauma related problems and underwent EPR at a specialist tertiary referral centre. The mean age was 71 years (range 44–87) and the median number of previous surgical procedures was 3 (range 0–11). Eight patients presented following failed internal fixation of proximal femoral fractures. Nine patients had periprosthetic fractures around joint arthroplasties, seven relating to total knee replacements (TKRs) and two to total hip replacements (THRs). One case of periprosthetic fracture around THR had undergone failed internal fixation. Two patients had distal femoral fractures, of which one was infected and had undergone failed internal fixation, while the other was unreconstruc-table. Two patients had proximal tibia fractures which had both undergone failed internal fixation.

Results: The mean Harris Hip Score was 89.5 (range 64–85) at a mean follow up period of 8 months (minimum 4 months). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75) at a mean follow up period of 6 months (minimum 2 months). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout.

Conclusion: Modular EPR in the lower limb is a durable reconstructive option in complex trauma problems, particularly in the elderly and those patients with significant bone loss. Preliminary functional results indicate very satisfactory results.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 54 - 54
1 Jan 2011
Dean B Moore E Matthews J Stubbs D Whitwell D Gibbons C
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Although originally designed to aid the management of primary malignant bone tumours, the indications for modular endoprosthetic replacement (EPR) have expanded to include complex periprosthetic fractures and failed internal fixation. The incidence of these challenging cases is increasing with an aged population. We reviewed retrospectively our experience with the use of EPR in patients who had undergone limb salvage following complex trauma presentations.

Between 2003 and 2008 twenty one patients underwent EPR following referral to the Oxford Sarcoma Service following lower limb trauma. The average age was 71 years (44–87). The average number of previous surgical procedures was 3 (range 0–11).

The mean Harris Hip Score was 89.5 (range 64–85). The mean American Knee Society Score was 82 (range 62–100) and the mean functional score was 62 (range 30–75). Complications included two cases of deep infection; one resulted in a two stage revision procedure, while the other retained the EPR following a washout. EPR is an effective salvage procedure for failed trauma fixation and periprosthetic fractures. Immediate weight bearing and a good functional outcome can be expected in this difficult group of patients.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 47 - 47
1 Jan 2011
Matthews J Schranz P
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Purpose: Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months).

Methods: Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed.

Results: No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion. No patients sustained a patellar fracture.

Conclusions: Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft using a longitudinal tunnel technique provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.

Level of evidence: Level IV, therapeutic case series.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 417 - 417
1 Jul 2010
Dean B Matthews J Reed D Pandit H McNally E Athanasou N Gibbons C
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The infrapatellar (Hoffa’s) fat pad can be affected by a variety of tumours and tumour-like conditions which can occasionally present a diagnostic and therapeutic challenge to the treating surgeon. The fat pad can be affected by diffuse or solitary disease. Solitary tumours are relatively uncommon but with widespread uptake of Magnetic Resonance Imaging Scans (MRI) an increasing number of Hoffa’s fat pad tumours (HFP) are being recognized.

Between 1999 and 2008, 20 patients with HFP pathology referred to Oxford bone and soft tissue tumour service underwent resection and histological examination. Clinical records, imaging and histological findings were reviewed. Histology showed eight different diagnoses with Pigmented Villonodular Synovitis (PVNS) and ganglia being the most common pathology.

In one patient, MRI identified the cause of hypophosphataemic osteomalacia as an HFP phosphaturic mesen-chyma tumour despite the lack of local symptoms.

In conclusion, the majority of solitary HFP tumours are benign and maybe cystic or solid. MRI and plain radiographs are the imaging of choice. Cystic tumours maybe aspirated but the definitive treatment of both cystic and solid tumours should be open arthrotomy and excision biopsy. Arthroscopic resection is not advised, as complete excision is not always possible. None of the 20 patients in this series had a malignant tumour but this has been reported in the literature. Calcification on plain radiographs may indicate a malignant lesion. All patients in our series reported substantial improvement in symptoms following open tumour resection.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 502 - 502
1 Sep 2009
Matthews J Schranz P
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Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months).

Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed.

No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion.

Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_II | Pages 212 - 212
1 May 2009
Ball L Matthews J Rosewarne A Cox P
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Our study looked at the short and medium-term results of a new and cost-effective method of bone surface preparation and cement introduction. Early failure and loosening of components in knee arthroplasty has been attributed to inadequate bone-cement and prosthesis- cement interfaces, established at the time of surgery. Cement pressurisation and interosseus suction have been shown to achieve effective cement penetration and interdigitation into cancellous bone.

We have devised a technique of cement pressurisation using a modified 20 ml syringe, combined with interosseus suction. Retrospective evaluation of a series of 50 post-operative radiographs of total knee replacements, undertaken without the use of tourniquet, have shown that even and effective penetration of cement to a depth of 8.0 10.6 mm can be achieved consistently using this technique. Evaluation of post-operative radiographs at a minimum of 5 years follow-up showed 16 knees with minor lucent lines about the tibial component with a maximum Knee Society Total Knee Arthroplasty Roentgenographic Score of 2.

In conclusion, we propose that this simple technique of bone surface preparation and cement introduction produces good results in the short and medium term.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 343 - 344
1 Jul 2008
Matthews J Guhan B Dainton J Hutchins P
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Introduction: The long term results of a previously published (J Shoulder Elbow Surg. 2002 Sep–Oct; 11(5):486–492) series of 44 primary Souter-Strathcyde total elbow arthroplasties performed on 36 patients with rheumatoid arthritis by a single surgeon in a district general hospital are presented.

Methods: Of the 36 patients 14 patients had died leaving 22 patients or 28 elbows that could be followed up with a mean follow up of 11 years (range 9.7–17.8 years). Patients were followed up in research clinics. They underwent plain radiographs and clinical examination. The notes of the deceased patients were reviewed.

Results: In the surviving patients 60% reported complete freedom of pain, 28% mild intermittent pain and 11% moderate pain. The mean range of motion at follow up was 91 degrees (range 30–130 degrees). This represented a mean gain of 15 degrees of flexion, but only a 1 degree gain in extension. Fourteen elbows had a range of motion of 100 degrees or greater compared with 9 before surgery.

In the deceased patients 2 patients had undergone revision and the remaining patients had died of causes unrelated to the surgery with the prosthesis intact. There was 1 permanent ulnar nerve palsy and two deep infections one requiring debridement. Eight of the original 44 primaries required revision, 3 for fractures and 5 for loosening.

Discussion: In patients with rheumatoid arthritis and low functional demand, the Souter-Strathclyde total elbow arthroplasty performs well in abolishing pain and increasing independence in carrying out the activities of daily living.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 332 - 332
1 Sep 2005
Pimpalnerkar A Matthews J Walker R Mohtadi N
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Introduction and Aims: Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50percent of these injuries occur in athletes, classically in weight-lifters during bench press.

Method: In this study, 13 cases of rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair. Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients. Intra-operative findings correlated with the reported scans in 11 patients with minor differences in two patients.

Results: During follow-up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their pre-operative level.

Among our patients we emphasise that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.

Conclusion: According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle, which is essential for the active athlete.


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 2 | Pages 172 - 174
1 Mar 1984
Leyshon R Matthews J

Nine cases of acetabular erosion following insertion of the Monk "hard top" hip prosthesis for subcapital fractures are presented. All of these patients had significant symptoms and represented 5% of the total group. In our experience acetabular erosion has proved to be a significant complication of the Monk "hard top" prosthesis.


The Journal of Bone & Joint Surgery British Volume
Vol. 64-B, Issue 1 | Pages 88 - 91
1 Feb 1982
Matthews J Lawford P Duckworth T