Background

Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting intramedullary fixation of adolescent clavicle fractures. 2) Review current management in a major trauma center (MTC) with a view to assess feasibility for a randomised controlled trial (RCT).

Background

Visual representation help make the ever-increasing data more attractive, thought provoking and informative. In the field of surgical training, Procedure Based Assessment is a structured method of assessing surgical performance and skills of trainees in the UK and is a valuable tool for trainers in the Annual Review of Competence Progression. Trainers can view PBA's on the online-based Intercollegiate Surgical Curriculum Programme individually in a long-form format with no visual representation.

Applying the concept of a regional trauma network to the UK paediatric trauma population has unique difficulties in terms of low patient volume and variation in paediatric service provision. In addition, no consensus exists as to which radiological investigations should be employed and an increasing trend towards computerised tomography raises concerns over radiation exposure. We carried out a retrospective review of all paediatric trauma calls from April 2010 and March 2013 around becoming a Major Trauma Centre. We aim to analyse the impact this has on trauma calls and assess the radiological investigations currently used in this population.

The number of yearly paediatric trauma calls doubled during our study and totalled 132. The commonest mechanisms of injury were road traffic collisions, fall from a height or fall off a horse. 91.7% of children had some form of radiological investigation; 67% plain radiograph, 37.1% trauma CT, 21.2% focused CT and 5.3% abdominal ultrasound scan. Of the 77 CT scans performed 57.1% were reported as normal and 54.5% of these patients were discharged home the same day. Five children re-attended the emergency department within 30 days with two positive findings; a subdural haematoma and a tibial plateau fracture.

The current use of harmful radiological investigations in paediatric trauma patients is not uniform. We propose implementation of radiology protocols and clinical guidance to imaging in paediatric trauma to limited radiation exposure.

This study is a mid-term follow up of an original series of 51 babies treated with a modified Ponseti technique for idiopathic congenital talipes equinovarus using below-knee Softcast (easier to remove and hygienic)¹ to determine whether this method is as effective as traditional above-knee plastering.

Introduction

No previous studies have attempted to measure parental satisfaction and service quality in regards to paediatric orthopaedic service inpatient care. We performed a prospective observational study to assess parental satisfaction with the level of service provided for paediatric orthopaedic inpatient care in our unit.

Introduction

Simulation is increasingly perceived as an important component of surgical training. Cadaveric simulation offers an experience that can closely simulate operating on a living patient. We have explored the feasibility of providing cadaveric training for the whole curriculum for trauma and orthopaedic surgery speciality trainees, before they perform those operations on living patients.

Introduction: Total hip replacement (THR) and total knee replacement (TKR) are widely accepted as effective surgical procedures to alleviate chronic joint pain and improve functional ability. Clinical evidence suggests that joint replacement results in excellent outcomes. Traditionally, reporting of outcomes has been focused on implant survivorship and surgeon based assessment of objective outcomes, such as range of motion, knee stability and radiographic results. However, because there is a discrepancy between patient and clinician ratings of health, patient-reported outcome measures have been validated to allow patients to rate their own health, thereby placing them at the centre of outcome assessment. The aim of this study was to compare the mid-term functional outcomes of TKR and THR using validated patient-reported outcome measures.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR or TKR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Participants completed an Oxford hip score (OHS) or Oxford knee score (OKS). The Oxford questionnaires are self-report joint-specific measures that assess functional ability and pain from the patient’s perspective. They consist of 12 questions about pain and physical limitations experienced over the past four weeks because of the hip or knee.

Results: 1112 THR patients and 613 TKR patients returned a completed questionnaire, giving a response rate of 72%. The median OKS of 26 was significantly worse than the median OHS of 19 (p< 0.001). TKR patients experienced a poorer functional outcome than THR patients on all domains assessed by the Oxford questionnaire, independent of age. The percentage of patients reporting moderate-severe pain was two-fold greater for TKR than THR patients (26% vs 13%, respectively).

Conclusion: This survey found that TKR patients report more pain and functional limitations than THR patients at 5–8 years post-operatively, independent of age. The finding that over a quarter of TKR patients reported moderate-severe pain at 5–8 years post-operative indicates that a large proportion of people are undergoing major knee surgery that is failing to achieve its primary aim of pain relief. This raises questions about whether patient selection for TKR is appropriate. To improve patient selection, it may be necessary to have a preoperative screening protocol to identify patient factors predictive of a poor outcome after TKR. Currently, no such protocol exists and this is an area of orthopaedics requiring further research.

Introduction: Although THR can provide excellent pain relief and restore functional ability for most patients, there is a proportion of patients who experience a poor functional outcome after THR. One factor that could contribute to a poor outcome after THR is leg length discrepancy (LLD). Restoration of leg length is important in optimising hip biomechanics and LLD has several consequences for the patient, including back pain and a limp. Assessment of LLD using radiographs is time consuming and labour intensive, and therefore limits large scale studies of LLD. However, patients self-report of perceived LLD may be a useful tool to study LLD on a large scale. Therefore, the aim of this postal audit survey was to determine the prevalence of patient-perceived LLD after primary THR and its impact on mid-term functional outcomes.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Several questions about LLD were included on the questionnaire. Firstly, patients were asked if they thought that their legs were the same length. For those who thought their legs were different lengths, they were asked if the difference bothered them, whether the difference in length leg was enough to comment upon, and whether they used a shoe raise. Participants also completed an Oxford hip score (OHS), which is a self-report measure that assesses functional ability and pain after THR, including limping

Results: 1,114 THR patients returned a completed questionnaire, giving a response rate of 73%. 329 patients (30%) reported that they thought their legs were different lengths. The median OHS for patients with a perceived LLD was 22, which was significantly worse than the OHS of 18 for patients who thought their legs were the same length (p< 0.001). Of the 329 patients with a perceived LLD, 161 patients (51%) were bothered by the difference, 65 patients (20%) thought the discrepancy was sufficient to comment upon and 101 patients (31%) used a shoe raise. 31% of patients with LLD limped most or all of the time compared to only 9% of patients without LLD.

Conclusion: In conclusion, this study found that the prevalence of perceived LLD at 5–8 years after THR was 30%. Of the patients with LLD, over 50% were bothered by the LLD and over a third used a shoe raise to equalise leg lengths. Patients with perceived LLD have a significantly poorer self-report functional outcome than those patients without LLD. It is therefore important that patients are informed pre-operatively of the high risk of LLD after THR and the associated negative impact this may have on their outcome.

Aims: To establish the best teaching method for medical students and ascertain the students’ preferred method of teaching.

Material and Methods: 30 medical students in were picked randomly and divided into two equal groups. Group 1 received Standard bedside teaching and Group 2 watched an interactive DVD. Each group then undertook a validated OSCE and the examiners were blinded as to which teaching method the students had received. The groups then received the other method of teaching followed by another OSCE. A questionnaire was given to all the students, to assess their satisfaction of the teaching session.

Results:

Conclusion: Interactive teaching method can be a useful technique for teaching medical students, however the students’ preferred method of teaching is standard bedside teaching. Efficiency of knowledge transfer can be improved if interactive teaching is followed by standard bed side teaching but not the other way around.

We report the results of the use of the Long Gamma Nail in the treatment of complex proximal femoral fractures in our hospital.

All patients at one hospital treated with the Long Gamma Nail were reviewed. Information collected included the age, sex, type of injury, fracture classification, intra-operative complications, post-operative complications, and survival of the implant and patient.

One hundred nails were reviewed which were inserted in 97 patients. 70 patients were followed up for 1 month or more and their mean follow up was 8 months (range 3 months to 6 years). The mean age was 74 (range 16–98). Twenty were inserted into femurs with metastatic malignancy and four patients were victims of poly-trauma. The average length of the operation was 2 hours 22 minutes. Blood transfusion was required in 74% and on average was 2.5 units. There were 7 significant complications. Five patients underwent revision, 2 to Total Hip Arthroplasty after proximal screw migration and 2 patients required exchange nailing. There was one broken nail and two peri-prosthetic fractures at the tip of the nail.

Success was defined as achievement of stability of fracture until union or death; this was achieved in 15% of cases. The mortality was 7% at 30 days and 17% at one year. One death was directly related to the nail and the rest due to medical co-morbidities. Complication rate fell with increasing experience in the unit. The training of surgeons had no detrimental effect on outcome.

Complex proximal femoral fractures including pathological lesions, subtrochanteric fractures and pertrochanteric fractures with subtrochanteric extensions are difficult to treat, with all implants having high failure rates. The long gamma nail allows early weight bearing and seems effective in treating these difficult fractures. Furthermore the majority of these unstable fractures tend to occur in the very elderly with osteoporosis and other medical co-morbidity. Care should be taken to avoid malpositioning of the implant, as this was the major cause of failure and revision. The length of time surgery may take and the anticipated blood loss should not be underestimated especially when dealing with challenging fractures in frail and elderly patients or those with medical co-morbidity.

The aim of this study was to determine the outcome of total hip arthroplasty, with regard to dislocation, at our unit.

1727 primary total joint arthroplasties and 305 revision total hip arthroplasties were performed between 1993 and 1996 at our unit. We followed up 1567 of the primary hip arthroplasties and 284 of the revision hip arthroplasties at 8 to 11 years post surgery. Patients were traced by postal questionnaire, telephone interview or examination of case notes of the deceased.

The dislocation rates by approach were: 23 out of 555 (4.1%) for the posterior approach, 0 out of 120 (0%) for the Omega approach and 30 out of 892 (3.4%) for the modified Hardinge approach.

58.5% of dislocations after primary total hip arthroplasty were recurrent. The mean number of dislocations per patient was 2.81.

8.1% of revision total hip arthroplasties suffered dislocation. 70% of these became recurrent. The mean number of dislocations per patient was 2.87. The vast majority of dislocations occur within 3 months of surgery.

To our knowledge this is the largest multisurgeon audit of dislocation after total hip arthroplasty published in the United Kingdom. The follow-up of 8 to 11 years is longer than most comparable studies.

The aim of our study was to determine the current incidence and outcome of infected total knee arthroplasty (TKA) in our unit comparing them with our earlier audit in 1986, which had revealed infection rates of 4.4% after 471 primary TKAs and 15% after 23 revision TKAs at a mean follow-up of 2.8 years. In the interim we introduced stringent antibiotic prophylaxis, and the routine use of occlusive clothing within vertical laminar flow theatres and 0.05% chlorhexidine lavage during arthroplasty surgery.

We followed up 931 primary TKAs and 69 revision TKAs for a mean of 6.5 years (5 to 8). Patients were traced by postal questionnaire, telephone interview or examination of case notes of the deceased.

Nine (1%) of the patients who underwent primary TKA, and four (5.8%) of those who underwent revision TKA developed deep infection. Two of nine patients (22.2%) who developed infection after primary TKA were successfully treated without further surgery. All four of the patients who had infection after revision TKA had a poor outcome with one amputation, one chronic discharging sinus and two arthrodeses.

Patients who underwent an arthrodesis had comparable Oxford knee scores to those who underwent a two-stage revision. Although infection rates have declined with the introduction of prophylactic measures, and more patients are undergoing TKA, the outcome of infected TKA has improved very little.

Background: Posterior dislocation of the elbow with fractures of the radial head and coronoid process is a rare injury which, when treated conservatively, has a high redislocation rate and poor results (7/11 in the largest published series). Methods: Six patients with this injury were treated with triple reconstruction, involving exploration of the joint via a lateral approach with insertion of a radial head prosthesis. The coronoid fracture and anterior capsule was repaired (using an in-to-out technique) and the lateral collateral ligament was reat-tached, using Mitek Super Anchors. All patients were evaluated prospectively. Results: The average age was 52 years (37–75y). At one year follow up all elbows remained in joint and all were pain free or causing slight pain only. The average range of ulno-humeral movement was 55 degrees (range 38–68) and the average forearm rotation was 67 degrees (range 18–104). Functional assessment showed an average Liverpool score of 23/36 (range 17–29) and average Broberg and Morrey score of 74/100 (range 68–84). Conclusions: Triple reconstruction recognises and remedies the three elements of this devastating injury. All of these must be addressed in order to fulþll the short-term goal of restoring and maintaining stability. Our patients have a stable, pain free, though stiff, elbow in contrast to the poor results reported from previous conservative and operative treatments.

Our aim in this study was to determine the outcome of hip arthroplasty with regard to infection at our unit. Infection after total joint arthroplasty is a devastating complication. The MRC study in 1984 recommended using vertical laminar flow and prophylactic antibiotics to reduce infection rates. These measures are now routinely used. Between 1993 and 1996, 1727 primary total hip arthroplasties and 305 revision hip arthroplasties were performed and 1567 of the primary and 284 of the revision arthroplasties were reviewed between five and eight years after surgery by means of a postal questionnaire, telephone interview or examination of the medical records of those who had died.

Seventeen (1.08%) of the patients who underwent primary and six (2.1%) of those who underwent revision arthroplasty had a post-operative infection. Only 0.45% of patients who underwent primary arthroplasty required revision for infection.

To our knowledge this is the largest multi-surgeon audit of infection after total hip replacement in the UK. The follow-up of between five and eight years is longer than that of most comparable studies. Our study has shown that a large cohort of surgeons of varying seniority can achieve infection rates of 1% and revision rates for infection of less than 0.5%.