Patients who present with a fractured neck of femur (NOF) have a significant rate of morbidity and mortality. In 2011, the National Institute for Health and Care Excellence (NICE) published clinical guidelines in order to improve these rates. Within this guideline NICE state that surgery should be performed on all NOF fractures within 36 hours. Within ABMU Health board the 1000 Lives Campaign goes a step further and aims to operate on 90% of patients within 24 hours.

This study investigates the effect of an additional NOF theatre list on compliance to these national guidelines.

This retrospective study was performed between October-December 2013 and December-February 2015. The first period of data collection represents a daily trauma list whilst the second period allowed an additional NOF theatre list. Data was collected using the National Hip Fracture Database and the Trauma Theatre List.

The number of patients meeting the national guidelines increased with the presence of an additional theatre list (75.19% v 60%). This represents a reduction to the average time to theatre of 4 hours and 30 minutes (29:47 v 34:17). The additional theatre list improved prioritisation of patients with NOF fractures on the list (29.46% v 13.33% listed first on list) and reduced the rate of cancellations (19.38 v 29.17%).

During this study Morriston Hospital did not meet national guidelines, however an additional theatre list did significantly improve average time to theatre. This study highlights the significant impact a dedicated NOF fracture theatre list can have.

Winner – Best Paper Award

Transferring patient data to the care of the oncoming team is the point at which the patient is most vulnerable on their journey through the healthcare system. Effective handover is vital to protect patient safety and has become increasingly more important after introduction of shift patterns for junior doctors following the implementation of the European Working Time Directive. The aim was to assess whether the introduction of a standardised proforma and traffic light system, would improve weekend handover of patients in our orthopaedic unit.

Data was collected in the form of hand written data, for 3 months, in our department. This was analysed and a standardised handover sheet and traffic light system to highlight patient priority was introduced. Following a 1 week trial, the proformas were reviewed following feedback from colleagues. A re-audit was commenced and data collected for a further 2 months.

There were 108 patients handed over on weekends during the re-audit compared to the 126 in the initial audit. The handover of patient data improved across all areas, with the most improved areas in recording the patients' diagnosis (58.4% to 94.4%) and noting the results of significant or pending investigations (61.2% to 91.7%). The traffic light system improved recording the patient's condition (8.5% to 81.5%) as well as logging the urgency or frequency of patient review (25.9% to 96.8%).

Standardised proformas improve patient data transferred at handover and the traffic light system allows improved prioritisation of patients, thus improving patient safety at weekends.

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings.

The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed.

Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (sd 14), 64.9 (sd 15) (n = 135), six months 67.8 (sd 16), 73.8 (sd 15) (n = 103) and nine months (72.4; sd 14) 72.3 (sd 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum.

The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs.

Cite this article: Bone Joint J 2015; 97-B:510–15.

Introduction:

Historically the incidence of Achilles re-ruptures has been described as around 5% after surgical repair and up to 21% after conservative management. In 2008 we commenced a dedicated Achilles tendon rupture clinic for both conservative and surgically managed patients using new standardised operating procedures (SOP). We have evaluated the impact of this new service, particularly with regard to re-rupture rate.

Introduction

Chronic mid body Achilles tendinopathy is a common problem. There is no consensus on treatment. The aim of this review was to assess the effectiveness of physiotherapy interventions (non surgical and non pharmacological) for this condition.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score.

Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Introduction: With increasing availability of CT scans their use in the investigation of the subtalar joint increases, whilst we continue to use plain x-ray. Using a standardised reporting protocol, we graded x-rays and CT scans to compare the diagnosis made using each modality.

Materials and Methods: An atlas and reporting system of the subtalar joint was designed using a modification of Kellgren and Lawrence’s system. 50 consecutive CT scans of the subtalar joint were identified and saved along with paired plain x-rays of the foot and ankle. All investigations were anonymised. Scans were excluded if there were no plain films or there was evidence of previous trauma. Orthopaedic surgeons were asked to report on the 50 CT scans and 50 plain radiographs using the reporting protocol, commenting on two components for each investigation; the anterior and middle facets and the posterior facet of the subtalar joint.

Results: In 33% of cases the facets of the subtalar joint could not be appreciated from the plain x-rays. The difference between the modalities in reported grade of degeneration of the anterior and middle facets of the subtalar joint was statistically significant (p= 0.014) but not for the posterior facet (0.726). When looking at the Spearman correlation coefficient, the anterior and middle facets had no correlation (r = − 0.067) although the posterior facet did (r = 0.029).

Discussion: When looking at the posterior facet of the subtalar joint plain x-rays and CT scans give comparable results. When looking at the anterior and middle facets the information gained from the plain x-rays bears no resemblance to that gained from the CT scans.

Conclusion: The plain x-ray is an inaccurate, unreliable method of investigating degenerate pathology of the subtalar joint and should be superseded, and perhaps replaced, by the CT scan.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score.

Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Introduction: Tibial pilon fractures are complex and difficult to manage. Results with extensile approaches, rigid internal fixation and bone grafting remain poor. Percutaneous treatment does not allow anatomic restoration. Current classifications are not helpful. Understanding the anatomy and behaviour of the fracture would allow development of logical algorithms for treatment.

Method: We have analysed plain radiographs and CT scans in a consecutive series of 126 pilon fractures and have defined the fracture anatomy and developed a new classification.

Results: There are six constant articular fragments: anterior, anterolateral (insertion of AITFL), medial, posterior, posterolateral (insertion of PITFL) and die-punch.

Two main fracture families exist depending on the articular fracture pattern. T-type and V/Y-type fractures. A lateral disruption type fracture represents a further important group. An evolution of fracture is evident within the groups.

T-type fractures tend to occur in varus and result from higher energy injuries in younger patients. V/Y-type fractures tend to occur in valgus and result from lower energy injuries in older patients.

Conclusions: We have defined distinct articular fragments, allowing development of safe direct surgical exposures. Stabilisation of the tibial fracture with fine-wire fixators or plates may be employed. The Pathoanatomy could be used in optimal design of such plates. Defining the fracture types gives us a useful and reproducible classification of injury.

Background: Tibial Pilon fractures pose a difþcult management problem. For logical fracture treatment, precise understanding of the 3-D anatomy is essential. Methods: We have studied a consecutive series of 126 pilon fractures. Digitised Xrays and CT scans were analysed using a CAD programme. Results: We have deþned 6 main fragments, at the articular surface. The primary fracture line varied in orientation from coronal (93%) to sagittal (7%), in contrast to the classic description. Observation of the articular fracture patterns revealed ñTñ, ñVñ, ñYñ and pure split fractures with respect to the medial fragment. Fractures, which displace into varus, show a ÒTÒ conþguration, those in valgus a ÒYÒ or ÒVÒ conþguration, (p < 0.001). Fractures with no coronal mal-alignment produce a talo-þbular joint disruption. These different articular patterns require individual techniques for anatomic reduction and þxation.

Tibial Pilon fractures pose a difficult management problem. For logical fracture treatment, precise understanding of the 3-D anatomy is essential.

We have studied a consecutive series of 126 pilon fractures. Digitised X-rays and CT scans were analysed using a CAD programme.

We have defined six main fragments at the articular surface, their relative frequency and their proportion: Anterior (A) present in 89%, 28% of area. Posterior (P) present in 89%, 40% of area. Medial (M) present in 74%, 29% of area. Anterolateral (AL) present in 34%, 8% of area. Posterolateral (PL) present in 21%, 9% of area. Die-punch (DP) present in 43%, 4% of area.

The primary fracture line varied in orientation from coronal (93%) to sagittal (7%), in contrast to the classic description.

Within those cases where the primary fracture line was coronal we found hitherto undescribed variations in the articular pattern, there being ‘T’, ‘V’, ‘Y’ and pure split fractures with respect to the medial fragment. Fractures which displace into varus show a “T” configuration, those in valgus a “Y” or “V” configuration, (p < 0.001). Fractures with no coronal mal-alignment produce a talo-fibular joint disruption.

Once recognised these different articular patterns require individual techniques for anatomic reduction and fixation.

Optimal treatment of articular fractures is open anatomic reduction and rigid internal fixation. In pilon fractures, this has been associated with unacceptable complication rates.

The cutaneous blood supply of the anterior aspect of the distal tibia is from short direct radial vessels which themselves arise from arteries closely adherent to the deep fascia. On the anteromedial aspect of the leg the deep fascia is fused with the periosteum. We hypothesise that shearing associated with displaced fractures divide these short radial vessels, rendering the skin critically ischaemic. Standard extensile approaches lead to further devitalisation and wound breakdown. It follows that a direct approach onto the fracture line should do minimal extra damage to the blood supply.

Of 97 pilon fractures, 53 have required an open reduction. Median age 43, 39 male. Mechanism of Injury: fall-41, RTA-10, other-two. 19% open (60% IIIB). Time to surgery nine days.

A longitudinal incision with full thickness flaps is based directly over the fracture, not necessarily following internervous planes.

Anatomic reduction was achieved in all cases. There was only one complication of wound breakdown (2%).

This technique affords a safe and reliable approach to the fractured articular surface. Lack of wound breakdown may rely on the use of fine-wire circular frame external fixators for stabilisation of the proximal fracture. Whether this approach will allow plate fixation, remains to be seen.

The perineal traction post has been reported to cause pressure sores, skin necrosis, and pudendal nerve palsy. Tissue pressures of 70 mm Hg applied for two hours have been shown to result in microscopic tissue change whilst pressures of 1.4 kg/cm² for 90 minutes produced severe or complete nerve conduction block.

To demonstrate perineal traction post interface pressures. To assess effect of padding type on these pressures.

Healthy volunteers were positioned supine on the traction table with the right lower limb supported in flexion and abduction. Longitudinal traction of 40kg was applied to the left lower limb through the boot. Pressures were measured using a pressure pad consisting of individual calibrated inch square pressure cells. The pad was placed around the traction post. Five different types of padding were used on a standard traction post. These were: gamgee, small gel pad, 10cm gel bolster, 10cm soft foam roll and 10cm hard foam roll. With each device, the leg was positioned in neutral, internal rotation, external rotation and adduction. Pressure readings and pain scores were recorded with each manoeuvre.

Maximum pressures were experienced with the gamgee wrap. All subjects noted their highest pain score here. Peak pressures of 100 mm Hg were demonstrated over the ischial tuberosity and adductor tendons. The larger padding devices resulted in significantly lower pressures. Of the different positions, adduction was that which resulted in highest pressures and pain scores, though this was not significant.

The highest pressures exceeded the 70 mm Hg limit known to cause tissue damage. These pressures can be reduced with alteration of the padding. In all procedures it is important to pad the post carefully and use adducted positions for as short a time as possible.

Tunnel placement in Anterior Cruciate Ligament (ACL) reconstruction is the single most important variable that a surgeon can control in order to achieve a successful outcome. The femoral tunnel is more critical than the tibial.

Audit tunnel positions after ACL reconstruction in a regional centre.We studied 114 patients undergoing primary isolated ACL reconstruction within a 12-month period. Case notes and radiographs were reviewed retrospectively. Tunnel position was assessed on lateral and AP radiographs of the knee. A review of literature established optimal tunnel position. Measurements of tunnel position were made according to the methods described by Jonsson.

16 surgeons (8 consultants and 8 registrars) performed 57 arthroscopic and 57 open reconstructions, using 24 hamstring and 90 bone-tendon-bone autografts. Femoral tunnel drilling was through the medial arthroscopic portal (24) or the tibial tunnel (90). 85 sets of radiographs were available for review (21 not performed post-operatively, 8 not found)

In the sagittal plane, the femoral tunnel insertion should be within the posterior third along an extended Blumensaat’s line and the tibial tunnel between 41 and 49% along the tibial joint line from anterior to posterior. In the coronal plane, the tibial tunnel should exit between 41% and 49% along the tibial joint line, from medially. Our results showed that 65% of femoral tunnels were outside this position, 23% of the tibial tunnels out in the sagittal plane and 55% out coronally. Of those drilled through the medial portal, only 5% of the femoral tunnels were outside our recommended position.

Clinical Governance demands that guidelines for best practice are established and that audit ensures these standards are met. Anatomical studies give useful data in determining acceptable standards, as demonstrated in our audit. To enable this it is imperative that post-operative radiographic assessment is performed routinely.