Objectives

Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study.

The requirement for the peer support groups were born out of concern for the psychological wellbeing of the paediatric patients and to assess if this would improve their wellbeing during their treatment. Groupwork is a method of Social Work which is recognised as a powerful tool to allow people meet their need for belonging while also creating the forum for group members to empower one another. Social Work meet with all paediatric patients attending the limb reconstruction service in the hospital. The focus of the Medical Social Worker (MSW) is to provide practical and emotional support to the patient and their parent/guardian regarding coping with the frame. Some of the challenges identified through this direct work include patient's struggling with the appearance of the frame and allowing peers to see the frame.

The peer support group aims to offer its attendees the opportunities to engage with fellow paediatric patients in the same position. It allowed them to visually identify with one another. We wanted to create a safe space to discuss the emotional impact of treatment and the frames. It normalises the common problems paediatric patients face during treatment. We assisted our participants to identify new coping techniques and actions they can take to make their journey through limb reconstruction treatment more manageable. Finally, we aimed to offer the parents space to similarly seek peer support with regard to caring for a child in treatment. All paediatric patients were under the care of the Paediatric Orthopaedic Consultant and were actively engaging with the limb reconstruction multi-disciplinary team (MDT). The patient selection was completed by the MDT; based on age, required to be in active treatment, or their frames were removed within one month prior to the group's commencement. Qualitative data was collected through written questionnaires and reflection from participants in MSW sessions. We also used observational data from direct verbal feedback from the MDT. In the first group, parents gave feedback due to participants age and completed written feedback forms. For our second group, initial feedback was collated from the participants after the first session to get an understanding of group expectations. Upon completion, we collected data from both the participants and the parents. Qualitative and scaling questions gathered feedback on their experience of participating in the group.

We held two peer support groups in 2022:One group for patients aged between 3–6 years in January 2022 across two sessions, which was attended by four patients. The second group for young teenage patients aged between 11–15 years in April 2022 across four sessions, which was attended by five patients. The written feedback received from group one focused on eliciting the participant's experience of the groupwork. 100% of participants identified the shared experience as the main benefit of the groupwork. 100% of participants agreed they would attend a peer support group again, and no participant had suggestions for improvement to the group. Feedback did indicate that group work at the beginning of treatment could be more beneficial. In relation to the second group, 60% of the paediatric patients and their parents returned the questionnaires. All of the parent's feedback identified that it was beneficial for their child to meet peers in a similar situation. They agreed that it was beneficial to meet other parents, so they could get support and advice from one another. On a scale between 1 and 5, 5 being the highest score, the participants scored high on the group work meeting their expectations, enjoyment of the sessions, and the group work was a beneficial aspect of their treatment. All respondents would strongly recommend groupwork to other paediatric patients attending for limb reconstruction treatment.

Overall, the MDT limb reconstruction team, found the peer support group work of great benefit to the participants and their parents. The MSW team identified that during a period on the limb reconstruction team, when a high number of patients were in active treatment, the workload of the MSW also increased reflecting this activity. Common issues and concerns were raised directly to MSW (particularly from group two) regarding numerous difficulties they experienced trying to cope with the frame. The group work facilitators created a space where the participants could get peer support, share issues caused by the frame, hear directly from others, and that they too experience similar feelings or issues. Collectively, they identified ways of coping and promoting their own wellbeing while in treatment. The participants in group two, subsequently created a group on social media, to be able to continue their newly formed friendships and to continue to update one another on their treatment journeys. The participants self-requested another group in the future. This was facilitated in November 2023, the facilitators sought more feedback from all participants and their parents after this session. These findings will contribute towards the analysis for the presentation. Peer support groupwork was presented at the hospital's foundation day and has been well received by senior management in the hospital, as a positive addition to the limb reconstruction service. The focus of the MDT in 2024, is to further develop and facilitate more peer support groups for our paediatric patients.

Abstract

We report the medium term outcome of a 15 degrees face-changing acetabular cup in THA due to secondary OA in DDH.

We analysed 28 Hips in 26 patients who underwent THA between May 2007and September 2009. There were 20 females and 6 males with a mean age of 52 yrs (range 33–68yrs).

All patients received a cementless Exceed Advanced Bearing Technology 15° Face-changing cup (Biomet) with a ceramic liner through a posterior approach. A cementless or a cemented femoral stem, with 28 or 32mm Biolox Delta ceramic head, was used in all cases. All patients started full weight-bearing the next day. The average clinical and radiological follow-up was for 50 months (range 36–76 months). The mean Harris Hip Score improved to 94 and the Oxford Hip Score improved to 44. There was 100% survivorship of the hip joint for both components.

Post-operative radiographs revealed integration of the cup with no signs of loosening or osteolysis. The mean covered acetabular lip inclination angle was 51 degrees (range 43–61)and the true inclination angle of the bearing was 36 degrees (range 28–46).

The clinical results support the use of the cementless 15 degrees face-changing acetabular cup in the dysplastic acetabulum.

Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described.

We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months.

Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered.

The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis.

We retrospectively reviewed the mid term outcome of 88 MoM THA in 84 patients and 21Hip Resurfacing using Recap Magnum bearing surface performed during 2006 – 2009.

There were 41 males and 47 females in the THA group and 17 males and 4 females in the Hip Resurfacing group.

All procedures were performed through a posterior approach. The average head size for the THR group was 46mm and the cup size was 52mm and the average head size for the resurfacing was 50mm and cup size was 56mm respectively.

Median age for the THA group was 60 yrs. (28–73) and for the Resurfacing it was 51.5 yrs. (32–62). Average follow up was 76 months for the THA group and 78 months for the Resurfacing group.

Average serum cobalt for the THA and the Resurfacing groups were 53.2nmol/l (119) and 30.85 and the Chromium levels were 82.44nmol/l(134.5) and 67.49 respectively. Eight MRI scans showed abnormal fluid collections suspicious of ARMD in the THA group and 2 showed fluid collection in the Resurfacing group. There were five revisions in the THA group with the tissue diagnosis of ALVAL. In all except one case a well fixed uncemented stem (Taperloc) was retained.

In our series Recap Magnum on a Taperloc stem showed 94% survival at five years and therefore we continue to review the cases annually with serum cobalt chromium levels and MRI scans.

Stable, anatomical fixation of acetabular fractures gives the best chance of a good outcome. We performed a biomechanical study to compare fracture stability and construct stiffness of three methods of fixation of posterior wall acetabular fractures.

Two-dimensional motion analysis was used to measure fracture fragment displacement and the construct stiffness for each fixation method was calculated from the force / displacement data.

Following 2 cyclic loading protocols of 6000 cycles, to a maximum 1.5kN, the mean fracture displacement was 0.154mm for the rim plate model, 0.326mm for the buttress plate and 0.254mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p=0.015) and spring plate fixation (p=0.02).

The rim plate was the stiffest construct 10962N/mm (SD 3351.8), followed by the spring plate model 5637N/mm (SD 832.6) and the buttress plate model 4882N/mm (SD 387.3).

Where possible a rim plate with inter-fragmentary lag screws should be used for isolated posterior wall fracture fixation as this is the most stable and stiffest construct. However, when this method is not possible, spring plate fixation is a safe and superior alternative to a posterior buttress plate method.

Introduction

Pelvic and acetabular injuries are relatively rare and surgical reconstruction usually occurs only in specialist centres. As part of their work up there is a local protocol for radiological investigations including Judet oblique views for acetabular fractures, pelvic inlet and outlet for pelvic ring fractures and urethrograms for sustaining anterior pelvic injury. The aim of this service evaluation was to assess whether patients had these radiological investigations prior to transfer.

Aim

Evaluate the outcome and complications of anterior pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries.

Background

Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws.

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating.

The purpose of this study was to assess the clinical and radiological outcome following spring plate fixation of posterior wall fractures.

Spring plates are fashioned from a one third tubular plate cutting through one of the holes in the plate and bending the sharp edges through 90 degrees allowing screw fixation of small acetabular margin fragments well away from the joint reducing the risk of joint penetration.

From July 1993 to August 2004, 89 patients with displaced posterior wall fractures underwent posterior wall fixation with one or more spring plates. Patients were assessed post-operatively with a CT scan and annually for up to 5 years for a clinical and radiological assessment. Clinically patients were graded according to the Epstein modification of Merle d'Aubigné/Postel Hip Score. The radiographs were graded using the Roentographic Grade criteria used by Matta.

Patients were reviewed at a mean 55 month follow-up. There were 12 post-operative complications. Clinically excellent or good results were seen in 70% and radiologically in 70%. There were 15 revisions for osteonecrosis, infection and osteoarthritis. 91% (20/22) of fractures had excellent/good clinical results if reduced anatomically compared with 66% (24/36) of those reduced to within 2mm as assessed by the post-operative CT scan. Only 44% (8/18) of those reduced leaving a gap of greater than 2mm had an excellent/good clinical result.

Posterior wall fractures can be treated successfully by the use of spring plates. Clinical results correspond closely with radiological appearance. The accuracy of reduction correlates highly with the subsequent prognosis and we recommend routine post-operative CT scanning to identify misplaced metalwork and the accuracy of reduction to help predict prognosis.

Aims: To determine the incidence and pattern of pain in patients with displaced pelvic ring injuries treated surgically. To investigate the link between pain and neurological injury.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Assessment was made from validated pain scores, pain maps, a Visual Analog Scale (VAS) and correlated with outcome scores including SF36 and Euroqol. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. There were 31% Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 76% of all patients reported activity related pain; 70% of APC, 73% of LC and 86% of VS injuries (p=0.05, Chi-squared test). These results correlated directly with the pain domain of the Euroqol tool. There were however no statistically significant differences in the interference of pain with work (SF36) or the VAS between injury classes. There was a 15% prevalence of neurological injury in the cohort (9% of APC, 11% of LC and 27% of VS injuries; p=0.03 Chi-squared test). There were no statistically significant differences in the prevalence of moderate to severe pain (Euroqol) or the VAS between those with and without significant neurological injury. The presence of neurological injury significantly affected return to employment but not return to sports or social activities.

Conclusions: These results illustrate the prevalence of significant morbidity in patients with surgically treated pelvic ring fractures. Presence of pain could be linked to injury category but a link with neurological injury was not obvious. This can help give prognostic information to patients suffering displaced pelvic ring injuries requiring surgical reconstruction.

Aims: To determine the incidence and pattern of sexual dysfunction in patients with displaced pelvic ring injuries treated surgically. To investigate a link between sexual and urological dysfunction.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Sexual function was assessed using elements of the validated Sexual Function Questionnaire. Patients were also asked specifically about new-onset sexual and urological dysfunction. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male.

31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries.

32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients.

41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test).

There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test).

Conclusions: This large outcome study of UK patients illustrates the significant prevalence of new onset sexual dysfunction in patients with surgically treated pelvic ring fractures. The results also suggest an association between sexual and urological dysfunction. This can help give prognostic information to patients and plan service provision.

We aimed to determine multi-modality outcomes in surgically treated patients with high energy pelvic ring injuries. A retrospective cohort study of all patients with pelvic ring fractures treated surgically within our specialist tertiary referral unit was undertaken between 1994 and 2007. Case-notes and radiographs were reviewed and patients were contacted by postal questionnaire. Outcome measures were return to work, return to pre-injury sports and social activities, and the Short Form-36 (SF-36) outcome tool. Injuries were classified using the Young and Burgess (YB) classifications.

There was a response rate of 70% (145 of 209 patients), 74% of the study subjects were male. Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3 yrs (1–12 yrs). There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries. 58% of the APC injuries had returned to work (including changed roles at work), compared with 68% of the LC injuries and 51% of the VS injuries. 27% of the APC injuries had returned to their pre-injury sports, compared with 39% of the LC and 33% of the VS injuries. 64% of the APC injuries had returned to their pre-injury social activities compared with 77% of the LC and 49% of the VS injuries.

The SF-36 average Physical Functioning Score was better for the LC group (73.2) than the APC (61.7) and VS (63.3) groups. This general trend was repeated when the General Health and Social Functioning scores were reviewed.

These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. The LC injuries appear to have better outcomes with all outcome measures than APC and VS injuries. Further studies are underway to look at other factors and their relationship to outcomes.

Introduction: Injuries to the bony pelvis are a significant group of injuries with often serious implications. The close proximity of the bony pelvis to vital organs, it’s involvement in weight bearing and ambulation, and the high energy mechanisms usually required to produce these injuries produces a variety of injury patterns, associated injuries and possible outcomes.

Aims: To determine the long-term functional outcomes of displaced pelvic ring injuries treated surgically in the United Kingdom

Methods: All patients with pelvic ring fractures treated surgically were contacted by postal questionnaire. Outcomes were measured using the SF-36, as well as ad-hoc tools including return to work and sporting activities. Injuries were classified using the Young and Burgess (YB) classification system.

Results: There was a response rate of 70% (145 of 209 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs).

There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries.

69% of the LC injuries had returned to some form of employment, compared with 58% of the APC injuries and 51% of the VS. 39% of the LC injuries had returned to their pre-injury sporting activities, compared with 27% of the APC and 33% of the VS.

The average Physical Functioning Score of the SF-36 outcome tool was 73.2 for the LC injuries, 61.7 for the APC injuries and 63.3 for the VS injuries (scale 0–100, 100 representing best status). These trends were mirrored in the other outcome domains of the SF-36 tool.

Conclusions: These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. LC injuries appeared to perform better than APC and VS injuries in all outcome measures utilized. These findings may aid in determining the prognosis and provision of services for patients with pelvic ring injuries.

The Stoppa approach was originally conceived to deal with difficult abdominal hernia surgery. Its use has been modified to deal with Acetabular and Pelvic surgery. We report on our use of the Stoppa approach in 26 cases from 1998–2003 to fix Pelvic, Acetabular, and combined Pelvic/Acetabular fractures.

The Stoppa approach was used in combination with other approaches to afford the best access for fixation. 11 of the cases were Acetabular fractures with no pelvic ring disruption (42.3%), 4 cases (15.3%) were pelvic ring disruptions without an Acetabular component. The other 11 cases (42.3%) were combined Pelvic and Ace-tabular fractures where this approach came into its own. In particular it is to be noted that the Corona Mortis was easily identifiable in 5 (19.2%) of the cases to allow its safe ligation.

The anatomy of the approach and the access afforded are considered, along with the plating techniques that can be achieved because of its use.

Patients were followed up for an average of 17.39 months with one lost to follow up. Clinical results were excellent in 20 cases, good in 2, fair in 2, and poor in 1.

Complications were lateral femoral cutaneous nerve palsy in 11 patients, 1 bladder rupture, 2 superficial wound infections, one lateral incisional hernia related to an ilioinguinal approach, and 1 deep vein thrombosis. Heterotopic Ossification occurred in 3 patients in whom the Kocher-Langenbeck approach was used. One revision for screw proximity to the joint was undertaken.

The Stoppa approach allows safe access and ease of reduction and fixation in these complex fractures, in combination with other approaches, particularly in combined pelvic and Acetabular fractures. We outline our recommendations for its use in this paper and outline a series of fracture patterns where it is most helpful.

In a prospective study of 205 consecutive patients undergoing surgical stabilisation of acute pelvic and/or acetabular fractures, the incidence of proximal deep vein thrombosis (DVT) was 9.2%, pulmonary embolism (PE) was 1.9% and fatal PE 0.5%.

Use of a DVT prophylaxis protocol, using a low molecular weight heparin (LMWH), administered within 24 hours of injury or achieving haemodynamic stability, was associated with a significantly lower incidence of thromboembolism (p=0.036). Increased rates of thromboembolism were associated with longer delays to surgery (p=0.013), delays to mobilisation of the patient post-operatively (p=0.017), delay in starting chemoprophylaxis (p=0.039) and higher injury severity scores (p=0.042).

Patient age, sex, Glasgow Coma Scale and fracture classification were not associated with the development of thromboembolic complications.

One hundred and thirty four patients had a pre-operative venous Doppler, seven patients had a proximal DVT identified of which six patients had a preoperative inferior vena caval filter applied and underwent successful surgical fracture stabilisation. Five filters were unable to be removed postoperatively and the patients remain on lifelong warfarin.

A DVT prophylaxis protocol using LMWH is reported that is safe and effective.

Introduction We present prospective and retrospective reviews of sacral nonunions treated with posterior tension band plate and iliosacral screws at Frenchay Hospital from 1994.

Methods Using the pelvis data base at Frenchay (Bristol, UK) Hospital six patients were identified. A further two patients were followed prospectively. Clinical outcome was measured using a visual analogue score ( VAS ) for pain. Radiological analysis was done using pre-injury x-ray and CT when available, pre-revision and post-operative CT. Eight patients were reviewed. Average follow-up was two years (range 6 months to 5.5 years). The average time from initial injury and surgery to diagnosis of sacral nonunion was 7.5 months (range 3 to 18). Six patients had been treated previously with sacro-iliac screws and an anterior external fixator.

Results Pre-operative VAS scores averaged 9.2, postoperatively they averaged 3.4. All nonunions fused radiologically post-operatively. Anterior posterior displacement was able to be corrected by an average of five millimetres. The three fractures that were vertically displaced were not corrected because of coexisting neurological injury.

Conclusions Posterior tension band plating and iliosacral screw fixation reliably allows union to be obtained in sacral nonunions.

Introduction We report on the clinical and radiological outcomes and complications associated with percutaneous ilio-sacral screw fixation of the pelvis.

Methods Patients were located on the plevic data base held at Frenchay Hospital, Bristol, UK. Patient charts were reviewed and their clinical outcomes had been determined using a visual analogue (VAS) pain score. All patients had pre and post-operative x-rays and CT scans. These were used to determine fracture type and subsequent post-operative reduction. All complications and subsequent surgery required was noted.

Results One hundred and seven patients with 76 disruptions of the sacro-iliac joint and 62 sacral fractures treated with percutaneous ilio-sacral screws were reviewed. Average follow-up was 2.5 years (range 6 months to 8 years). Half of the patients had a VAS score of zero post-operatively, 30% had scores of one to five and 20% had scores of greater than five. The majority of these patients had a coexisting neurological lesion. Seventy-one percent had an anatomical reduction (within 5 mm), 18% had displacements of between five and 10 mm and 11% had displacements of greater than 10 mm. There were five infections, four sacral nonunions, four failures of fixation and one case of a transient L5 nerve plasy following inadvertent screw positioning.

Conclusions Percutaneous ilio-sacral screw fixation of the pelvis allows safe, reliable and accurate reduction. Poor clinical results are often attributable to coexisting neurological lesions.