Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice. 236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41).Background
Methods
We investigated whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration producing greater compression across the fracture. An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. There were two arms to this investigation. (1) Standard tension band wire configuration with stainless steel. (2) Modified tension band wire configuration with stainless steel. The simulated elbow was put through a range of movement and sensors measured the compression at the articular and non-articluar surfaces of the fracture. Measurements were taken for compression with different weights applied to challenge both the techniques of tension band wiring. Measurements from the non articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p<0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. The alternative tension band wiring technique proved superior in providing greater compression over the fracture site.
In the early 2000s hip resurfacing became an established bone conserving hip arthroplasty option particularly for the fit and active patient cohort. The performance of second-generation metal-on-metal bearings had led to the reintroduction of hip resurfacing. The Birmingham Hip resurfacing (BHR) was introduced in 1997. This was followed by a number of different designs of the hip resurfacing. The Durom hip resurfacing was introduced in 2001. These two designs had different metallurgical properties, design parameters particularly clearance and different implantation techniques. Data from joint registries show that both prosthesis perform well. Our objective was to perform a retrospective survival analysis comparing the Birmingham to the Durom hip resurfacing and analyse the mode of failures of the cases revised.Introduction
Objectives
To reduce several disadvantages many surgeons are not using tourniquet in TKA. Here we compared functional outcome along with pain and blood loss in sixty patients. 60 patients who underwent TKA wererandomized into a tourniquet group (n2 = 30) and a non-tourniquet group (n1 = 30). All operations were performed by the samesurgeon and follow-up was for 6 month. Primary outcomes werefunctional and clinical outcomes, as evaluated by KSS and postoperative pain. Secondary outcomes were blood loss, surgical time and visibility, extensor lag and Knee ROM, DVT and radiolucency.Introduction
Material and Method
Management of failed total ankle replacements (TAR) remains a difficult challenge. Ankle arthrodesis, revision TAR, debridement and amputation are all utilized as surgical options. The purpose of the study was to review a series of failed TAR surgically managed in our tertiary referral centre. A retrospective review of 18 consecutive failed TARs, either within or referred to our institution, which required surgical management were reviewed. The average age was 58.2 (range 25–77) with 11 males and 6 females.Background
Methods
In 2009 the Smart Toe implant was introduced as an option for lesser toe fusion in our department. The Smart Toe is an intramedullary device made from Nitinol, an alloy that can change shape with a change of temperature, expanding within the intramedullary canals of the proximal and middle phalanx to achieve fixation. The advantages of the Smart Toe are that patients are spared 6 weeks with K-wires protruding from their toes and there is no need for wire removal. We conducted a retrospective review of radiographic and clinical outcomes to assess the performance of this implant. We present a consecutive series of 192 toe fusions using the Smart Toe implant in 86 patients, between January 2009 and November 2013. All radiographs and case notes were reviewed to assess for radiological fusion, satisfactory clinical outcome and complications.Introduction:
Methods:
Recent published studies have examined the normal dimensions of the syndesmosis on CT. However, previous anatomical studies have shown variations of the articulating facets within the tibialae fibularis and may contribute to the false appearance of increased spacing within the syndesmosis. In this study, we measured and compared anterior and posterior distances of the distal tibiofibular(DTF) syndesmosis on MRI and CT imaging. We identified adult patients who had had both a CT scan and an MRI scan of their ipsilateral ankle to investigate symptoms Introduction:
Methods:
Both conservative and operative forms of treatment
have been recommended for patients with a ‘floating shoulder’. We
compared the results of conservative and operative treatment in
25 patients with this injury and investigated the use of the glenopolar
angle (GPA) as an indicator of the functional outcome. A total of
13 patients (ten male and three female; mean age 32.5 years (24.7
to 40.4)) were treated conservatively and 12 patients (ten male
and two female; mean age 33.67 years (24.6 to 42.7)) were treated
operatively by fixation of the clavicular fracture alone. Outcome
was assessed using the Herscovici score, which was also related
to changes in the GPA at one year post-operatively. The mean Herscovici score was significantly better three months
and two years after the injury in the operative group (p <
0.001
and p = 0.003, respectively). There was a negative correlation between
the change in GPA and the Herscovici score at two years follow-up
in both the conservative and operative groups, but neither were
statistically significant
(r = -0.295 and r = -0.19, respectively). There was a significant
difference between the pre- and post-operative GPA in the operative
group (p = 0.017). When compared with conservative treatment, fixation of the clavicle
alone gives better results in the treatment of patients with a floating
shoulder. The GPA changes significantly with fixation of clavicle
alone but there is no significant correlation between the pre-injury
GPA and the final clinical outcome in these patients. Cite this article:
Distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. Thus implant fixation is more difficult. Dorsal and radial comminution are frequent in these patients and so reduction and angle stable osteosynthesis needed. The angle stable plate, often also multidirectional is today the most common stabilisation device. Because of the introduction of bulky and bended implants as the Micronail or Targon DR wich require difficult opening of the bone with awles we decided to test the XS radius nail witch is a 4,5mm or 3,5mm straight nail and witch is introduced after guide wire placement and over drilling with a canulated drill of the same diameter. It is locked parallel to the joint in 3 different directions with angular stability with threaded wires. Methods 16 radius sawbones were osteotomised corresponding to a A3 Fracture and stabilised with a angle stable plate (8) and XS nail (8). 1000 alternating load cycles from 20–200N were performed and the deformation was registered. Also a FE analysis with the MSC Patran/Marc softwere were performed. Also the calculated deformation in the FE study was 20% lower. Also deformation amplitude was lower with 0.31mm compared to 0.42mm in the plate group. The differences however were not significant. Both devices show good biomechanical results. The XS nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. Styloideus radii and over drilling with a canulated drill of the same size. The exposure of the N rad. superf. must be performed. First clinical evaluation is presented. Due to the results we developed a anatomically adapted XS radius nail. The results of the first 100 patients are presented. Both angular stable plate and XSR nail can be used in unstable distal radius fracture fixation. The mainly intraosseus position of the nail and saving of the pronator quadratus as well as lower deformation are in favour of the XSR nail. However frontal plane fractures and very comminuted fractures are better treated with a multidirectional locking plate due to technical reasones so that we use the XSR nail mainly in A3 and C1 fractures.Conclusions
The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries.
Retrospective review of growth sparing spinal instrumentation. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants.Purpose
Methods and results
To highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative.Aim of Study
Study Method
Tibiotalocalcaneal arthrodeisis is performed for a variety of conditions, including advanced osteoarthritis, Charcot arthropathy, rheumatoid arthritis, post-traumatic arthrosis and foot deformities such as fixed equinovarus. There have been few published studies showing the results of such a procedure for limb salvage. Over a period of 11 years between 1996 and 2007, 18 patients underwent calcaneotalotibial arthrodeisis using either cannulated screws or a retrograde intramedullary locking nail. Post-operative rehabilitation regimes were standardised. VAS, AOFAS ankle-hindfoot, SF-36 and patient satisfaction scores were obtained and analysed. Eighteen patients (10 male and 8 female) with 19 ankles underwent tibiotalocalcaneal arthrodeisis at an average age of 52.3 (31.4 to 70.2 years). Seven patients had cavovarus deformity, six had osteoarthritis, three had Charcot's joint, two had failed previous fusions and one patient had a footdrop post-T12 tumour resection. Twelve right and seven left fusions were performed, with six cannulated screws and 13 retrograde nails. The mean time to complete fusion was 5.89 (3 to 11) months in 18 ankles (94.7%). There was one pseudoarthrosis (5.3%). Patients were followed up for an average of 35.6 (11 to 144) months. Four wound infections (21%) occurred post-operatively. Two patients died from unrelated caused whilst on follow-up. Thriteen patients returned for follow-up scoring. VAS scores improved from 7.85 to 2.54 (p=0.00). AOFAS ankle-hindfoot scores improved from 30.50 to 63.62 (p=0.00). SF-36 scores also improved in several parameters. Physical function improved from 40.38 to 66.15 (p=0.02); physical role improved from 15.38 to 53.85 (p=0.03); Bodily pain improved from 36.69 to 62.23 (p=0.00); emotional role improved from 69.23 to 100 (p=0.04); and mental health improved from 62.77 to 0.15 (p=0.04). Eleven patients (84.6%) reported good to excellent satisfaction and expectation scores. Hindfoot arthrodesis, via retrograde imtramedullary nailing or cannulated screw insertion, are effective techniques for treating complex foot deformities and often is the only alternative to amputation. Although a demanding procedure with high potential complications, they provide effective relief from pain, improves the quality of life, and has high patient satisfaction.
Traditional teaching, and indeed the impression from the BOA BAPS working party report on open tibial fractures, suggests that soft tissue cover of the distal third of the leg will often need a free flap. However, more recently with the introduction of propeller flaps by Quaba, and the reintroduction of the concept of Ponten's nerve oriented flaps with the reverse sural artery flap, the role of free tissue transfer comes into question. The attraction of local flaps for distal third fractures is the reduced operating time, reduced morbidity of donor site, versatility and reliability. However, detractors would argue that muscle enhances bone union and reduces local infection. Previous reviews of lower limb soft tissue cover look at all areas of the leg. This series of 30 (14 free and 16 local flaps) cases looks exclusively at the distal third fractures, compares the complication rate of free versus local flaps and looks at the change in approach to distal third fractures with the more recently described fascio-cutaneous flaps. Our results challenge the conventional teaching and indicate that fasciocutaneous flaps can play a more active role in distal third fractures. Our study shows that the local flaps are a valuable alternative to free flaps for managing soft tissue defects in distal third fractures of tibia especially in smaller wound size and low energy fractures. The advantages are lesser operating time, reliability, versatility, lesser wound complication and osteomyelitis incidence, earlier flap cover and lesser post op morbidity leading to shorter hospital stay. The free flaps on balance are probably better with larger soft tissue defects and with more severe limb injury. This supports the use of fascio-cutaneous flaps in distal third tibial fractures.
We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1.
Primary TKR:
At 6 weeks: Correlation for OKS and pain, OKS and satisfaction, Pain and satisfaction were r = 0.782, 0.736 and 0.796 respectively (p<
0.001) At 6 months: Correlation for OKS and pain, OKS and satisfaction, Pain and satisfaction were r = 0.718, 0.749 and 0.767 respectively (p<
0.001) At 1 year: Correlation for OKS and pain, OKS and satisfaction, Pain and satisfaction were r = 0.7, 0.703 and 0.793 respectively (p<
0.001) Primary THR: At 6 weeks: Correlation for OHS and pain, OHS and satisfaction, Pain and satisfaction were r = 0.361, 0.309 and 0.477 respectively (p<
0.001) At 6 months: Correlation for OHS and pain, OHS and satisfaction, Pain and satisfaction were r = 0.596, 0.673 and 0.635 respectively (p<
0.001) At 1 year: Correlation for OHS and pain, OHS and satisfaction, Pain and satisfaction were r = 0.682, 0.636 and 0.862 respectively (p<
0.001)
What was the question? The treatment of multi-injured patients requires initial stabilization of general conditions and vital parameters. The first stage in orthopedic management of the fractures in trauma involves stabilization of the bone segments to reduce blood loss and allow nursing. External fixators are fast, versatile and essential in the emergency situation in cases of multiple fractures, especially with soft tissue loss. According to damage control orthopedics (DCO) concepts, it is possible to replace an external fixator (EF) with internal synthesis (ORIF) after a period of time to reduce the risks of ORIF. However, surgery can be difficult to perform and pin sites can be the source of bone infection, in which the EF as a definitive treatment option may be considered. How did you answer the question? In trauma surgery, instability of the hardware, fractures near the joint, frame extending across the knee and the ankle, initial fixation was converted to definitive treatment with circular frames according to the Ilizarov method. Fourteen patients (2 female and 12 males; age 24 to 80 yrs, average age 43,4 y/o) were treated with various circular framses as definitive treatment: Ilizarov (2), Sheffield (7), Taylor Spatial Frame (TSF) (4) and TrueLok (1) between November 2002 and December 2007 in multiply injured patients with ISS >
20. Seven cases were femoral and seven tibial. The femoral group had four knee spanning fixator configurations and three unilateral external fixators. The tibial group had 4 unilateral frames, 1 hybrid EF, 1 across the knee EF and 1 across the ankle EF. Five patients had temporary femoral and tibial hardwares in the same side. Three patients had unilateral tibial and femoral fractures. What are the results? All patients achieved consolidation. The mean duration of femoral EF was 7.6 months (5–9 months). One bone loss in a distal femoral shaft treated with Sheffield EF had lengthening (5 cm) after acute short-hening. Two patients had a gradual distal femoral fracture reduction and a mechanical axis correction by TSF. Three patients with tibial bone loss had 2 trifocal bone transport (17,5 and 9 cm) and 1 bifocal bone transport 5 cm. The TSF had no additional pre-operative planning and major post-operative frame adjustments. The intra-operative devices was easier for the TSF. What are your conclusions? Circular frame osteosynthesis following initial EF, is a reliable and effective strategy for treatment in severe open femur and tibia fractures and post traumatic reconstruction.
We describe the clinical and radiological results of 38 total hip replacements (THR) using the JRI Furlong hydroxyapatite-ceramic (HAC) – coated femoral component in patients younger than 50 years. The mean age at the time of operation was 42 years and the mean length of follow-up was ten years. All patients receiving a Furlong HAC THR were entered into the study regardless of the primary pathology including patients who had undergone previous hip surgery. The mean Harris hip sc ore improved from 44 before operation to 92 at the last post-operative review. After 12 years the cumulative survival for the stem was 100%. No femoral component was revised. Our results show that the Furlong HAC implant gives excellent long-term results in young patients with high demands.