Aim

To quantify the micro-motion at the fracture gap in a tibial fracture model stabilised with an external fixator.

There is an ongoing revolution in the use of data within orthopaedics and medicine in general, with an imperative for surgeons to be involved from the bottom up and better define the data collection culture.

The use of registries plays a major role in the development of “big data” in orthopaedics. There are multiple examples that are already set up and running, both those inspired and set up by clinicians or those where the main stakeholders may lay people, with some input from clinicians. The British Limb Reconstruction society is no exception, with registries for lengthening nails and pilon fractures due to roll out imminently.

The BLRS has tasked this years BOA clinical leadership fellow to investigate the current state of registries among the specialist orthopaedic societies. In particular, comparison of the already well established registries and national audits with the development of registry projects in the smaller societies.

The issues of funding, consent, infrastructure and governance each infer particular challenges when translating the methods of the larger registries to the needs and resources of a smaller group. We have aimed to consider these challenges in relation to the set-up of the BLRS registries in order to better understand the potential future pitfalls and opportunities.

Purpose

To review the natural history of posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition.

Background

Severe infantile Blount's disease can result in a multiplanar deformity of the proximal tibia with both intra-articular and metaphyseal components. Correction can represent a significant surgical challenge. We describe our results using the Taylor spatial frame for acute tibial hemiplateau elevation combined with gradual metaphyseal correction in patients with severe infantile blounts with an associated physeal bony bar.

This study aims to evaluate the development of deformity in patients with hypophosphataemic rickets and the evolution of the orthopaedic management thereof.

Fifty-four patients had undergone treatment for hypophosphataemic rickets at our institution since 1995. Clinical records for all patients were obtained. Forty-one patients had long leg radiographs available that were analysed using Traumacad™ software. Statistical analysis was performed using SPSS 23 (SPSS Inc., Chicago, Illinois, USA).

Of the 41 patients, 18 (43%) had no radiographic deformity. 20 have undergone bilateral lower limb surgery for persistent deformity (Mechanical Axis ≥ Zone 2). A further 3 patients are awaiting surgery. Six patients (12 limbs, 14 segments) had osteotomies and internal fixation as primary intervention: only one limb developed recurrent deformity. There were no major complications.

Fourteen patients (28 limbs) had 8-plates (Orthofix, Verona) applied. In 5 limbs correction is on-going. Neutral alignment (central Zone 1) was achieved in 14/20 (70%) patients. Two patients required osteotomy and external fixation for resistant deformity. The mean rate of angular correction following 8-plate application was 0.3 and 0.7 degrees/month for the tibia and femur respectively. The mean age at 8-plate insertion was 10.25y (5–15y). Patients with more than 3 years of growth remaining responded significantly better than older patients (Fisher Exact Test, p=0.024). Guided growth was more successful in correcting valgus deformity than varus deformity (Fisher Exact Test, p=0.04). In the younger patients, diaphyseal deformity corrected as the mechanical axis improved at the rate of 0.2 and 0.7 degrees /month for the tibial and femoral shafts. Serum phosphate and alkaline phosphatase levels did not affect response to surgery or complication rate.

Guided growth by means of 8-plates is a successful in addressing deformity in hypophosphataemic rickets. Surgery is best performed in patients with more than 3 years of growth remaining.

Children with congenital vertical talus (CVT) have been treated with extensive soft-tissue releases, with a high rate of complications. Recently, reverse Ponseti-type casting followed by percutaneous reduction and fixation has been described, with excellent results in separate cohorts of children with CVT, of either idiopathic or teratological aetiology. There are currently no studies that compare the outcome in these two types. We present a prospective cohort of 13 children (21 feet) with CVT of both idiopathic and teratological aetiology, in which this technique has been used. Clinical, radiological and parent-reported outcomes were obtained at a mean follow-up of 36 months (8 to 57). Six children (nine feet) had associated neuromuscular conditions or syndromes; the condition was idiopathic in seven children (12 feet).

Initial correction was achieved in all children, with significant improvement in all radiological parameters. Recurrence was seen in ten feet. Modification of the technique to include limited capsulotomy at the initial operation may reduce the risk of recurrence.

The reverse Ponseti-type technique is effective in the initial correction of CVT of both idiopathic and teratological aetiology. Recurrence is a problem in both these groups, with higher rates than first reported in the original paper. However, these rates are less than those reported after open surgical release.

Cite this article: Bone Joint J 2014;96-B:274–8.

Background

Congenital vertical talus (CVT) is a rare deformity of the foot. It has been historically treated with extensive soft tissue releases with significant associated complications. Recently, reverse Ponseti-type casting followed by minimally invasive or percutaneous reduction and fixation has been described with excellent results in separate cohorts of either idiopathic or teratologic cases of CVT. There are currently no studies that compare the outcomes between the two types.

Identification of the paediatric orthopaedic patient at high risk of venous thromboembolism (VTE) can allow a targeted approach to thromboprophylaxis. There is currently no national consensus on the correct method of risk assessment in this patient group. The Royal National Orthopaedic Hospital has developed a guideline using the evidence available to allow stratification of risk for the paediatric orthopaedic patient.

A list of departments offering specialist paediatric orthopaedic surgery was obtained from the member list of the British Society of Paediatric Orthopaedic Surgeons (BSCOS). These hospitals were contacted via telephone interview to determine if they have a specific guideline or risk assessment proforma for paediatric VTE risk.

A total of 74 hospitals were identified with a specialist paediatric orthopaedic practice in the United Kingdom. A response rate was gained from 100% of these hospitals. Only 3/74 of these hospitals had a guideline or protocol in place for the formal assessment of VTE risk in the paediatric patient (Royal National Orthopaedic Hospital, Stanmore; Sheffield Children's Hospital; Barts & the London NHS Trust). All three hospitals were able to provide details of their guideline. Both the RNOH and Barts & the London commented that their guideline was based on that of the Sheffield group, with adaptations for their own requirements.

The majority of hospitals in the UK with a paediatric orthopaedic interest do not have guidance available for the management of VTE risk. Presented here is the outcome of using the limited evidence available, in combination with expert opinion, to develop a guideline suitable for the requirements of a paediatric unit in an orthopaedic hospital. This may be of benefit to other units producing their own guidelines, producing thought and discussion as to the specific requirements of paediatric patients undergoing orthopaedic procedures.

Aim

The use of intraoperative cell salvage as a tool for reducing allogenic transfusion has been demonstrated in pelvic osteotomies. The aims of this audit were to identify any problems or complications with cell salvage, reduction in allogenic transfusion and identify procedures that would benefit.

Background

The aim of our study was to assess the ability of orthopaedic surgical trainees to adequately assess ankle radiographs following operative fixation of unstable ankle fracture.

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented.

Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed.

77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points.

The XXS nails allow a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low.

Background

There is much research on metal on metal hip resurfacing arthroplasty (HRA) but few studies have reported the outcome with respect to implant characteristics from non-specialist centres.

Background

Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms.

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK.

A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used.

Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12)

The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight.

Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture.

Purpose: Reducing wait times for total hip (THA) or knee (TKA) joint arthroplasty is a Canadian health care priority. Models that maximise the capacity of advanced practice clinicians (nurses, physical therapists, sports medicine specialists) have been established to streamline care. Hospitals across the Hamilton Niagara Haldimand Brant Local Health Integration Network in Ontario collaborated to establish a Regional Joint Assessment Centre (RJAC). This study was designed to profile patients deemed suitable for surgical review, and to examine wait times for THA or TKA in RJAC patients compared to those referred directly to an orthopaedic surgeon’s office.

Method: Patients referred to the RJAC between July 2007 and August 2008 with knee or hip OA were included. Self-reported function was evaluated using the Oxford Hip and Knee Score that is scored out of 60 (higher scores reflect greater disability). Time to surgery was measured as the number of days from initial review to surgery. Group one consisted of patients that were referred to the RJAC while group two was comprised of patients who were referred directly to a surgeon’s office. Patient characteristics were examined using univariate analyses. Independent t-tests were used to examine between group differences.

Results: One hundred thirty-six patients (mean±sd: 68±2 years, body mass index 31±6 kg/m2, 83 females) with 150 hip and/or knee joint problems were reviewed in the RJAC. Of those, only 33% (45/136 patients) were deemed suitable for surgical review. Self-reported function (Oxford Scores) in the group requiring surgical review was significantly worse (40±7, p=0.03) than in those patients deemed unsuitable for surgical review (37±9). The RJAC group waited on average 130 days for THA and 129 days for TKA (below the provincial target of 182 days) while those referred directly to the surgeons’ offices waited significantly longer (194 days for THA and 206 days for TKA, p< 0.001).

Conclusion: Patients with hip and knee OA who require surgical review have worse self-reported function than those triaged to conservative care. Wait times for THA or TKA were significantly shorter for patients referred to the RJAC under the new model of care than for those referred directly to an orthopaedic surgeon’s office.

Little is known about the priorities of patients undergoing surgery for idiopathic scoliosis. This study explores the priorities of adolescents and contrasts them from their parents and their surgeons. Fifty-five pairs of children and parents underwent structured interviews separately, to explore their concerns, desires and expectations both about scoliosis and surgery. Surgeons of these patients and from across Canada completed a similar questionnaire. We found a significant mismatch between child, parent and surgeon priorities. This mismatch has implications on matters relating to decision making, informed consent, understanding of patient satisfaction, and measuring outcomes that are meaningful to patients.

To define the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis and to contrast them from their parents and surgeons.

We conducted structured interviews of fifty-five pairs of adolescents and parents separately. The questionnaire had sections on concerns, desires and expectations regarding both scoliosis and surgery, with items pertaining to present and future effects on appearance, pain, physical and psychosocial function and health. Parents also reported what their child’s responses might be. Their surgeons (four) and paediatric spine surgeons (twenty-four) across Canada completed the same questionnaire. Analysis involved repeated measures ANOVA, intra-class correlation coefficients and kappa statistics.

Parents were more concerned than their children about present and future consequences of scoliosis. Surgeons were least concerned. Children, parents and surgeons agreed that improving physical appearance was the primary goal of surgery. Surgeons agreed very little about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Adolescents had different priorities from their parents, but parents were aware of this difference and knew what their child’s priorities were.

Adolescents with idiopathic scoliosis, their parents and surgeons have different priorities. This mismatch might stem from uncertainty about the natural history of idiopathic scoliosis for individual patients.

Knowledge of patient priorities is vital for shared decision making, informed consent, understanding patient satisfaction, and for measuring outcomes that matter most to patients.

Funding:

Orthopaedic Research & Education Foundation: (Unni. G. Narayanan: AAOS/OREF Health Services research Fellowship award)

The purpose of this study is to compare the efficacy of home based vs. inpatient rehabilitation following total joint arthroplasty (TJA). Primary outcome was the self-reported WOMAC pain and function score that was used to evaluate a stratified random sample of two hundred and thirty-two patients. Despite concerns about early hospital discharge there was no difference in functional outcomes at the primary endpoint (twelve weeks post TJA) between the group receiving home based vs. inpatient rehab. Given that home- based rehab is less expensive; we would recommend the use of home based rehab protocols following elective primary TJA.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. The aim of this RCT was to compare the efficacy of home based vs. inpatient rehab following Total Joint Arthroplasty (TJA).

Despite concerns about early hospital discharge there was no difference in functional outcomes twelve weeks post TJA between the group receiving home based vs. inpatient rehab.

With no significant difference in functional outcomes, less expensive home based rehabilitation protocols are recommended following elective total joint arthroplasty.

We randomized two hundred and thirty-two patients to either home based or inpatient rehab following TJA using block randomization techniques. All patients at a tertiary referral centre and large volume community hospital undergoing primary elective total hip or knee arthroplasty for osteoarthritis or inflammatory arthritis were eligible. Standardized care pathways were followed for both procedures. All patients were evaluated at baseline (two weeks prior to surgery) and twelve weeks post surgery using standardized questionnaires including history, physical exam, demographics and WOMAC pain and function (the primary endpoint). In total one hundred and fifteen received a total hip and one hundred and seventeen a total knee arthroplasty; there were eighty-five men and one hundred and forty-seven women with a mean age of sixty-seven (range thirty-eight to eighty-nine) years. The groups were similar at baseline for patient demographics and WOMAC scores. At follow-up (twelve weeks post TJA) there was no statistically significant difference in WOMAC scores.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes. This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA). Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation.

This study compares the efficacy and patient satisfaction of home- based verses inpatient rehabilitation following total joint arthroplasty (TJA).

Given that home- based rehab is less expensive, we would recommend the use of home based rehab protocols following elective primary TJA.

Home- based rehab is increasingly utilized to save costs but concerns have been raised about early hospital discharge and adverse clinical outcomes.

The groups were similar at baseline for patient demographics and WOMAC scores. At the six weeks, twelve weeks and one- year follow-up post TJA there was no statistically significant difference in WOMAC pain, physical function, stiffness and overall WOMAC scores. Both groups showed a trend of decrease in pain, stiffness, restriction in physical function over the follow-up period. Similarly, patient satisfaction scores at six, twelve weeks and one year did not show a statistically significant difference between the home versus inpatient group (P> 0.05)

Two hundred and thirty-four patients were randomized to either home based or inpatient rehabilitation following TJA, using block randomization techniques. Standardized care pathways were followed for both procedures. All patients were evaluated at baseline (two weeks prior to surgery), six weeks, twelve weeks and one- year post surgery using standardized questionnaires. Primary outcomes were the self-reported WOMAC pain and function score and satisfaction in terms of improvement in pain and function.

Despite concerns about early hospital discharge there was no difference in functional outcomes and in patient satisfaction with procedure at the primary endpoints, between the groups receiving home based verses inpatient rehabilitation.

Funding: PSI

The purpose of this study was to determine which activities are important to patients and to determine the severity of those problems. The five most important activities were walking outside, driving, walking indoors, stair climbing and daytime pain. Importance of these did not change postoperatively. The five most severe problems causing limitation were a limp, stiffness, loss of energy, daytime pain and locking. All these activities become statistically less severe over twenty-four months. Activities that are important to patients are different than the problems that are ranked by severity. Surgeons can educate patients that the severity of problems do improve over time following TKA.

The objectives of this study were:

to determine the five most important activities and five most severe problems for patients prior to total knee arthroplasty (TKA) using the Patient Specific Index (PASI) and

Activities that are most important to patients are different than problems that patients find severe. Important activities remain important over time. Severe problems become less severe over time.

Functional activities and PASI scores improve after TKA. Surgeons can educate patients that the problems they find most severe preoperatively do improve over time following TKA. Important activities remain important.

Patients scheduled for elective primary (or revision) TKA at two tertiary care teaching hospitals were enrolled in the study, excluding those not fluent in English and those undergoing TKA for a tumour, acute fracture, or an infection of the prosthesis. Patients completed the PASI pre-operatively, six, twelve and twenty-four months post-operatively.

One hundred and nineteen subjects were enrolled, nineteen were excluded. The five most important activities (ten- point scale, ten is most important) preoperatively were (mean; 95% CI): walking outside (6.25; 6.23–6.27), driving (6.17; 6.12–6.22), walking indoors (6.14; 6.12–6.16), climbing stairs (6.12; 6.10–6.14), and daytime pain (5.84; 5.81–5.87). These activities were not statistically less important over time. The most severe problems were limping (4.81; 4.77–4.85), stiffness (4.59; 4.56–4.62), lack of energy (4.51; 4.47–4.55), daytime pain (4.46; 4.43–3.39) and locking (4.38; 4.27–4.49). These were significantly less severe at twenty-four months (p < .001).

Purpose: To assess the change in disease-specific quality of life associated with operating on patients with AIS, compared to non operative patients.

Methods: The Climent Quality of Life for Spinal Deformities Scale (QLPSD)was administered prospectively to 119 patients undergoing scoliosis surgery and 42 patients followed for bracing or observation. Change in quality of life after two years (adjusted for baseline quality of life) was used to estimate the short term benefit of scoliosis surgery. Bracing status was also analyzed at baseline as a covariate to determine its effect on improvement in quality of life.

Results: The operated group experienced an increase in quality of life of 4.3 points (95% C.I. 0.69, 7.88) on the 105 point Climent scale. Although statistically significant, this increase was lower than the 5.5 point cutoff we had defined a priori as clinically significant. Among the operative patients, there was no difference in the quality of life score between those braced at baseline (91.2) and those not (90.5) (p=0.73). In non operative patients, those braced had a baseline quality of life score of 88.2, and those not braced 83.3, this difference was also not significant (p=0.13).

Conclusions: Scoliosis surgery results in a small increase, of questionable clinical significance, in spine-related quality of life at two years.

Funding : Commerical funding

Funding Parties : This trial was funded by (in alphabetical order) Canadian Institutes of Health Research, DePuyAcroMed-Johnson & Johnson Medical Products, and Synthes, Canada.