Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation in patients in the Trauma and Orthopaedic wards of the University Hospital of North Staffordshire.

Design Prospective audit.

Patients and methods: Over a three month period from 1st March to 31st May 2003 359 patients attending the elective orthopaedic outpatient department for major joint surgery were screened at the pre-operative assessment clinic; 105 of these patients were screened again on the elective orthopaedic wards. 197 patients were screened on the trauma wards. 31 patients of other/outlying specialities were screened. Patients whose stay was expected to be for 48 hours or more were included in the audit. Patients were screened for MRSA colonization on admission, transfer and discharge. Colonised patients were treated according to the local infection control policy.

Results: 31 elective orthopaedic patients (29%); 46 trauma patients (23%) and 8 other/outlying patients (26%) were colonized with MRSA. On admission, 23 elective orthopaedic patients (22%), 32 trauma patients (16%), and 7 patients (23%) which were of other/outlying specialties were colonized with MRSA. 22 patients (6.6%) positive on admission, treated with eradication therapy, became negative on discharge. An additional 22 patients (6.6%) positive on admission became negative on discharge without receiving any treatment. During the audit period, 23 patients (6.9%) were negative for MRSA on admission and positive on discharge. 9 patients (39%) and 20 patients (62.5%) colonised in elective and trauma wards respectively, developed an MRSA infection, which required treatment.

Conclusion: There is a relatively high prevalence of MRSA colonisation in patients admitted to orthopaedic and trauma wards. A proportion (22%) of patients are colonised with MRSA in the short time between testing and admission. Not all patients positive for MRSA following admission to hospital will have been colonised within the nosocomial environment.

Purpose To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons.

Methods In males, we studied biopsies from tendinopathic Achilles (n = 28; average age 34.1 years) and patellar tendons (n = 28; average age 32.1), and Achilles tendons (n = 21; average age 61.8 years) from deceased patients with no known tendon pathology, and patellar tendons (n = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Haematoxylineosin stained slides were interpreted using a semi-quantitative grading scale (0: normal to 3: maximally abnormal) for fibre structure; fibre arrangement; rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (Kappa statistics).

Results The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 ± 5 and 10.4 ± 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low.

Conclusions Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etio-pathological mechanism may have acted on both these tendon populations.

Using a comparative, longitudinal study design, we studied the effects of early weight bearing and ankle mobilisation following acute repair of ruptured Achilles tendon.

Patients in Group 1 (22 males and 4 females; mean age 44.7 years [range 31–69], 11 right- and 15 left-sided ruptures) were immobilised with their ankle in gravity equinus, and encouraged to fully weight bear. They received a single cast change at 2 weeks, when the ankle was accommodated in an anterior splint, allowing full plantarflexion but not dorsiflexion above neutral.

Patients in Group 2 (23 males and 4 females; mean age 43.8 years [range 30–67], 11 right- and 16 left-sided ruptures) were immobilised in full equinus. They received a cast change at 2 and 4 weeks, when the ankle was immobilised in a plantigrade position. They were advised to weight bear 4 weeks after the operation.

Patients in Group 1 attended less outpatient visits and completely discarded their crutches at an average of 2.5 weeks after the operation. Group 2 discarded their crutches at an average of 5.7 weeks after from the operation (p=0.013). At ultrasound scan, the average thickness of the repaired tendon was 12.1 mm (SD 2), with no difference in the thickness of the ruptured tendon regardless of the method of post-operative management. There was no significant difference in isometric strength between the two groups of patients. A greater proportion of patients in Group 1 were satisfied with the results of surgery (p=0.04).

Early weight bearing with the ankle plantigrade is not detrimental to the outcome of repair following rupture of the Achilles tendon, and shortens the time needed for rehabilitation. However, strength deficit and muscle atrophy are not prevented.

Background Achilles tendinopathy is prevalent in athletes and individuals with an active lifestyle. It causes significant morbidity, which at times leads to changes in exercise habits. Recently, the VISA-A questionnaire, based on a visual analogue score to assess pain and activity, has been devised as a clinical tool to assess the severity of Achilles tendinopathy (minimum score – 0, maximum possible score – 100).

Aim To assess the clinical progress in patients with Achilles tendinopathy using the VISA-A questionnaire.

Method Thirty-four patients (18 males, mean age 44 years, range 23–67; 16 females, mean age 51 years, range 20–76) were selected to complete the VISA-A questionnaire, after a diagnosis of Achilles tendinopathy had been made at first and subsequent visits to a specialised outpatient clinic.

Results The average pre-treatment VISA-A score was 39 (SD 22.8, range 3–82, 95% CI: 31–47). The patients received intensive physiotherapy, including graded progressive eccentric calf strengthening exercises, and were offered a peritendinous injection of Aprotonin and local anaesthetic if physiotherapy was ineffective. Surgery was performed in six patients when six months of conservative management failed to produce improvements. The average post-treatment VISA-A scores at the latest follow up was 50 (SD 26.5, range 1–97, 95% CI: 40.8–59.3), with a mean difference between pre and post-treatment scores of 11.5 (SD 18.8 range -28.5–67.5, 95% CI: 4.9–18). The mean VISA-A score in patients offered surgery was 36, and 20 in patients who received a peri-tendinous injection of Aprotonin and local anaesthetic

Conclusion The VISA-A score can identify patients who need more aggressive management, and can be used to monitor their progress.

Neglected rupture of quadriceps tendon is an infrequently occurring lesion resulting from sport, but it is very interesting as regards the physiological and functional repercussions. The lesion is common in football players. The pathogenesis is a flexion trauma of knee. Many authors point out the importance of a pre-existent degeneration due to exogenous and endogenous factors. Pain, inextensible knee, ecchymosis, axe hit are a common presentation in acute events, difficult knee extension and pain in chronic. X-ray study shows calcification at the tendon-bone junction.

The treatment of neglected rupture of quadriceps tendon is surgical. If a defect of 5 cm or more is present between the ends of tendon the fascia lata can be used to correct the gap. When the ends can be apposed an end-to-end repair is possible. We treated a neglected rupture of quadriceps femoris muscle tendon in a bodybuilder with a particular technique: we stripped and harvested the semitendinosus and gracilis tendon and sutured them together. Then we made a transverse hole in the mid-portion of the patella; the tendons were passed through the transverse hole in the patella and sutured with the lateral, medial and intermendial vastus, and with the rectum femoral. At 6-month follow-up the patient has no pain and stability is improved, a practical range of knee motion regained. Full forceful extension is not completely restored.

Objective- To evaluate three femoral cement pressurization techniques in a laboratory setting.

Design- Observational study using a plastic femur (sawbone) model.

Materials and Methods- 12 femoral bone models were cemented and pressurized using three different cement pressurization techniques (standard technique, pressuriser in situ technique, and thumb pressurisation technique). Four sets of observations were taken for each technique. Intramedullary pressure readings were obtained using proximal and distal pressure monitoring transducers. The peak pressure and the time for which the pressure was above a particular cut off level (5 KPa and 100 KPa) were compared.

Results- There were significant variations between the peak pressure and the duration for which the pressure was above 100 KPa. The pressuriser in situ technique yielded significantly (p< 0.001) higher peak pressure both proximally (397.5 ± 40.2 KPa) and distally (597.3 ± 102.4). The standard technique produced the optimum pressure of 100 KPa for significantly (p< 0.001) longer duration proximally and distally (66.8 ± 29.5 and 45.2 ± 15.5 seconds respectively) compared to the other two techniques (less than 5 and 17 seconds for thumb pressurisation technique and pressuriser in situ technique respectively, both proximally and distally). There were no significant statistical differences between the three methods for the time for which the cement pressure was higher than 5 KPa.

Conclusion- Although the pressuriser in situ technique produced highest peak pressure, the standard technique produced optimum pressure for longer duration. The standard technique seems to be adequate to achieve optimum pressurization during femoral cementing without increased risk of embolisation.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

Aim: Congenital Talipes Equinovarus (CTEV) is managed in a variety of ways, with little agreement on how best to assess outcome. Some authors advocate patient based subjective assessments, while others use a variety of objective measures. Without agreement, it is impossible to evaluate different management methods. We have therefore evaluated a number of objective parameters compared to a subjective assessment following management of CTEV. Methods: 216 children and their families consented to participate in the study. The children had been managed in a number of hospitals across Scotland, and in a variety of ways. Outcome was assessed by a researcher not involved in the management of the children. Subjective assessment consisted of a postal questionnaire. Objective assessment consisted of a number of anthropometric measures. Results: A strong correlation was seen between subjective assessment, and several objective outcome measures including foot length discrepancy, calf muscle wasting, and range of movement at the ankle. Conclusions: Objective assessment using several parameters correlates well with subjective assessment. Using these objective measures, it is possible to evaluate and compare different management protocols in CTEV.

Control and ruptured Achilles tendons underwent lectin staining with Aleuria aurantia, Canavalia ensiformis, Galanthus nivalis, Phaseolus vulgaris, Arachis hypogea, Sambucus nigra, Triticum vulgaris. The mean pathology score of ruptured tendons was significantly greater than that of control Achilles tendons from individuals with no known tendon pathology. Four of the seven lectins used exhibited significantly positive results. Ruptured tendons show different lectin staining properties than non-ruptured ones. This difference may results from post-translational changes in the extracellular matrix producing biochemical alterations which might interfere with the interaction with the lateral sugar residues of the collagen molecules, or cause steric blockade.

To ascertain whether lectins could be a useful tool for investigation of the extracellular matrix of degenerated and normal tendons, haematoxylin-eosin stained slides were assessed blindly using a semi-quantitative grading scale for fibre structure; fibre arrangement, rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation; glycosaminoglycan, with a pathology score giving up to three marks per each of the above variables, with 0 being normal, and 3 being maximally abnormal. For lectin staining with Aleuria aurantia, Canavalia ensiformis, Galanthus nivalis, Phaseolus vulgaris, Arachis hypogea, Sambucus nigra, Triticum vulgaris, assessment of staining on a scale from 0 (no staining) to 5 (strong staining) was performed blindly. The mean pathology sumscore of ruptured tendons (n=14; average age 46.5 years, range 29–61) was significantly greater than the mean pathology score of the control tendons of Achilles tendons from individuals with no known tendon pathology (n=16; average age 62.5 years, range 49–73) (pathology score: 18.5 ± 3.2 vs 6.1 ± 2.3) Four of the seven lectins used exhibited significantly positive results. Ruptured tendons are histologically significantly more degenerated than control tendons. Ruptured tendons show different lectin staining properties than non-ruptured ones. This difference may result from post-translational changes in the extracellular matrix producing alterations in the biochemistry of the tendon which might interfere with the interaction with the lateral sugar residues of the collagen molecules, or cause steric blockade.

Sublaminar wiring with posterior instrumentation is one of the methods used when long fusions involving 10 to 12 thoracolumbar levels are required. Classically wires are used at every consecutive level to make the construct as rigid as possible although complications like dural tears, CSF leak, and neurological deficiet have been reported during their passage.

We compared the mechanical stability of five specimens of each of the three construct designs by static and fatigue testing to torsional strain on Electro-servo-hydraulic testing machine. In construct A, a contoured Hartshill rectangle was used from T2 to L2, with sub-laminar wires passed at every level. In construct B, every alternate level was wired. In construct C, every alternate level was wired except at the proximal end two consecutive levels were wired. Industrially fabricated spine models were used to prepare these constructs. The intervertebral motion within the construct was measured using FASTRAK magnetic field sensor device.

On static testing, no statistically significant difference was found in the rotational displacement of the three construct designs. On fatigue testing, all samples of construct B consistently failed with breakage of the wire at the most proximal level on the left side. But on adding additional wires to the next level (Construct C), all five samples withstood fatigue testing at 300 Newton load to 3 million cycles.

Wiring alternate levels instead of every level, does not compromise the stability of the construct provided the most proximal two levels are consecutively wired. This practise would minimise the risk of dural tears and cord damage during wire passage and reduce surgical time, not to mention the economical benefit.

To report the long term outcome of patients with a partial tear of the anterior cruciate ligament (ACL).

We reviewed 26 of 31 athletes who had a diagnosis of acute, incomplete tear of the anterior cruciate ligament (ACL) between November 1986 and December 1991. All patients had arthroscopy and examination under anaesthesia within 8 weeks of acute knee injury, and were included in the study if there were still ACL fibres remaining which resisted anterior tibial translation. We excluded patients with associated major ligamentous lesions. Patients were reviewed by a combination of questionnaire and clinical examination at a mean of 38 months after the index injury (range 18 to 66).

At review, 20 patients (77%) had developed some symptoms of knee instability. The number of patients with a positive Lachman’s test had increased from 17 to 18, and those with a positive pivot shift had increased from 9 to 13. Seven patients (27%) had undergone ACL reconstruction, 7 other patients (27%) had been unable to return to sport, and 6 patients (23%) continued to participate in sport, but at a reduced level. Only 6 patients (23%) were able to continue in sport at their pre-injury level without reconstructive surgery. Patients with a tear of the anteromedial bundle of the ACL were more likely to have signs of instability at review and to require ACL reconstructive surgery than patients with a tear mainly affecting the posterolateral bundle.

Partial lesions of the ACL, especially when involving the AM bundle, should not be regarded as benign injuries. They often result in symptomatic instability necessitating intra-articular reconstruction of the ACL, and, in the long run, in marked decrease in the level of sports participation.

We evaluated sensitivity, specificity, reproducibility and predictive value of palpation, of the painful arc sign, and of the ‘Royal London Hospital test’ in 10 patients with Achilles tendinopathy, and in 14 asymptomatic subjects using a test-retest study design.

Ten male athletes on the waiting list for exploration of one of their Achilles tendons for tendinopathy of the main body of the tenon attended a special clinic. Each was invited to bring at least one athlete of the same sex in the same discipline aged within two years of themselves, with no history and no symptoms of AT. A total of 14 controls were thus recruited.

Pain and tenderness following performance of palpation, the painful arc sign, and the ‘Royal London Hospital test’ were recorded.

There were no statistically significant differences at the 5% level among the effects of investigator or between morning and afternoon measurements for any of the three assessment methods. There was no evidence of a difference of the three assessment methods (p> 0.05). When the three methods were combined, the overall sensitivity was 0.586 (CI 0.469 – 0.741) and the overall specificity was 0.833 (CI 0.758 – 0.889).

In patients with tendinopathy of the Achilles tendon with a tender area of intratendinous swelling which moves with the tendon and whose tenderness significantly decreases or disappears when the tendon is put under tension, a clinical diagnosis of tendinopathy can be formulated, with a high positive predictive chance that the tendon will show ultrasonographic and histological features of tendinopathy.

Disuse atrophy is the basis for profound physiological changes of the muscles of immobilised limbs. The aim of this study was to use ultrasound to assess the quadriceps musculature and to try and measure atrophy. We monitored the effects of enforced reduction of mobility due to trauma on the intramuscular architecture of the quadriceps using high resolution real-time ultrasonography (HRRTU) in 13 skeletally mature male patients (43.2 years, range 16 to 82 years), with an isolated unilateral diaphyseal fracture of the femur or of the tibia. All patients had undergone interlocked intramedullary nailing (IIN). Using HRRTU, the pennation angles and muscle fibre lengths of vastus lateralis, the cross sectional area (CSA) of the rectus femoris, and the quadriceps muscle layer thickness (MLT) were measured in the injured and the normal contralateral limb. Repeated measurements showed the technique of measurement of the variables used in this study to be highly reproducible. There was a significant difference in the angle of pennation of the vastus lateralis in the nailed (15.4°) and the unnailed limb (21.2°), documenting that muscle atrophy causes a change to muscle architecture that results in a significant decrease in pennation angle (p = 0.0002). The muscle fibre length was significantly different (p=0.002) and there was a significant correlation between pennation angle and muscle fibre length (r=−0.51, p=0.001). There was also a significant difference in the quadriceps MLT (p=0.001) and CSA of the rectus femoris (p=0.0004) implying that the whole of the quadriceps muscle is affected.

Displaced fractures of the forearm in children are often treated conservatively, but there is a relatively high incidence of redisplacement, malunion and consequent limitation of function. We have performed percutaneous Kirschner (K) wire fixation in 72 such children under the age of 14 years, of which 57 were reviewed for our study. Both the radius and ulna were fractured in 45 (79%), the radius only in eight and the ulna only in four. The mean initial angulation was 19° in the lateral plane and 9° in the anteroposterior plane for the radius and 15° and 9°, respectively, for the ulna. In 42 patients (74%) we performed closed reduction. In the remaining 15 (26%) closed reduction failed and an open reduction, through a minimal approach, was required before K wiring.

At a mean follow-up of 20 months all patients had good functional results with an excellent range of movement. Only five had angulation of from 10° to 15° and none had nonunion, premature epiphyseal closure or deep infection. Percutaneous intramedullary K wiring for forearm diaphyseal fracture is a convenient, effective and safe operation, with minimal complications.