Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims

Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK.

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

Abstract

Abstract

Abstract

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures.

Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database.

Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14).

The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes.

This study was designed to compare atypical hip fractures with a matched cohort of standard hip fractures to evaluate the difference in outcomes.

Patients from the American College of Surgeons National Surgical Quality Improvement Program's (NSQIP) targeted hip fracture data file (containing a more comprehensive set of variables collected on 9,390 specially targeted hip fracture patients, including the differentiation of atypical from standard hip fractures) were merged with the standard 2016 NSQIP data file. Atypical hip fracture patients aged 18 years and older in 2016 were identified via the targeted hip fracture data file and matched to two standard hip fracture controls by age, sex, and fracture location. Patient demographics, length of hospital stay, 30-day mortality, major and minor complications, and other hip-specific variables were identified from the database. Binary outcomes were compared using the McNemar's test for paired groups, and continuous outcomes were compared using a paired t-test.

Ninety-five atypical hip fractures were identified, and compared to 190 age, sex, and fracture location matched standard hip fracture controls. There was no statistical difference in body mass index (BMI), race, ASA score, smoking status, timing of fixation, or functional status between the two groups (P>0.05). Thirty-day mortality was significantly higher in the atypical hip fracture group (atypical 7.36%, standard 2.11% p

This is the first study, to our knowledge, that demonstrates an increase in the rate of mortality in atypical hip fractures. Comparing atypical hip fractures with a matched cohort of standard hip fractures revealed a significantly greater 30-day mortality rate with an odds ratio of 3.62 in atypical hip fractures (95% CI 1.03–12.68). Prospective, clinical studies are recommended to further investigate these findings.

Osteoarthritis of the hip is common and the mainstay of surgical treatment for end-stage disease is total hip replacement. There are few RCTs comparing long-term outcomes between prostheses; therefore, surgeons and patients are reliant on single-centre case-series and recently, analysis of joint registries, when making evidence-based implant choices.

We conducted a systematic review, conforming to PRISMA, of Medline and Embase in September 2017. Single-centre case-series and papers analysing registries were included. Series looking at disease-specific cohorts (other than OA), under 15 years follow-up or lacking survival analyses were excluded. Resurfacings, revisions and complex-primaries were also excluded. 2750 abstracts were screened, resulting in 299 full-text articles. Following full review 124 articles were excluded and 21 series added from references, resulting in 150 analyses of individual prostheses/constructs and 12 papers from registries. We also analysed annual reports of registries.

Registry data indicated cemented prostheses tended to better outcomes at late follow-ups, whereas case-series showed cementless prostheses tended to have better survival past 15 years with revision for any reason (of stem, cup or either component) as the end-point.

The discrepancy between results from registry data and single-centre case series is stark, and whilst the reasons for these differences may be multifactorial, single-centre case-series included in this review often lacked sufficient power to provide precise estimates of survival. This is contrasted to data from registries, which tended to have far greater numbers from multiple centres, allowing results to be generalised to the population.

The difference between these two modes of analysis suggests bias exists in selection and outcomes from single-centre series. The varied quality of reporting in case-series make it difficult for a reader to adequately assess bias, and accurately inform contemporary decision making.

Surgeons and patients should be cautious when interpreting single-centre case series and systems relying on data generated from them.

Hip fracture is a common injury with a high associated mortality. Many recommendations regarding timing of operative intervention exist for patients with such injuries. The Best Practice Tariff was introduced in England and Wales in 2010, offering financial incentives for surgery undertaken within 36 hours of admission. The England and Wales National Institute for Health and Clinical Excellence (NICE) Guidance states that surgery should be performed on the day or day after admission. Due to lack of clear evidence, this recommendation is based on Humanitarian grounds. NICE have called for further research into the effect of surgical timing on mortality.

We utilised data from the National Hip Fracture database prospectively collected between 2007 and 2015, comprising 413,063 hip fractures. Using 11 variables, both Cox and Logistic regression analysis was used to establish the effect on mortality of each 12 hour interval from admission to surgery.

For each 12 hour time frame from admission to surgery a trend for improved 30 day survival was demonstrated the earlier the surgery was performed. However, this did not reach significance until beyond 48 hours (Hazard ratio of 1.12, 95% CI: 1.04–1.20). Surgery after 48 hours suffered significantly higher chance of mortality compared to surgery done within 12 hours.

This is the largest analysis undertaken to date. Lowest mortality rates are found within the 0–12 hour window. After 48 hours there is a significant increased risk of mortality compared to the 0–12 hour time frame. As such, expeditious surgery within 48 hours can be justified both on humanitarian and survivorship grounds.

Hip fracture surgery performed within 48 hours is associated with reduced mortality when compared to that beyond this time. This is in agreement with Blue Book recommendations and extends the currently recommended NICE and Best Practice Tariff targets of 36 hours.

Background

A dedicated referral pathway for patients with bony metastases was introduced at Guy's and St Thomas’ Hospitals (GSTT) in 2009. The aim was to facilitate prompt, consultant-led decision-making and intervention for patients at risk of pathological fracture of long bones.

Background

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.

Introduction

Partial meniscectomy, a surgical treatment for meniscal lesions, allows athletes to return to sporting activities within two weeks. However, this increases knee joint shear stress, which is reported to cause osteoarthritis. The volumes and locations of partial meniscectomy that would result in a substantial increase in knee joint stress is not known. This information could inform surgeons when a meniscus reconstruction is required.

Background

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.

Introduction:

The Best Practice Tariff (BPT) for hip fractures was introduced in April 2010 to promote a number of quality markers, including surgery within 36 hours. We conducted an audit to see whether the introduction of the BPT has had an inadvertent adverse effect on delay to fixation of unstable ankle fractures.

Introduction:

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.

Routine postoperative radiographs following hip hemiarthroplasty are commonly undertaken despite it being suggested that they can cause delays to discharge, discomfort to patients and unnecessary radiation. Our study considered the necessity of these post-operative radiographs.

A retrospective search was conducted of all hemiarthroplasty procedures on the Royal Cornwall Hospital database. These were reviewed for cases where re-operation was conducted within 6 weeks. Notes and post-operative check radiographs of those who underwent re-operation were reviewed to determine how essential radiographs were in diagnosing complications requiring re-operations.

A total of 1557 hemiarthroplasty operations were identified. There were 37 incidences of re-operation within 6 weeks. 29 cases had normal check radiographs. 8 dislocations were picked up on post-operative radiographs. In all but one of these cases, clinical suspicion of complication had been raised prior to the radiograph. In the remaining case documentation was poor and no firm conclusion as to clinical suspicion could be drawn.

Our review of over 1500 hemiarthroplasty cases, demonstrated one incident where the check radiograph solely diagnosed an abnormality needing intervention that might not have been apparent clinically. We thus suggest that check radiographs following hip hemiarthroplasty should not be routinely ordered for all patients.

Aims

Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome.

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation.

A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score.

The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions.

This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet.

Introduction

Chronic ruptures of the Achilles tendon pose a significant management challenge to the clinician. Numerous methods of surgical reconstruction have been described and are generally associated with a higher complication rate than with immediate repair. We report our results with a single 5cm incision technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also enables easy tensioning of the graft/reconstruction to match the uninjured leg and early mobilisation.

Introduction

We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals.

Introduction

Scaphoid fracture is the most common undiagnosed fracture. Occult scaphoid fractures occur in 20-25 percent of cases where the initial X-rays are negative. Currently, there is no consensus as to the most appropriate investigation to diagnose these occult frctures. At our institution MRI has been used for this purpose for over 3 years. We report on our experience and discuss the results.

14.1% of men & 22.8% of women over 45 years show symptoms of osteoarthritis OA of the knee [1]. Knee OA is usually associated with lower limb malalignment [2]; 50 of varus results in 70% −90% increase in compressive loading of the medial tibio-femoral compartment [3] and OA worsening over 18 months [4]. High Tibial Osteotomy (HTO) enables preservation of bone stock and soft tissue structures and could be an attractive option to younger patients who wish to return to high level activity. However, results of HTOs are unpredictable, which could be due to patient selection or surgical techniques. The long-term aim of this work is to develop a predictive tool to aid the surgeon in the selection of optimal HTO geometry for improved and more consistent surgical outcomes. The first step in achieving our longterm goal was to determine whether stress predictions at the tibio-femoral articulation were sensitive to simulated high tibial osteotomy, using finite element (FE) method.

CT and MRI data of a cadaveric knee were used to create geometrically accurate 3D models of the femur, tibia, fibula, menisci and cartilage and tendon of the knee joint, using the Mimics V12.11 commercially-available software (Materialise, Belgium). The Simulation module was used to register the bones and the soft tissues. The resulting STL files were exported to CATIA V5R18 pre-processor to generate surface meshes and create the corresponding 3D solid and FE models of the osseous and soft tissues from the STL cloud of points.

The Young’s moduli for cortical bone, cancellous bone, cartilages, menisci and ligaments were taken from literature as 17 GPa, 500 MPa, 12 MPa, 60 Mpa and 1.72 MPa respectively [5,6,7]. The Poisson’s ratios for osseous and soft tissues were taken as 0.3 and 0.45, respectively [8]. The nodes between the bones and the corresponding cartilages were merged and surface contact was applied between the cartilages. The distal ends of the tibia and fibula were fixed and a load of 2.1 KN, corresponding to 3 x body weight, was applied perpendicularly to the proximal end of the femur. Results of finite element analyses show a reduction of 67 % in principal stresses in the knee joint following an open wedge HTO surgery simulating 100 varus correction.

FE analysis results of this study show that HTO reduces stresses in specific regions of the knee, which are associated with OA progression [4]. Our future works include corroborating our results with controlled cadaveric experiments and implementing optimization techniques to predict optimum HTO geometries for patient-specific FE models.

Introduction: Acetabular fractures are increasing in incidence and no previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and recovery. The incidence, outcome and recovery of operatively managed acetabular fractures with associated neural injuries were studied from a three-year cohort of patients.

Methods: This retrospective case series study of 456 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 29 (6.3%) acetabular fractures associated with neural injuries. The fractures were classified using the Letournel system, neural injuries classified as either complete or incomplete and the degree of post-operative skeletal displacement quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: Overall, the cohort had a mean age of 34 years, 17 (59%) were male and the mean delay from time of injury to time of acetabular surgery was 16 days (range 4 – 53 days). All fractures involved posterior wall and/or posterior column and 23 (79%) were of the more complex, associated type, Letournel fracture patterns. Full resolution of neural symptoms was observed in 9 (31%) patients with a mean fracture reduction of 1.6mm. Partial neurological improvement was observed in 15 patients. Ongoing complete nerve palsy was observed in 5 patients, associated with a mean fracture reduction of 2.5 mm and a significantly longer delay to surgery of 32 days (p< 0.05).

Discussion: Acetabular fractures involving the posterior wall or column have a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, affords a good neural outcome for these patients. In similiar injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predicts a poor prognosis.

Introduction: The incidence, outcome and recovery of operatively managed pelvic ring fractures were studied from a three-year cohort of patients. No previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and natural recovery in these potentially devastating injuries.

Methods: This retrospective case series study of 489 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 42 (8.6%) patients who had sustained pelvic ring injuries with associated neural injuries. Each pelvic injury was classified using the Tile and Burgess & Young classifications, neural injuries were classified as either complete or incomplete and the degree of post-operative skeletal displacement was quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: The mean age of patients with neural injuries was 28 years, 32 (76%) were male and 37 (88%) had unstable, Tile type C, fracture patterns. The mean delay from time of injury to time of pelvic surgery was 11 days (range 3 – 42 days). Full resolution of neural symptoms was observed in 16 (38%) patients, with a mean fracture reduction of < 6mm. Incomplete improvement was observed in 11 patients and 15 patients had ongoing complete lumbosacral palsy. Patients who failed to achieve full resolution of neural function had a mean fracture or sacro-iliac joint reduction of 8.8 mm and the mean delay to surgery was 24 days.

Discussion: Pelvic ring injuries with an unstable fracture pattern are associated with a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, creates a better environment to achieve a good neural outcome. In such injuries with complete nerve palsy, delayed and suboptimal surgical reduction predicts a poor prognosis.

Introduction: Acetabular fractures are increasing in incidence and no previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and recovery. The incidence, outcome and recovery of operatively managed acetabular fractures with associated neural injuries were studied from a three-year cohort of patients.

Methods: This retrospective case series study of 456 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 29 (6.3%) acetabular fractures associated with neural injuries.

The fractures were classified using the Letournel system, neural injuries classified as either complete or incomplete and the degree of post-operative skeletal displacement quantified using radiographs.

A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: Overall, the cohort had a mean age of 34 years, 17 (59%) were male and the mean delay from time of injury to time of acetabular surgery was 16 days (range 4 – 53 days).

All fractures involved posterior wall and/or posterior column and 23 (79%) were of the more complex, associated type, Letournel fracture patterns.

Full resolution of neural symptoms was observed in 9 (31%) patients with a mean fracture reduction of 1.6mm. Partial neurological improvement was observed in 15 patients.

Ongoing complete nerve palsy was observed in 5 patients, associated with a mean fracture reduction of 2.5 mm and a significantly longer delay to surgery of 32 days (p< 0.05).

Discussion: Acetabular fractures involving the posterior wall or column have a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, affords a good neural outcome for these patients. In similiar injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predicts a poor prognosis.

Purpose: The purpose of this study was to compare the biomechanical behavior of locking plates to conventional plate and allograft constructs for the treatment of periprosthetic femoral fractures.

Methods: Twenty synthetic femora were tested in axial compression, lateral bending and torsion to characterize initial stiffness and stiffness following fixation of an osteotomy created at the tip of a cemented femoral component. Stiffness was tested with and without a 5mm gap. Axial load to failure was also tested. Four constructs were tested: Construct A – Synthes locked plate with unicortical locked screws proximally and bicortical locked screws distally; Construct B – Synthes locked plate with alternate unicortical locked screws and cables proximally and bicortical locked screws distally. Construct C – Zimmer cable plate with alternate unicortical non locked screws and cables proximally and bicortical non locked screws distally. Construct D – Zimmer cable plate in same fashion as construct C plus anterior strut allograft secured with cables proximally and distally.

Results: In axial compression, construct D was significantly stiffer compared with all other constructs in the presence of a gap, with no differences between groups without a gap. For lateral bending stiffness, construct D was significantly stiffer than the other groups with and without a gap. In torsional testing, construct D was significantly stiffer than all other constructs in the presence of a gap. With no gap, construct D was significantly stronger than construct B. There were no significant differences between constructs A and B in all testing modalities. Axial load-to-failure ranged from 5561.5 to 6700.2 N. There were no significant differences in axial load to failure.

Conclusions: This study suggests that a single locked plate does not provide the same initial fixation stiffness as a plate-allograft strut construct in the setting of a gapped osteotomy. This may be particularly important in the setting of a comminuted fracture or with bone loss. In these settings, a construct with a lateral plate and an allograft strut placed anteriorly at 90 degrees to the plate, may be optimal.

Purpose: The purpose of this study was to examine how the “ideal” tibial nail insertion point varies with tibial rotation and to determine what radiographic landmarks can be used to identify the most suitable rotational view for insertion of a tibial intramedullary nail.

Methods: Twelve cadaveric lower limb specimens with intact soft tissues around the knee and ankle joints were used. A 2.0mm Kirschner wire was placed in the center of the anatomic safe zone and centered on the tibial shaft. The leg was rotated and imaged using a fluoroscopic C-arm until the K-wire was positioned just medial to the lateral tibial spine (defined as the neutral anteroposterior radiograph). The leg was then fixed and radiographs were taken in 5 degree increments by rotating the fluoroscope internally and externally (in total, a 50 degree arc). Following this a second K-wire was placed in 5 mm increments both medially and laterally and the fluoroscope rotated until this second K-wire was positioned just medial to the lateral tibial spine. Radiographs were digitized for measurements.

Results: Given the presence of a 30 degree rotational arc through which the radiograph appeared anteroposterior, it was possible to improperly translate the start point up to 15 mm. Relative external rotation of the image used for nail placement led to a medial insertion site when using the lateral tibial spine as the landmark. A line drawn at the lateral edge of the tibial plateau to bisect the fibula head correlated with an entry point that was central or up to 5 mm lateral to the ideal entry point. The use of a fibula head bisector line avoided a medial insertion point.

Conclusions: Rotation of the tibia may result in up to 15 mm of translation of the start point that may be unrecognized. Relative external rotation of the film used for nail placement leads to medial insertion sites when using the lateral tibial spine as a landmark. The fibula head bisector line can be used to avoid choosing external rotation views and thus avoid medial insertion points.

Purpose: This cadaveric study examines how changes in femoral entry point for intramedullary instrumentation of total knee replacements affects femoral component positioning.

Methods: Twelve cadaveric lower limb specimens with intact hip, knee and ankle joints were obtained. Total knee navigation instrumentation was secured. Anatomical landmarks required for axes generation were obtained. An initial entry point was made at the center of the distal femur. An intramedullary rod was the introduced into the femur. Five and seven degree cutting blocks were placed onto the rod and positioned against the distal femur with the rotation parallel to the epicondylar axis. The navigation system was then used to generate a varus/valgus angle and flexion/extension angle with respect to the previously generated femoral mechanical axes. This allowed determination of an angle at which the distal femoral cutting block would need to be set to make a neutral distal femoral cut. The guide rod was removed and reinserted five times and measurements recalculated. Data was then collected with entry points 5mm medial, 5mm anterior and 5mm medial and anterior to the initial entry point.

Results: There was no significant difference in varus/ valgus angle with a central compared with 5mm anterior entry point and no difference with a 5mm medial versus 5 mm medial and anterior entry point. The valgus angle required to give a neutral distal femoral cut with a central entry point was 4.98o (SD 0.91o; range 3.5o–6.0o). The valgus angle for a 5mm medial entry point was 6.92o (SD 0.97o, range 5.5o–8.0o). With regards to the sagittal plane a 5mm anterior translation of the entry point changed the flexion/extension angle by 1.58o (SD 0.52o, range 0.5o–2.5o).

Conclusions: Small changes in the entry point can significantly affect component alignment. When moving more medial with the entry point a more valgus angle is required for the cutting block. An entry point at the deepest point of the trochlea may be more reproducible than an anteromedial one but requires a valgus cutting block closer to 5 degrees.

Funding : Commerical funding

Funding Parties : Stryker

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).

Introduction and Aims: Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50percent of these injuries occur in athletes, classically in weight-lifters during bench press.

Method: In this study, 13 cases of rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair. Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients. Intra-operative findings correlated with the reported scans in 11 patients with minor differences in two patients.

Results: During follow-up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their pre-operative level.

Among our patients we emphasise that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation.

Conclusion: According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle, which is essential for the active athlete.

External fixation of distal radius fractures usually involves the use of a bridging fixator. However, immobilisation of the wrist can be associated with various complications and therefore dynamic external fixators were developed to allow wrist mobilisation with the fixator in place. But dynamic fixators themselves are not without complications and more recently interest has been rekindled in non-bridging external fixators (otherwise called metaphyseal or radial-radial fixators).

Following a pilot study using a non-bridging external fixator (Delta frame) in the treatment of intra-articular distal radius fractures, our aim in this study was to compare the functional and radiological outcome of the Delta frame and a standard wrist-bridging static external fixator in the treatment of such fractures. Sixty patients with intra-articular distal radius fractures were randomly allocated to receive either a static bridging Hoffman external fixator or a non-bridging Delta frame. All patients had the fixator removed at six weeks. Clinical and radiographic assessment was performed regularly up to a maximum of twelve months with the clinical results being expressed in terms of range of movement, pain, grip strength and ability to perform certain activities of daily living. Radiological assessment was performed by an independent radiologist. Mean follow-up was ten months.

The only sustained significant difference in function was a greater range of flexion in the Hoffman group. No significant difference could be detected between the two groups in terms of the radiological outcome. Complications included pin-site infection, paraesthesia, extensor pollicis longus tendon rupture and chronic regional pain syndrome. Three patients underwent further surgery. We did not demonstrate any advantage in the use of a non-bridging fixator in the treatment of intra-articular distal radius fractures.

Introduction: Current fixation methods for distal radial fractures usually involve immobilisation, which has been suggested to have adverse effects on wrist function. The aims of this study were to compare the clinical, functional and radiological outcomes of a bridging, and a non-bridging external fixator that did not cross the wrist joint, in the management of intra-articular fractures of the distal radius.

Methods: Sixty subjects were randomly allocated to receive a bridging Hoffman frame and limited wrist range of movement (ROM) exercises for 6 weeks, or a non-bridging Delta frame and full active wrist ROM exercises commencing at 2 weeks. All frames were removed at 6 weeks. Radiographic and clinical assessments were made at regular postoperative time intervals for 12 months with clinical outcomes including measures of pain, ROM, grip strength, function and quality of life.

Results: Preliminary clinical results analysing pain, grip strength and ROM including flexion, extension, pronation and supination at 1–6, 26 and 52 weeks postoperatively indicated that no statistically significant difference could be detected between the two groups at any time frame. Complication rates were similar for both groups. Preliminary radiographic analysis of dorsal angle, radial angle and radial length at 6, 26 and 52 weeks postoperatively also indicated that no statistically significant difference could be detected between the two groups.

Conclusion: Preliminary results of this trial suggest that no difference can be detected in the clinical and radiographic outcomes of subjects receiving a bridging external fixator with limited early wrist ROM exercises, or a non-bridging external fixator with early full active ROM exercises in the management of intra-articular fractures of the distal radius.