The need to accurately forecast the injury burden has never been higher. With an aging, ever expanding trauma population and less than half of the beds available compared to 1990, the National Health Service (NHS) is stretched to breaking point^1,2.

We utilised a dataset of 22,585 trauma patients across the four countries of the United Kingdom (UK) admitted to 83 hospitals between 22/08/22 – 16/10/22 to determine whether it is possible to predict the proportionality of injuries treated operatively within orthopaedic departments based on their number of Neck of Femur fracture (NOF) patients.

More operations were performed for elderly hip fractures alone than for the combined totals of the next four most common fractures: ankle, distal radius, tibial shaft and forearm (6387 vs 5922). Conversely, 10 out of the 13 fracture types were not encountered by at least one hospital and 93% of hospitals encountered less than 2 fractures of a certain type.

60% trauma is treated within Trauma Units (TUs) however, per unit, Major Trauma Centres (MTCs) treat approximately 43% more patients.

After excluding NOF, lower limb fractures accounted for approximately 57% of fractures in all countries and ankle and distal radius fracture combined comprised more than 50% in 74% of regions.

The number of hip fractures seen on average by an individual unit remains relatively consistent as does the regional variation of any given fracture; resultantly, it is possible to predict injury proportionality based off a unit's hip fracture numbers. This powerful tool could transform both resource allocation and recruitment.

Abstract

Abstract

Abstract

Abstract

Introduction

Non-unions often arise because of high strain environments at fracture sites. Revision fixation, bone grafting and biologic treatments to treat long bone fracture non-union can be expensive and invasive. Percutaneous strain reduction screws (PSRS) can be inserted as a day-case surgical procedure to supplement primary fixation at a fraction of the cost of traditional treatments. Screw insertion perpendicular to the plane of a non-union can resist shear forces and achieve union by modifying the strain environment. A multi-centre retrospective study was undertaken to confirm the results of the initial published case series, ascertain whether this technique can be adopted outside of the developing institution and assess the financial impact of this technique.

All skeletally immature patients who presented with a supracondylar fracture between 01/09/2013 and 24/11/2015 (n = 50) were used to compare the current management of supra-condylar fractures of the humerus in children to the standards set by the BOAST 11 guidelines. 8.1% did not have full documentation of their neurovascular assessment. 93.9% underwent surgery within 24 hours of presentation. Average time to theatre for neurovascularly compromised patients was 4 hours 46 minutes. 81.8% were managed with 2 K-wires as recommended. Only 39.4% of the patients had their wires removed within 3 – 4 weeks. Only 6.1% had the recommended 2 mm wires. AO recommends the use of 2mm wires if 2 lateral wires are used whereas the BOAST 11 guideline recommends 2mm wires where possible. The results clearly demonstrate a need for further education and awareness of the BOAST 11 guidelines. Of particular interest is the documentation of patients' neurovascular status for appropriate management and for medico-legal purposes. Long term outcome comparison of surgical fixation with 2mm and 1.6mm wires would be useful to support the use of 2mm wires as recommended by the professional consensus in the BOAST 11 guidelines.

Best Practice Tariff (BPT) recommends operation for hip fracture within 36 hours. Anticoagulation reversal often delays this. Audit of our service, to establish the impact on BPT of anticoagulation reversal, showed a loss of revenue and delays. Subsequently an ‘early trigger’ Intravenous Vitamin K (IVK) pathway was introduced and re-audit completed. Hip fracture patients admitted over a 32-month period were reviewed. Primary outcome was time to theatre for warfarinised and non-warfarinised patients. This was analysed using independent t-tests. A change in practice, involving nurse led administration of 2mg IVK in the Emergency Department prior to knowledge of the coagulation screen, was instigated. Three months later a re-audit occurred. In the first audit cycle, 83 patients were admitted on warfarin with a median time to theatre of 49.7 hours. 21% of these patients gained BPT. Following protocol change, over three months, 14 warfarinised hip fracture patients were admitted. Twelve patients achieved satisfactory reversal; eight with one IVK administration. Median time to theatre was 33.9h. Compliance with BPT in terms of delay due to anticoagulation was 86%. Our audit demonstrates that ‘early-trigger’ IVK reduces delays to theatre and helps reduce BPT related financial loss. It enables high quality patient-centred care within financial constraints.

Commissioning for quality and innovation (CQUIN) guidelines specify that diaphyseal fractures of the tibia should be treated within 24 hours of admission. We aimed to identify our compliance at a Major Trauma Centre.

Restrospective analysis of all tibia fractures over 12 months. Fractures that were not diaphyseal nor open were excluded. Time of presentation, x-ray, arrival to ward and arrival in theatre were analysed against CQUIN guidelines.

43 fractures, 18 (42%) arrived in theatre for operative management within 24 hours. 15 (35%) were managed operatively in the subsequent 24 hours and 10 (23%) were managed after 48 hours. Average time to theatre was 38 hrs 37 mins (SD 29hrs 42mins). It took on average 51mins (SD 43 mins) for a patient to have an xray and 3 hrs 53 mins (SD 1hr 47mins) to arrive on the ward, and average 3 hrs 2 mins (SD 1hr 43mins) between xray and the ward.

42% of patients are making CQUIN standards for closed tibial shaft fractures. There are logistical and resource factors contributing towards this as well as clinical issues. To address this there needs to be an agreed multidisciplinary pathway developed to ensure compliance with CQUIN standards.

In a recent publication, 4.6% of 6450 Coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional hemorrhage control device.

Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel over a 2 year period were reviewed. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established.

Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 92 died. Pelvic injury was the cause of death in 42; only 1 casualty was identified where death was at least in part due to a vascular injury below the inguinal ligament, not controlled by a tourniquet, representing <1% of all deaths. Twenty one deaths were due to vascular injury between the aortic bifurcation and the inguinal ligament, of which 4 survived to a medical facility.

Some potentially survivable deaths due to exsanguination may be amenable to more proximal vascular control. We cannot substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. There may be a role for more proximal vascular control of pelvic bleeding.

Circumferential pelvic binders have been developed to allow rapid closure of the pelvic ring in unstable fracture patterns. Despite evidence to support the use of pelvic binders, there is a paucity of clinical data regarding the effect of binder position on symphyseal diastasis reduction.

All patients presenting to the UK's military hospital in Afghanistan who survived and underwent pelvic radiography were reviewed. Cases were identified by retrospective assessment of all digital plain pelvic radiographs performed between January 2008 and July 2010. All radiographs and CT images were assessed to identify the presence of any pelvic fracture. Patients were grouped into three categories according to the vertical level of the buckle: superior to the trochanters (high), inferior to the trochanters (low) and at the level of the trochanters (troch). Diastasis reduction was measured in patients with Anterior-Posterior Compression (APC) grades II and III, or Combined Mechanical Injuries(CMI). Comparison of diastasis reduction between the high and troch groups was assessed by an independent samples Student's t-test.

We identified 172 radiographs where the metallic springs in the buckle of a SAM Pelvic Sling^™ were clearly visible. The binders were positioned at the trochanteric level in 50% of radiographs. A high position was the commonest site of inaccurate placement (37%). In the patients with fractures and an open diastasis, the mean pelvic diastasis gap was 2.75 times greater in the high group compared to the trochanteric level (mean difference 22 mm) (p < 0.01).

Application of pelvic binders superior to the greater trochanters is commonplace and associated with inadequate fracture reduction, which is likely to delay cardiovascular recovery in these significantly injured casualties.

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II.

From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded.

At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8).

This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team.

Extremity injury and complications such as wound infection remain a significant problem for the military. This study investigates the anti-microbial efficacy of four dressings used in militarily relevant complex extremity injury.

Under general anaesthesia, the flexor carpi ulnaris of 24 New Zealand White rabbits was exposed to a high-energy impact and then inoculated with 10⁶ colony forming units of Staphylococcus aureus. Dressings: gauze soaked in saline, Chlorhexidine, Betadine or Acticoat¯, were randomised and applied 3 hours post injury, to replicate casualty evacuation. Once recovered, animals were checked at least twice daily and body temperature recorded. Analgesia was administered once a day. At 48hrs animals were culled, the muscle harvested and analyzed by a blinded investigator. Group sizes of 6 were required to detect a statistically significant effect of a mean one log reduction in bacterial counts at 48 hours.

No dressing gave a significant reduction in bacterial counts at 48 hours. A paired t-test of contamination versus recovered dose gave p values of 0.903, 0.648, 0.396 and 0.336 for saline, Acticoat¯, chlorhexidine and iodine respectively. Contamination dose between groups compared using ANOVA showed no significant difference (p=0.566). Recovered bacterial loads between groups revealed no significant difference (p=0.280).

This study indicates that over a 48 hour period, dressings with reported anti-bacterial properties offer no advantage over saline soaked gauze in reducing the bacterial burden in a contaminated soft tissue injury. Future work will extend the study temporally and introduce multiple contaminants.

Crown copyright 2009. Published with the (permission of the Defence Science and Technology Laboratory on behalf of the Controller of HMSO

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation.

Introduction. This is the first study to illustrate spinal fracture distribution and the impact of different injury mechanisms on the spinal column during contemporary warfare. Methods Retrospective analysis of Computed Tomography (CT) spinal images entered onto the Centre for Defence Imaging (CDI) database, 2005-2009. Isolated spinous and transverse process fractures were excluded to allow focus on cases with implications for immediate management and prospective disability burden. Fractures were classified by anatomical level and stability with validated systems.

Clinical data regarding mechanism of injury and associated non-spinal injuries for each patient was recorded. Statistical analysis was performed by Fisher's Exact test. Results 57 cases (128 fractures) were analysed. Ballistic (79%) and non-ballistic (21%) mechanisms contribute to vertebral fracture and spinal instability at all regions of the spinal column. There is a low incidence of cervical spine fracture, with these injuries predominantly occurring due to gunshot wounding. There is a high incidence of lumbar spine fractures which are significantly more likely to be caused by explosive devices than gunshot wounds (p<0.05). 66% of thoracolumbar spine fractures caused by explosive devices were unstable, the majority being of a burst configuration. Associated non-spinal injuries occurred in 60% of patients.

There is a strong relationship between spinal injuries caused by explosive devices and lower limb fractures Conclusion Explosive devices account for significant injury to both combatants and civilians in current conflict. Injuries to the spine by explosions account for greater numbers, associated morbidity and increasing complexity than other means of injury.

Introduction

Electrolyte imbalance in the elderly is a clinical problem faced by both elderly care physicians and orthopaedic surgeons alike. Hyponatraemia is a common condition with a vague clinical profile and severe consequences if untreated. Recent medical editorials have criticised orthopaedic handling of this problem. We therefore sought to establish the incidence of hyponatraemia within our orthopaedic population and a similar age-matched elderly care population in the light of changing attitudes to fluid management.

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma.

A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits.

232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases.

Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent.

Over 75% of combat casualties from Iraq and Afghanistan sustain injuries to the extremities, with 70% resulting from the effects of explosions. Damage to peripheral nerves may influence the surgical decision on limb viability in the short-term, as well as result in significant long-term disability. To date, there have been no reports of the incidence and severity of nerve injury in the current conflicts.

A prospective assessment of United Kingdom (UK) Service Personnel attending a specialist nerve injury clinic was performed. For each patient the mechanism, level and severity of injury to the nerve was assessed and associated injuries were recorded.

Fifty-six patients with 117 nerve injuries (median 2, range 1–5) were eligible for inclusion. This represents 12.9% of casualties sustaining an extremity injury. The most commonly injured nerves were the tibial (19%), common peroneal (16%) and ulnar nerves (16%). 25% (29) of nerve injuries were conduction block, 41% (48) axonotmesis and 34% (40) neurotmesis. The mechanism of injury did not affect the severity of injury sustained (explosion vs gunshot wound (GSW), p=0.53). An associated fracture was found in only 48% of nerve injuries and a vascular injury in 35%. The presence of an associated vascular injury resulted in more severe injuries (conduction vs axonotmesis and neurotmesis, p< 0.05). Nerves injured in association with a fracture, were more likely to develop axonotmesis (p< 0.05).

The incidence of peripheral nerve injury from combat wounds is higher than previously reported. This may be related to increasing numbers of casualties surviving with complex extremity wounds. In a polytrauma situation, it may be difficult to assess a discrete peripheral neurological lesion. As only 35% of nerves injured are likely to have anatomical disruption, the presence of an intact nerve at initial surgery should not preclude the possibility of an injury. Therefore, serial examinations combined with appropriate neurophysiologic examination in the post-injury period are necessary to aid diagnosis and to allow timely surgical intervention. In addition, conduction block nerve injuries can be expected to make a full recovery. As this accounts for 25% of all nerve injuries, we recommend that the presence of an insensate extremity should not be used as an indicator for assessing limb viability.

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements. We report a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

Seventy patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0 – 15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.

Aim: To investigate the training of civilian Orthopaedic Trainee’s in complex trauma management.

Methods: A web-based survey of orthopaedic trainees utilising three scenarios for investigating complex trauma management. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence.

Results:

Pelvic packing in exanguinating pelvic trauma:

2.2% fully confidentto manage such a case. A positive correlation exists between increasing training and confidence. 58.9% have never seen such a case. No correlation exists between time in training and exposure. 62.8% report training in this case inadequate. A positive correlation exists between time in training and perceived inadequacy of ability to manage such a case.

Junctional traum with non-compressible groin haemorrhage:

0.4% fully confident. A positive correlation exists between time in training and confidence. 73.0% have never seen such a case. 67.9% report training in this case inadequate. No correlation was found between time spent in training and perceived training adequacy.

Blood product resuscitation in trauma:

11.6% were fully confident. 18.8% have never seen such a case. No correlation exists between time in training and confidence or exposure. 45.0% report training as inadequate in this case. No correlation seen between time in training and perceived training adequacy.

Conclusion: Current training provides limited opportunities for exposure to significant trauma.

The quality of care afforded to service personnel and civilians in recent conflict is unsurpassed and it is essential that the lessons learnt by deployed surgeons form a continuum to their successors.

For military orthopaedic trainees this reinforces the need for closely supervised secondments on deployment; attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to first consultant deployment.

Aim: To establish confidence and perceived adequacy of training of UK Orthopaedic Specialist Trainees in assessment of limb viability and amputation.

Methods: A web based survey of orthopaedic trainees using scenarios centred around limb viability assessment and amputation resultant from trauma. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence.

Results:

Limb viability:

27.8% were fully confident. A positive correlation exists between training year and fully confident reports. 68.6% encounter such injury either every six months or less frequently. 18.6% regard their training in these cases inadequate. No correlation seen between experience and perceived adequacy of training.

Amputation:

10.3% were fully confident. A positive correlation exists between time in training and perceived fully confident reports.

57.3% encounter such injury either every six months or less frequently. 36.3% regard their training in these cases inadequate. No correlation seen between experience and exposure to cases or perceived adequacy of training.

Conclusion: Current training provides limited opportunities for decision making in limb viability and amputation. Confidence in dealing with such cases is seen to increase with training. Perceived adequacy of training did not change over time.

Military orthopaedic surgeons are providing injured service personnel and civilians with the best possible chance of successful rehabilitation from these injuries. It is fundamental that the experience of these individuals is accessible to their successors.

For military trainees, this reinforces the need for participation in closely supervised secondments on deployment, attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to completion of training and first consultant deployment.

Introduction: The Oxford Knee Score (OKS) is commonly used in the assessment of outcome for knee arthroplasty. All patients having knee arthroplasty at our institution undergo OKS at both nurse led pre-assessment and admission physiotherapy visit, a period of 10 to 30 days pre-operatively. At both instances, the scoring form is left with the patient and collected at the end of the visit.

Anecdotal evidence from our centre suggested that patients attending for arthroplasty surgery were scoring differently at each visit.

The aim of this study is to establish if there is a significant difference OKS at pre-assessment visit and on admission to the ward.

Statistical Method: A pilot study was carried out. A power calculation revealed a requirement for 44 patients to enter the study. The resultant probability was 90 percent that the study would detect a difference at a two sided 5.0 percent significance level, if the minimum clinical difference is 3 points. This is based on the standard deviation of the difference in the response variables of 6. A clinical difference of 3 is drawn from previous studies investigating the use of the OKS.

44 patients undergoing arthroplasty surgery had their OKS for both visits retrospectively analysed.

The mean of the totals of both visits was analysed and found to conform to normality and hence was further investigated by a paired samples t test.

Comparison of individual scoring revealed a violation of normality and hence was further analysed using a Wilcoxon Signed Ranks Test.

Results: A statistically significant result at the 5% level was observed t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI).

Analysis of the individual scoring at both intervals revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units. No significant difference was seen when time between assessments was analysed.

Conclusion: This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed.

This work supports earlier studies that pre-operative assessment using the OKS is robust to variance in the pre-operative scoring window.

All patients undergoing knee arthroplasty at our institution complete Oxford Knee Scoring (OKS) at nurse-led pre-assessment and again at an admission physiotherapy visit on the ward which may be up to 2 months later.

The aim of this study is to establish the extended reproducibility of the OKS by statistical analysis of scores taken at these intervals.

44 patients were required to achieve a 90 % probability to detect a difference at a two-sided 5 % significance level with a minimum clinical difference of 3 points, a cut off used in previous works regarding the use of OKS.

Both the overall population means and the differences between individual questions were analysed by a paired samples t test and a Wilcoxon Signed Ranks Test respectively.

Mean interval between attendance for pre-assessment and admission visit was 16 days (7–60).

A statistically significant result at the 5% level was observed for the t test t= 2.197 (44df), p= 0.03. OKS at pre-assessment was lower than at admission to the ward by 1.1 point. (−2.1 – 0.9 95% CI).

Analysis of difference between individual questions revealed only three of the pairs achieved statistical significance and in each case, the difference was less than 3 scoring units.

This study demonstrates that although there is a difference in total scoring using the OKS between two patient episodes prior to arthroplasty, a clinically relevant difference is not detected, and neither is a statistically significant difference detected when all scoring steps are analysed.

The original validation of the OKS was obtained using test-retest reproducibility over a 24 hour period. This work shows that the OKS is robust to violations in reproducibility at duration much greater than this and for practical purposes is valid if taken at any point during the pre-admission phase of care.

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma.

Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received.

Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training.

Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level.

Background: In a recent publication from the National Joint Registry it was suggested that prosthesis type influenced patient satisfaction at one year following knee arthroplasty. In this report Unicondylar Replacement (UKR) was associated with lower levels of patient satisfaction when compared to cemented TKR. The unicondylar group did however have a significantly lower Oxford Knee Score (OKS) than the TKR group and this occurred irrespective of patient age.

A common perception is that UKR is only offered to patients with lesser disease, with a decreased clinical profile. This may explain their higher levels of dissatisfaction as the overall change in their OKS from pre to post operation would be relatively smaller than for TKR.

Aim: We hypothesised that patients listed for UKR have less severe disease and therefore a lower preoperative OKS when compared to TKR.

Methods: After sample size calculation we retrospectively analysed 76 patients who underwent either UKR or TKR under the care of a single surgeon. OKS was recorded at a dedicated pre-assessment clinic. The decision to offer UKR was based on clinical and radiological criteria as outlined by the Oxford group.

Results: There were 38 patients in either group. The mean pre-operative OKS was 39.5 (26–56, SD 7.6) in the UKR group and 41.6 (31–51, SD 5.7) in the TKR group. There was no statistical difference between these two groups (p=0.18).

Discussion: Patients listed for knee replacement have significant pain and functional impairment. In our population those suitable for UKR have similarly severe symptoms to those who do not meet the criteria for UKR and are only eligible for TKR. It remains unclear why patients undergoing UKR should be less satisfied when they have better post operative patient reported outcome scores. It emphasizes the need for careful patient selection and counselling in patient undergoing UKR.

Objectives: To review the changing pattern of orthopaedic injury encountered by deployed troops with regard to the importance of hand trauma.

Methods: A literature review of orthopaedic practice in recent conflict. The search period extended from 1990–2007. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded according to Levels of Evidence.

Results: 210 published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. The evidence is overall level 5 with the majority of papers comprising reviews, individual sub-unit experiences, historical perspectives and individual database analyses.

The evolving importance of extremity trauma is clear from the quantity of its reporting. The paucity of life threatening cavity trauma is highlighted. Casualty survival off the battlefield is increasing perhaps due to the impact of personal protective equipment. The combination of changing ballistics and increasing survivability leads to an apparent increase in limb threatening and complex hand trauma being encountered by military surgeons.

Despite being rarely reported in isolation, the proportion of complex hand trauma is broadening with an increase in open fractures and mutilated soft tissue injuries resultant from high and low energy transfer ballistics.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Sporting activities and inappropriate use of equipment are responsible for soft tissue and bony injury with considerable morbidity.

The literature was analysed with regard to the classification of hand trauma. Articles relating to recent conflicts were notable for their lack of classification of these injuries.

The bulk of papers retrieved concerning military hand trauma management were published prior to the conflicts of the last decade. It is within these papers that classification and treatment priorities including the nature of debridement and fracture stabilisation are discussed and highlighted as core knowledge.

Conclusion: The nature of injuries sustained by troops in conflict is evolving. Changing survivability is resulting in increasingly complex hand trauma presenting to military surgeons.

Despite a culture of ensuring that today’s trauma surgeons learn from mistakes made by their predecessors, in the field of hand trauma this is not the case.

A comprehensive review of changing orthopaedic conflict related injury patterns with special regard to hand trauma and the key learning points from historical literature are highlighted. Proposals for improving management are discussed with regard to improved training opportunities and dialogue between military trauma surgeons.

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements.

This was a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

70 patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0–15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.

To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities.

Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence.

Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses.

The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons.

This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten.

Presentation and subsequent publication has become ‘the holy grail’ of surgical trainees. This perceived importance of presenting work is further reinforced by the fact that over sixty percent of information contained in standard orthopaedic texts is quoted from published abstracts and not full papers. There is concern that increasing reliance is placed on such work and there are calls to restrict the routine use of abstracts in this manner.

This concern is born out of evidence that conversion of presented work into peer-reviewed publication is globally poor throughout the medical specialities.

The purpose of this study is to determine the conversion rate of work presented at the Combined Services Orthopaedic Society into peer review publication.

A Medline search of 81 consecutive published abstracts over six years was carried out. Further cross-referencing was established using Dialog Datastar with a search strategy. The rate of publication of papers presented at these meetings was then compared against other medical specialities across national and international forums.

26 full paper publications were identified. This yields a conversion rate of 32%. This figure is on a par with meetings such as the BOA (35%), the AAOS (34%) and EFORT (40%). It is also a similar level to that seen with work presented at other speciality meetings.

The conversion rate of papers presented at the Combined Services Orthopaedic Society is competitive with other orthopaedic and medical meetings. Overall conversion of presented works to robust literature is poor. Reasons for low publication rates include pressures of time, insufficient planning and disputes amongst colleagues.

In light of increasing pressure on selection of trainees and the perceived need to present work at meetings, this paper reinforces the need for thorough planning when undertaking research & audit and strict acceptance criteria from organising bodies.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

MRSA infections are a current concern in the elderly orthopaedic patient, with colonisation rates of between 417% reported in these patient groups. In our institution there has been concern regarding MRSA surgical site infection and cross contamination of elective and emergency patients. This prompted the unit to consider a screening programme to identify MRSA carriers. We undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.

The aim was to to ascertain the incidence of colonisation with MRSA, rate of wound infection and associated risk factors in patients admitted with a fractured proximal femur.

This was a prospective, blinded case series of 100 consecutive patients admitted to the trauma ward with a fractured proximal femur. Three swabs (axilla, nasal and perineum) were taken within 24 hours of admission. Data from each patient was collated and each patient was followed until discharge to assess for surgical site infection.

The age range was 60–97 years. 26% were admitted from institutional care. Four patients were colonised with MRSA on admission. An association was seen between patients colonised on admission and long term or recent residence in institutional care. One of these patients went on to develop colonisation of the surgical wound however this did not lead to surgical site infection and the patient was successfully treated with MRSA eradication therapy only. In these 4 patients all wounds healed satisfactorily with no evidence of infection.

While MRSA continues to be a growing concern in the press we found that rates of colonisation and subsequent infection were not high. There were no documented cases of MRSA wound infection in colonised individuals. Given the cost to detect these low levels of colonisation we do not feel that a screening regime would be cost effective or justified.

Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.

Introduction: The surgical management of proximal humeral fractures continues to be an unsolved problem for the orthopaedic surgeon. Disagreement remains over how best to fix the more challenging complex fractures in younger patients where the ultimate goals of treatment are restoration of a painless shoulder, adequate function, and preservation of humeral head viability.

The PHILOS plate attempts to improve on previously designed implants by preserving the biological integrity of the humeral head articular fragment. The minimally invasive technique minimises soft tissue damage whilst at the same time securing the reduction using multiple locking screws with angular stability, thus allowing early mobilisation.

Methods: Retrospective review of the notes and x-ray images of 54 fractures treated with the PHILOS plate between Jan 2000 and Aug 2005. Data including baseline demographics, the presence of any complications and the need for reoperation were collected. In addition 43 (81%) patients were contacted and Oxford (OSS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were calculated to assess functional recovery. All patients were contacted at a minimum of 6 months following fixation with an average follow up of 18 months (Range 6–41 months)

We also present a cost analysis relating to the use of the PHILOS plate in practice.

Results: 54 fractures in 53 patients (25F:28M). Average age 54.4. There were 26 2-part, 15 3-part and 13 4-part fractures. A total of 11 (20%) patients had complications of which 7 (13%) required reoperation. These complications included deep infection (3 cases), AVN (4), Non Union (3) and plate impingement (1).

Mean OSS and DASH at follow up were 24.8 (S.D 11.6) and 28.0 (S.D 26.9) respectively. Worse scores were seen in those patients who had complications (OSS 39.4 Vs 22.6, DASH 58.2 Vs 23.4) although this difference was not statistically significant. There was also a trend for poorer scores with increasing fracture complexity and better scores in those patients operated upon by surgeons with a specific interest in the upper limb and in patients whose surgeon had performed more than 5 fixations.

Conclusion: Our series reports a much higher complication rate (20%) than that previously published. Whilst those patients who do not suffer complications reported good functional outcomes the presence of postoperative complications was associated with poorer results. Outcomes following surgery were affected by patient, implant and surgeon related factors. Given the high rate of serious complications and their detrimental affect on outcome surgeons should give serious consideration to the appropriateness of using such implants. To clarify these issues, further prospective randomised trials are needed.

Background: In recent years an increased trend in MRSA infection has been seen in hospitals and the community, with colonisation rates of between 4 – 17% reported in these patient groups. There is also an association between carriage of Staph. Aureus and staphylococcal surgical wound infection.

In our institution there has been concern regarding MRSA surgical site infection and possible cross contamination of elective and emergency patients. There would be implications for implant related infections if this were to occur. This had prompted the unit to consider adopting a screening programme to identify and treat MRSA carriers. This would aim to minimise risk of post operative infection and cross infection. As little was actually known about the MRSA colonisation rates of admissions to our hospital we undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.

Aim: To ascertain the incidence of colonisation with MRSA, rate of wound infection and the associated risk factors in patients admitted to the trauma ward with a fractured neck of femur.

Method: A prospective, blinded case series of 100 consecutive patients admitted to the trauma ward with a fractured neck of femur. Three swabs (axilla, nasal and perineum) were taken within 24 hours of admission. Data from each patient was collected to ascertain the presence of risk factors linked to MRSA colonisation and each patient was followed until discharged to assess for surgical site infection.

Results: 304 swabs were taken from 100 patients. Age range 60–97. 26% admitted from institutionalised care and 74% admitted from their own home. Four patients were colonised with MRSA on admission (2 nasal, 2 perineal). An association was seen between patients colonised on admission and long term or recent residence in institutionalised care. One of these patients went on to develop colonisation of the surgical wound however this did not lead to surgical site infection and the patient was successfully treated with MRSA eradication therapy only. In these 4 patients all wounds healed satisfactorily with no evidence of infection.

There were three superficial surgical site infections postoperatively, all in individuals who were clear on their admission screening. Of these two were due to MRSA and one was due to MSSA. There were no cases of deep infection requiring further surgery.

Conclusion:While MRSA continues to be a growing concern we found that, in our hospital, rates of MRSA colonisation and subsequent infection were not high. There were no documented cases of MRSA wound infection in colonised individuals. Given the cost involved in swabbing all patients to detect these low levels of colonisation we do not feel that an expensive screening regimen would be cost effective or justified in our institution.

Introduction A retrospective analysis of aeromedical evacuation of casualties from OP TELIC contrasting the demand for evacuation and nature of injury during both war fighting and peace enforcement missions. The study was performed to address a perception of clinicians working within the operational theatre that service personnel outside of times of conflict were being evacuated with increasingly trivial or chronic injuries compared with those evacuated when war fighting was occurring.

Methods A comprehensive record of patients evacuated was retrospectively studied. Consecutive cases were classified by diagnosis. The period of study was 1^st March 2003 to 30^th June 2004.

Results In the sixteen month period a total of one thousand nine hundred and twenty four patients were evacuated by air to the United Kingdom. In the first three months (immediately before, during and post conflict) eight hundred and thirty patients were evacuated, an average of 280 per month. Of these, 2.8% were as a result of battle. During the conflict phase, an average of 60 patients a month were evacuated due to a chronic orthopaedic condition. This is in contrast to an average of 10 a month in the post conflict phase. In the three months following the conflict (incorporating the Iraqi summer) four hundred and seventy one troops were evacuated - an average of 157 per month. Of these, heat illness accounted for 28%. In the following ten months 621 troops were evacuated, averaging 62 per month. During the post conflict period, Battle injuries accounted for 5.6% of those evacuated, which is double that seen during conflict. Chronic general surgery maintained a similar percentage of total sent home throughout both phases. Other specialities were more sporadic with no particular pattern other than a decrease in raw figures compared to the war fighting phase.

Conclusion This pattern of aeromedical evacuation in a modern major deployment illustrates the paucity of battle injury at the time of fighting in relation to non battle injury. It also highlights the impact of chronic injury on a deployed force, especially injury related to back pain. The study has shown that contrary to perception by the clinicians in theatre, there was no obvious increase in evacuation of troops as a result of chronic or minor injuries in the post conflict period. Heat illness clearly places an important predictable strain on this method of evacuation.

Introduction A prospective study of consecutive hand injuries treated at a British Field Hospital revealed a distinctive pattern of injury. This is a unique review of hand injuries in a recent military deployment.

Method Patients presenting to the field hospital with hand injuries over a two-month period were entered into a database.

The parameters studied included mechanism of injury, timing and nature of treatment and ultimate disposal. An anatomical comparison of pattern of injury with six months retrospective data and a literature search was performed.

Results Of nine hundred and thirty one patients attending the hospital in this period, fifty-three had injuries to the hand.

Only seven cases resulted from battle injuries. Of the remainder, thirty-three were work related and the 13 were due to sport.

Twenty-eight of the patients required a surgical procedure; the mean time to surgery was 1.7 hours.

Twelve patients were subsequently aero medically evacuated.

Conclusion Wounds of conflict account for a small proportion of hand injuries seen in the operational environment. The injury pattern seen reflects Daily Non-Battle Injury (DNBI) – the hazards encountered by deployed troops on a daily basis