Introduction

Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups.

Introduction

By utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs.

Introduction

Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture.

Introduction

A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction.

Our objective was to conduct a systematic review and meta-analysis, comparing differences in clinical outcomes between either autologous or synthetic bone grafts in the operative management of tibial plateau fractures: a traumatic pattern of injury, associated with poor long-term functional prognosis.

A structured search of MEDLINE, EMBASE, The Bone & Joint and CENTRAL databases from inception until 07/28/2021 was performed. Randomised, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture non-union or chondral defects were excluded. Outcome data was assessed using the Risk of Bias 2 (ROB2) framework and synthesised in random-effect meta-analysis. Preferred Reported Items for Systematic Review and Meta-Analysis guidance was followed throughout.

Six comparable studies involving 352 patients were identified from 3,078 records. Following ROB2 assessment, five studies (337 patients) were eligible for meta-analysis. Within these studies, more complex tibia plateau fracture patterns (Schatzker IV-VI) were predominant. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference −0.45mm, p=0.25, 95% confidence interval (95%CI): −1.21-0.31mm, I²=0%) and long-term (>6 months, standard mean difference −0.56, p=0.09, 95%CI: −1.20-0.08, I²=73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, defect site pain, occurrence of surgical site infections, secondary surgery, perioperative blood loss, and duration of surgery. Blood loss was lower (90.08ml, p<0.001, 95%CI: 41.49-138.67ml, I²=0%) and surgery was shorter (16.17minutes, p=0.04, 95%CI: 0.39-31.94minutes, I²=63%) in synthetic treatment groups. All other secondary measures were statistically comparable.

Our findings supersede previous literature, demonstrating that synthetic bone grafts are non-inferior to autologous bone grafts, despite their perceived disadvantages (e.g. being biologically inert). In conclusion, surgeons should consider synthetic bone grafts when optimising peri-operative patient morbidity, particularly in complex tibial plateau fractures, where this work is most applicable.

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

Abstract

Introduction

During its conception, Ilizarov advocated a fine wire tension of between 900N and 1200N for circular frame construction. Wire tension can be achieved via a tensioning device or ‘Russian tensioning’ (a fixed wire lengthening around a bolt). There is limited information on the latter technique. This study aimed to explore the tensions achieved via Russian tensioning and report the impact of a second wire on construct tension.

Introduction

Circular frame fixation has become a cornerstone of non-union and deformity management since its inception in the 1950s. As a consequence of modularity and heterogenous patient and injury factors, the prediction of the mechanobiological environment within a defect is subject to wide variations in practice. Given these wide range of confounding variables, clinical and cadaveric experimentation is close to impossible and frame constructs are based upon clinician experience. The Finite Element Analysis (FEA) method provides a powerful tool to numerically analyse mechanics. This work aims to develop an FEA model of a tibial defect and predict the mechanical response within the construct.

The aim of this study was to identify the effect of COVID-19 lockdown on the rates, types, mechanisms and mortality of musculoskeletal trauma across Scotland.

Data for all musculoskeletal trauma requiring operative treatment was collected prospectively from five orthopaedic units across Scotland during the initial lockdown period (23/03/2020-28/05/2020). This was compared with data for the same timeframe in 2018 and 2019. Data collected included all cases requiring surgery, injury type, mechanism of injury, and inpatient mortality.

1315 patients received operative treatment in 2020 compared to 1791 in 2019 and 1719 in 2018. The numbers of all injury types decreased, but the relative frequency of hip fractures increased(36.3% 2020 vs 30.2% 2019, p<0.0001 & 30.7% 2018, p<0.0001). Significant increases were seen in proportion of DIY-related injuries(3.1% 2020 vs 1.7% 2019, p=0.01 & 1.6% 2018, p<0.01) and injuries caused by falls(65.6% 2020 vs 62.6% 2019, p=0.08 & 61.9% 2018, p=0.05). Significant decreases were seen in proportion of RTCs(2.6% 2020 vs 5.4% 2019, p<0.0001 & 4.2% 2018, p=0.02) and occupational injuries(1.8% 2020 vs 3.0% 2019, p=0.03 & 2.3% 2018, p=0.01). A significant increase in proportion of self-harm injuries was seen(1.7% 2020 vs 1.1% 2019, p=0.19 & 0.5% 2018, p<0.0001). Mortality of trauma patients was significantly higher in 2020 (4.9%), than in 2019 (3.2%, p=0.02) and 2018 (2.6%, p<0.0001).

In conclusion, lockdown has resulted in a marked reduction of musculoskeletal trauma requiring surgery in Scotland. There have been major changes in types and mechanisms of injury, and mortality of trauma patients has risen significantly.

Gavril Ilizarov advocated a fine wire tension of between 900N and 1200N for circular frame construction. Wire tension can be achieved via a tensioning device or ‘Russian tensioning’ (a fixed wire lengthening around a bolt). There is limited information on the latter technique. This study explored the tensions achieved via Russian tensioning and reports the impact of a second wire on construct tension.

A single 160mm stainless-steel ring was constructed, then 1.8mm stainless steel wires were secured using a Russian fixation bolt and Russian tensioned with a 2nd bolt. The angle subtended by tensioning using the 2nd bolt was measured using a goniometer. Angles of 45°, 70° and 90° were repeated in triplicates, with wire tension measured using a calibrated tensiometer. A second, orthogonal wire was added and tensioned to the same angle. Tensions of both wires were remeasured and recorded. Unpaired t-tests were used to compare mean tensions. A value of p<0.05 was considered significant.

Tensioning at all angles was insufficient to achieve the target range of 900–1200N (range 99–110N). A second, orthogonal wire changed frame dynamics such that a 90° angle resulted in both wires achieving adequate tension (mean 1143N, SD 307N). Increases were significant across all tensioning angles (p=<0.002) however only biomechanically relevant for 90°.

Russian tensioning is insufficient with a single wire, however the addition of an orthogonal wire increases tension in both wires, reaching the target range at 90° deflection. Further study using wire tensioners is warranted, and also the impact of non-orthogonal wire constructs.

Aims

The UK government declared a national lockdown on 23 March 2020 to reduce transmission of COVID-19. This study aims to identify the effect of lockdown on the rates, types, mechanisms, and mortality of musculoskeletal trauma across Scotland.

Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.

Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. Most studies are from the Far-Eastern population and have short follow-up. The purpose of this study was to report the 5 year clinical outcomes of a dorsal closing wedge osteotomy in the treatment of advanced Freiberg´s disease in a Caucasian population.

Twelve patients (12 feet), with a mean age of 30.7 years (range 17–55), were treated with a synovectomy and a dorsal closing wedge osteotomy of the affected distal metatarsal. There were 10 females and 2 males. All patients were born in the United Kingdom. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Nine (75%) feet involved the 2^nd metatarsal and 3 feet (25%) involved the 3^rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. Radiological union was evaluated postoperatively.

No patients were lost to follow up and the mean follow-up time was 5.2 years (4–7). AOFAS scores improved from 48.1 +/− 7.4 to 88.9 +/− 10.1 postoperatively (p< 0.001) giving a mean improvement of 40.8. 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics.

A dorsal closing wedge osteotomy is an effective treatment of advanced Freiberg´s disease in a Caucasian population, with good outcomes and few complications.

Three distal femoral axes have been described to aid in alignment of the femoral component; the Trans Epicondylar Axis (TEA), the Posterior Condylar Axis (PCA) and the Antero Posterior (AP) axis. Our aim was to identify if there was a reproducible relationship between the axes which would aid alignment of the femoral component. This is the first study compare all three distal femoral axes with each other using magnetic resonance imaging (MRI) in a Caucasian population. Our sample group represents real life patients awaiting total knee arthroplasty (TKA), as opposed non-arthritic or cadaveric knees.

We identified the relationship between these rotational axes by performing MRI scans on 89 patients awaiting TKA with patient-specific instrumentation. Measurements were taken by two observers.

Patients had a mean age of 62.5 years (range 32–91). 51 patients were female. The mean angle between the TEA and the AP axis was 92.78° with a standard deviation of 2.51° (range 88° – 99°). The mean angle between the AP axis and the PCA was 95.43° with a standard deviation of 2.75° (range 85° – 105°). The mean angle between the TEA and the PCA was 2.78° with a standard deviation of 1.91° (range 0° – 10°).

We conclude that while there is a reproducible relationship between the differing femoral axes, there is a significant range in the relationship between the femoral axes. This range may lead to greater inaccuracy than has previously been appreciated when defining the rotation of the femoral component. There is most variation between the PCA and the AP axis. The TEA's relationship with the PCA and AP appears important in defining rotation. Due to the well accepted difficulty in defining the TEA intra-operatively, there may be a role for patient-specific instrumentation in TKA surgery with pre-operative MRI.

Calcaneal fracture fixation over the past decade has been practised via an extensile lateral incision. This can be complicated by infection and wound breakdown.

We have developed a new technique for fixation of the calcaneal fractures – MACO. We utilise a 4 cm sub fibular incision to aid joint visualisation and fracture reduction. Fixation is via percutaneous screws.

We analysed our prospectively collected database. 26 fractures were fixed over an 18 month period at Glasgow Royal Infirmary by three consultant surgeons. 22 patients were male and half were smokers. Mean follow up was 5 months (range 1.5 – 18 months).

The mean age of our patients is 41 (range 25–68). The mean pre operative Bohler's angle was 16.7 degrees. Gissane's angle was similarly abnormal with a mean of 129 degrees.

The average duration of surgery was 73 minutes (range 45–100 minutes). Post operatively, Bohler's angle was improved. The mean was 29 degrees. There was no significant difference with Gissane's angle. The mean was 128 degrees.

There were no superficial wound infections. One patient was troubled by wound breakdown with subsequent deep infection. There was no need for metalwork removal in our series of patients. Two patients developed post traumatic osteoarthritis of the sub talar joint. Only one has required sub talar joint fusion.

We conclude that the novel technique which we describe is successful in restoring calcaneal anatomy with few complications. Further follow up is needed to determine the long term outcomes of such surgery.

Three distal femoral axes have been described to aid in alignment of the femoral component; the Trans Epicondylar Axis (TEA), the Posterior Condylar Axis (PCA) and the Antero Posterior (AP) axis. Our aim was to identify if there was a reproducible relationship between the axes. Hopefully this will aid the surgeon to more accurately judge the rotation of the femoral cutting block by using the axes with the least variation. This is the first study compare all three distal femoral axes with each other using magnetic resonance imaging (MRI) in a Caucasian population awaiting total knee arthroplasty (TKA).

We identified the relationship between these axes by performing MRI scans on 89 patients awaiting TKA with patient-specific instrumentation. Measurements were taken by two observers.

Patients had a mean age of 62.5 years (range 32–91). 51 patients were female. The mean angle between the TEA and AP axis was 92.78°, standard deviation (SD) 2.51° (range 88°–99°). The mean angle between the AP axis and PCA was 95.43°, SD 2.75° (range 85°–105°). The mean angle between the TEA and PCA was 2.78°, SD 1.91° (range 0°–10°).

We conclude that while there is a reproducible relationship between the differing femoral axes, there is a significant range in the relationship between the femoral axes. This range may lead to greater inaccuracy than has previously been appreciated when defining the rotation of the femoral component. There is most variation between the PCA and the AP axis. Most systems have a cutting block with 3° of external rotation from the PCA and this would be parallel to the TEA in the majority, but not all, cases in this series. This data suggests that if the surgeon is to pick two axes to reference from, one should include the TEA.

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described.

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint.

The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm.

There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion.

This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty.

Knee osteoarthritis is common, disabling and can be effectively treated by total knee arthroplasty (TKA). In North America, consideration has been given to the varying outcomes amongst racial groups. However, scant attention has been paid to the outcomes of surgery in different racial groups found in the United Kingdom (UK). We investigated the results of surgery in one of the principal ethnic minorities in the UK; that of a south Asian population.

We retrospectively analysed our prospectively collected database at the Southern General Hospital, Glasgow. We identified 39 Asian patients who had TKA. They were age and sex matched to a Caucasian group. Mean follow up was 40.3 months.

Mean pre-operative oxford knee scores were poorer than in the Caucasian group (8.5 vs. 14.7, p=0.001.) Post operative oxford knee scores were similarly poorer in the Asian group (29.9 vs. 36.1, p=0.07.) Interestingly, the change in oxford knee scores was similar in both groups.

SF-12 and WOMAC scores demonstrated poorer pre and post operative scores in the Asian group. Knee flexion was greater in the Asian group, however (107.5° vs. 106.2°, p=0.742.)

We conclude that while patients of Asian origin have poorer post operative pain and function following TKA, they have a similar gain from surgery as do a Caucasian group and therefore surgery is effective intervention in this group. An important topic for further work is to identify why Asians present later in their arthritic disease process to healthcare professionals than do their Caucasian counterparts.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Introduction

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints.

Primary traumatic anterior dislocations of the shoulder are common injuries which are complicated by persistent instability in a high proportion of patients. Surgery is successful and has been well described in the literature. Current controversies centre on the role of open and arthroscopic techniques. We describe the outcomes of a new mini-incision surgical (MIS) technique which was developed within our institution.

27 patients with traumatic shoulder instability (2 bilateral) were prospectively entered into a database between June 1998 and March 2008. The mean age was 31 years and the mean follow up period was 53 months. 29 shoulders underwent diagnostic shoulder arthroscopy and mini-incision surgery using a delto-pectoral approach and 3 bio-absorbable anchors.

Patients reported no re-dislocation in 24 shoulders (83%). 5 shoulders, including one with a bony Bankart lesion, re-dislocated with additional trauma. One shoulder required revision to a Bristow-Latarjet. Satisfaction was very good in 16 and good in 9 shoulders (83%). 19 patients had minimal or no pain. 8 patients experienced moderate shoulder pain with the other two complaining of severe pain. QuickDASH scores were encouraging.

Our technique combines the ability to appreciate all shoulder pathology arthroscopically with the visualisation gained in open Bankart surgery. Functionally, patients do well. The higher than expected re-dislocation rate is concerning. We advise that long term outcomes are needed.

Upper limb lacerations are a common injury. Traditionally, these have been assessed and treated in the Emergency Department (ED). This has become increasingly rare. A number of different reasons have been postulated. These include the increasingly junior status of those that work within the ED and the 4 hour target within the ED. After referral to the orthopaedic department, these patients are often assessed by increasingly junior staff. Thus, when these patients are assessed by a sufficiently qualified practitioner, there exists no option but to take them to theatre for repair of their injury. The aim of our study was identify the number of patients requiring surgery for hand and wrist lacerations and identify if these patients could be managed without the need for theatre.

We collected data in a prospective fashion from 1/9/9 to 3/11/9 at a large district general hospital. Over this period, 36 patients required surgery for their hand or wrist laceration. 27 were male and 9 were female. The average age was 34 years. The average length of procedure from was 21 minutes. 32% of patients were admitted overnight.

In two thirds of cases, the operating surgeon felt the procedure could have been performed in a suture room rather than in theatre. Among those patients who could've been operated on within a suture room, 21 would not have required an admission for any other reason.

It seems likely that the number of referrals from the ED regarding patients with upper limb lacerations is not likely to decrease. It is, therefore, important to ensure that orthopaedic departments develop new ways of working to try and ensure that patients are treated in a prompt fashion. We believe that the addition of a suture room to the orthopaedic trauma room remains one possible way of achieving this.

Purpose: The young patient with hip arthritis remains one of the biggest challenges to arthroplasty surgeons. The difficulty of providing a long-lasting total hip arthroplasty (THA) has been clearly documented in the literature. The aim of this study was to assess the outcomes of uncemented THA’s performed in our unit in patients aged under 50.

Methods: In our unit information on all patients is recorded prospectively on an arthroplasty database. From this database we identified 273 uncemented THAs in 237 patients under the age of 50 performed in our unit between 1985 and 2000 with a minimum of 5 year follow up. Outcomes were assessed in terms of 10 and 15-year survival with revision for any reason as the endpoint. Hip scores at routine and most recent follow-up were also reviewed. All surviving implants were radiographically assessed for acetabular wear, component loosening and for the presence of osteolysis.

Results: The mean age of patients at the time of surgery was 41.1 years. 36 patients had bilateral THA. The overall 10 and 15 year survival was 88.7 ± 2.4% and 65.6 ± 4.8 % respectively. Femoral stem survival was significantly higher at 100 % and 98.4 ± 1.6% at 10 and 15 years. Acetabular component survival was 88.6 ± 2.5 % at 10 years and 65.9 ± 4.8 % at 15 years. In unrevised THA’s 56.9% had asymmetric polyethylene wear > 2mm. 2% had definite evidence of acetabular loosening. 25.5% had radiographic evidence of femoral cortical hypertrophy or spot-welds. The mean HHS pre–operatively, at 5 and 10-year follow-up was 46.4 ± 13, 90.7 ± 12.2 and 87.9 ± 14.7 respectively.

Conclusions: Uncemented THA is effective even in young active patients. The main challenges remain ace-tabular polyethylene wear and loosening. Femoral uncemented stems provide long-term functional fixation. Contemporary bearing surfaces in association with such stems may provide long lasting THA’s even in young active patients.