The incidence of hip fractures in the elderly is increasing. Minimally displaced and un-displaced hip fractures can be treated with either internal fixation or hemiarthroplasty. The aim was identifying the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method.

A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study.

1273 patients were included of which 26.2% (n=334) had cannulated hip fixation (CHF), 19.4% (n=247) had a dynamic hip screw (DHS) and 54.7% (n=692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n=23) vs. 33.3% (n=3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively.

Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. When considering a fixation method in such patients, DHS is more robust than a screw construct, followed by hemiarthroplasty.

Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health.

An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons.

The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001).

Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons.

The ‘Best Practice Tariff‘ (BPT) was developed to improve hip fracture care by incentivising hospitals to provide timely multidisciplinary care to patients sustaining these injuries. The current literature examining the association between BPT and patient outcomes is conflicting and underpowered. We aimed to determine if achieving BPT has an impact on 30-day mortality and postoperative length of stay.

A retrospective analysis for patients admitted to a major trauma centre (MTC) was performed between 01/01/2013 to 31/12/2020. Data were extracted from the National Hip Fracture Database. The study population was divided into two groups: those who achieved all BPT criteria (BPT-passed) and those who did not (BPT-failed). The primary outcomes of interest included the 30-day mortality rate and postoperative length of stay (LOS). As a secondary objective, we aimed to assess factors that predict perioperative mortality by utilising a logistic regression model.

4397 cases were included for analysis. 3422 (78%) met the BPT criteria, whereas 973 (22%) did not. The mean LOS in the BPT-achieving group was 17.2 days compared with 18.6 in the BPT-failed group, p<0.001. 30-day mortality was significantly lower in the BPT-achieving group i.e., 4.3% in BPT-achieved vs. 12.1% in BPT-failed, p<0.001. Logistic regression modelling demonstrated that attainment of BPT was associated with significantly lower 30-day mortality (OR: 0.32; 95% CI:0.24–0.41; p<0.001).

To our knowledge, this is the largest study to investigate the association between BPT attainment and 30-day mortality as well as the length of stay. The present study demonstrates that achieving BPT in hip fracture patients is associated with a significant reduction in the average length of stay and 30-day mortality rates. Our crude calculations revealed that achieving BPT for 3422 patients earned our hospital trust >£4 million over 8 years. Findings from this study suggest that achieving BPT not only improves 30-day survival in patients with hip fractures but also aids cost-effectiveness by reducing LOS and helps generate NHS Trusts a significant amount of financial reward.

Introduction and Objective

Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation.

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective.

Cite this article: Bone Jt Open 2021;2-10:893–899.

Abstract

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Introduction

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and major amputation. The treatment of these patients is controversial. Internal stabilization and/or external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective major amputation. However, we report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

Objectives

to evaluate effect of a dedicated ward for patients with fractured neck of femur on length of acute bed stay and 30 days mortality rate.

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration.

All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction.

Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases.

Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy.

In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration.

Massive segmental bone defects in long bones remain a considerable clinical challenge and are a source for significant morbidity and prolonged dysfunction for the patient. We demonstrate the successful use of resorbable polylactide membranes as a scaffold for autologous bone graft in the treatment of a 10cm traumatic femoral bone defect.

A 28-year-old male was involved in a motorcycle accident vs. tree at 140k/hr. He sustained a Gustillo grade 3b intercondylar fracture of his right femur, and a 10cm piece of his femoral bone found at the scene was brought to Emergency in a sterile container. He was taken to theatre for debridement and ORIF of the intercondylar fracture, with vacuum dressing cover. Day 5 post injury the patient returned to theatre and the LISS plate was revised to correct the rotation and 3cm shortening. The 10cm cortical defect now present was filled with antibiotic cement (Palacos) and delayed primary closure was performed.

Day 21 post injury the cement spacer was removed and replaced with two polylactide membrane tubes, one within the medullary canal and the other around the outside of the bone. The “neocortical” space thus produced was grafted with cancellous autograft mixed with bone morphogenic protein (OP1, Stryker). The remainder of the post-operative course was uncomplicated and the patient was discharged home 5 days later.

The patient was reviewed at the 6 week and 3 month mark post injury. The femoral defect demonstrated both radiological and clinical union at the 3 month mark and full weight bearing was permitted. His range of motion at that stage was 5 to 95 degrees with no sign of infection.

The use of polylactide membranes as a scaffold in the treatment of segmental long bone defects is an excellent and relatively straightforward technique. Forming a space between the 2 tubes controls cancellous graft to the site of the cortical area where it is required and the polylactide membrane then resorbs over years producing CO2 and water. This case demonstrates that the use of polylactide membranes is safe and effective in the management of segmental long bone defects.

Healthcare interventions are under increasing scrutiny regarding cost-effectiveness and outcome measures have revolutionised clinical research.

To identify all available outcome questionnaires designed for lowback, lumbar spine pathologies and to perform qualitative analysis of these questionnaires for their clinimetric properties.

A comprehensive e-search on PUBMED & EMBASE for all available outcome measures and published review articles for lowback and lumbar spine pathologies was undertaken over a two month period (Nov-Dec 2009). Twenty-eight questionnaires were identified in total. These outcomes questionnaires were evaluated for clinimetric properties viz:-

Validity (content, construct & criterion validity)

Reliability (internal consistency & reproducibility)

Responsiveness and scored on a scale of 0-6 points.

Eight outcomes questionnaires had satisfied all clinimetric domains in methodological evaluation (score 6/6).

Oswestry disability index (ODI)

Roland-Morris disability questionnaire (RMDQ)

Aberdeen lowback pain scale

Extended Aberdeen spine pain scale

Functional rating index

Core lowback pain outcome measure

Backpain functional scale

Maine-Seattle back questionnaire.

Sixteen of these questionnaires scored =5 when evaluated for clinimetric domains. RMDQ had the highest number of published and validated translations followed by ODI. Criterion validity was not tested for NASS-AAOS lumbar spine questionnaire.

32%(9/28) of the outcome instruments have undergone methodological evaluation for =3 clinimetric properties. Clinicians should be cautious when choosing appropriate validated outcome measures when evaluating therapeutic/surgical intervention. We suggest use of few validated outcome measures with high clinimetric scores (=5/6) to be made mandatory when reporting clinical results.

We compared the early complication rates of total hip (THA) and total knee (TKA) arthroplasty carried out at a regional orthopaedic hospital (AOC) and two Independent Sector Treatment Units (ISTUs) (WGH and CNH). After THA, reoperation rates were higher at CNH (9%) than AOC (0.6%) or WGH (1.4%). After TKA, reoperation rates at CNH were (8%) higher than AOC (1%) and WGH (1.9%).

5% of patients undergoing TKR at CNH underwent 2 stage revision for deep infection.

After THA, dislocation rates at CNH (6%) were higher than AOC and WGH (1.8%). Readmission from CNH (13%) was higher than AOC (1.2%) and WGH (0.6%).

Major wound problems at CNH (20%) were higher than WGH (3.8%) and AOC (0.4%).

After TKA, major wound problems were higher at CNH (19%) compared to WGH (1.9%) and AOC (1.1%). Readmission rates not requiring surgery from CNH (13%) were higher than AOC. (1.1%) and WGH (1%). AOC and WGH audited their outcomes. None were available from CNH. WGH initially missed many of their complications because they presented at base hospitals elsewhere.

ISTUs performed approximately 2/3rds of procedures for which patients had been referred from base hospitals.

At CNH, 23% were rejected on grounds of potential co-morbidity. Audit from ISTUs is inferior to NHS hospitals and the results in one of those audited significantly worse.

Patients offered surgery at ISTUs should be told that the audited outcome of the surgeon who will be treating them is not known and that, in some, results are inferior to surgery in the NHS.

Introduction: Radial styloidectomy as procedure has gained recognition over the last 60 years since its initial description for scaphoid nonunions. It is a recognised procedure in the treatment of distal radioscaphoid joint arthritis on its own or as an adjunct to another carpal procedure. There has been a debate regarding the length of styloid osteotomy and the risk of instability due to the damage of volar ligaments.

Aim: We set out to evaluate the anatomical variation of the volar ligament attachments

Methods: We performed dissection of 22 wrists in 11 embalmed cadavers (7 females, 4 males). Using dorsal approach we dissected down to the wrist and then to the volar ligaments. Measurements were taken from the tip of the radial styloid to the insertion of the volar ligaments, using digital vernier callipers. Measurements were carried out by two assessors and intra-observer and inter-observer variations were not found to be significant.

Results: Average age was 86.8 years (range 81–94). The average length of the volar ligament was found to be 7.19mm (range 5.37–10.01). No significant side dependant variation in measure was found. Predictably volar ligament length in females was found slightly lower compared to males.

Conclusion: Based on a standard 3–4mm radial styloidectomy recommended we do not feel that there would be any compromise of the volar wrist ligaments.

The nervous system is known to be involved in inflammation and repair. We aimed to determine the effect of physical activity on the healing of a muscle injury and to examine the pattern of innervation. Using a drop-ball technique, a contusion was produced in the gastrocnemius in 20 rats. In ten the limb was immobilised in a plaster cast and the remaining ten had mobilisation on a running wheel. The muscle and the corresponding dorsal-root ganglia were studied by histological and immunohistochemical methods.

In the mobilisation group, there was a significant reduction in lymphocytes (p = 0.016), macrophages (p = 0.008) and myotubules (p = 0.008) between three and 21 days. The formation of myotubules and the density of nerve fibres was significantly higher (both p = 0.016) compared with those in the immobilisation group at three days, while the density of CGRP-positive fibres was significantly lower (p = 0.016) after 21 days.

Mobilisation after contusional injury to the muscle resulted in early and increased formation of myotubules, early nerve regeneration and progressive reduction in inflammation, suggesting that it promoted a better healing response.

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology. In RA, inflammation and pain are initial symptoms followed by bone and cartilage destruction. Proinflammatory cytokines play a significant role in the initiation and progress of inflammation and tissue destruction. Sensory neuropeptide substance P (SP) participates not only in nociception but also in pro-inflammatory processes by enhancing vasodilatation and recruitment of inflammatory cells. Ubiquitin proteasome system (UPS) activates a transcription factor, NF-κB which regulates the synthesis of proinflammatory mediators like cytokines; however its role in regulating pro inflammatory sensory neuropeptides is unknown. A number of proteasome inhibitors have been shown to down regulate the activity of NF-κB and hence reduce inflammation. In the present study, the effect of proteasome inhibitor (MG 132) on the severity of arthritis and pain was observed along with the expression of SP-positive nerve fibres in the ankle joint in a chronic inflammatory model of rat adjuvant arthritis.

Histology and mechanical pain tests showed a significant reduction in inflammation and pain in ankle joint by daily administration of proteasome inhibitor MG132 at the dose of 1mg/kg body weight compared to untreated groups. Radiographic analysis of ankle joints indicated a reduction in soft tissue swelling and joint destruction in the treatment group. A marked reduction in the NF-κB activity was observed by EMSA. Furthermore, proteasome inhibition resulted in the normalization of up regulated neuronal response occurred during inflammation by significantly reducing the expression of SP-positive fibres in the ankle joint as demonstrated by immunohistochemistry.

Our data provide the evidence that proteasome inhibitor MG132 can reduce severity of arthritis and reverse inflammatory pain behaviour by influencing the peripheral sensory nervous system. The drugs targeting UPS can be developed for treatment of chronic inflammatory joint disorders.

We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats.

Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats.

The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot.

Introduction: A number of clinical and experimental studies suggest that an intact nervous system is essential for normal fracture healing. In the present study, we analysed the occurrence of regenerating and mature nerve fibres over time in fracture callus. Using antibodies against neuronal proteins specific for nerve regeneration (growth associated protein – GAP-43) and nerve maturity (protein gene product – PGP 9.5) it is possible to demonstrate regeneration and end differentiation of nerves by immunohistochemistry.

Methods: Twelve male Sprague Dawley rats, weighing 230–290 g were used. The right tibias were fractured under HypnormÒ anaesthesia and fixed with a 17-G cannula needle in the medullary canal. The left un-fractured tibia served as an internal control. X-rays was used to monitor progress of fracture healing. Three rats were killed at 3 days, 1, 2 and 3 weeks post-fracture and right and left tibia were prepared for immunohistochemistry. The tissue sections (15 mm thick) were incubated with antiserum to GAP-43 and then with biotinylated antibodies. Cy2-conjugated avidin was used for the fluorescent staining. For double staining, after the staining with first antibody, the sections were incubated with avidin blocking solution followed by biotin blocking solution. Incubation with the second antiserum to PGP 9.5 was performed in the same manner as for the first peptide. For fluorescent staining of PGP 9.5, the sections were incubated with Cy3-conjugated avidin. A Nikon epifluorescence microscope was used for photog

Results: In the un-fractured tibia. PGP 9.5-positive nerve fibres were consistently identified in periosteum, muscles and connective tissues. A number of nerve fibres also expressed GAP-43, although there were no signs of nerve sprouting, i.e. regeneration. In the fractured tibia, many GAP-43-positive nerves were identified already at 3 days post-fracture in the hematoma and periosteum. At 1 week, abundant sprouting of these nerves was seen in cartilaginous callus and hyperplastic periosteum. A number of nerve terminals were observed very close to the chondroid cells in the fibrocartilage of the fracture gap. At 2 and 3 weeks, GAP 43-positive fibres gradually shifted from the fibrocartilage area towards the outlying hyperplastic periosteum. Double staining studies showed that an increased expression of GAP-43 as compared to PGP 9.5 occurred in the early period of fracture healing. This relationship changed at 3 weeks when enhanced PGP 9.5 and less GAP 43 expression was found.

Discussion: Our study suggests that there was an intense nerve regeneration in the early phase of fracture healing. Thus, a prominent expression of GAP-43 was seen in sprouting nerves in the hyperplastic periosteum and the callus fibrocartilage as early as 1 week post-fracture. This expression remained high in the fractures up to 3 weeks, when healing was essentially completed. Possibly, this persistent occurrence of GAP-43 is necessary for the ensuing ossification and bone remodeling. PGP 9.5 expression was markedly low at one week, but became pronounced at 3 weeks, probably reflecting functional maturation of the regenerated nerve in the healing fracture. It may prove that strong regenerative capability of nerves seen in the fractures is a prerequisite for normal fracture healing. Our results point to the possibility that regenerating nerves provide the delivery system for GAP-43 and other neuronal mediators required for normal callus formation and/or neovascularization.

We studied the presence of sensory nerves by immunohistochemistry in the interface membranes of hip prostheses after aseptic loosening. Substance P (SP), neurokinin A (NKA) and calcitonin gene-related peptide (CGRP) were analysed as was protein gene product (PGP) 9.5, a general marker for nerve fibres.

We identified nerve fibres in all samples but differences in their density were found. SP- and NKA-positive fibres were predominantly non-vascular, forming varicose nerve terminals. CGRP-immunoreactive nerve fibres with varicose terminals were seen mostly close to blood vessels, but also as free nerve endings.

Sensory neuropeptides participate not only in nociception but also stimulate immune cells to release cytokines. The presence of sensory nerves in the interface membrane may reflect a pathophysiological response contributing to the aseptic loosening of hip prostheses.