Aims

Distal radial fractures are the most common fracture sustained by the adult population. Most can be treated using cast immobilization without the need for surgery. The aim of this study was to assess the feasibility of a definitive trial comparing the commonly used fibreglass cast immobilization with an alternative product called Woodcast. Woodcast is a biodegradable casting material with theoretical benefits in terms of patient comfort as well as benefits to the environment.

Aims

Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture.

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

This work aims to quantitatively assess the current opinions of foot and ankle surgery provision by podiatric surgeons within the UK. Three groups were targeted by postal questionnaire; Orthopaedic surgeons with membership to BOFAS, Orthopaedic surgeons not affiliated to the specialist foot and ankle society and surgical Podiatrists. In addition we aim to identify areas of conflict and suggestions for future integration.

A postal questionnaire was sent to all Fellows of the Faculty of Podiatric Surgery, College of Podiatrists (136), members of the British Orthopaedic Foot and Ankle Society, (156), and a randomly selected number of Fellows of the British Orthopaedic Association, who are not members of BOFAS (250).

We have received replies from 99 (73%) of the Podiatric Surgical group, 77 (49%) of the Orthopaedic Foot and Ankle surgeons and 66 (26%) from non-Foot and Ankle Orthopaedic Surgeons.

Respondents were asked to detail their present practice and issues that they considered to restrict closer working between Orthopaedic Surgeons and Podiatric surgeons. Additionally, each surgeon was given a range of surgical procedures and asked to identify the most appropriate surgical profession to undertake the procedure.

The good response rate amongst Foot and Ankle Practitioners (both Podiatric and Orthopaedic) reflects the interest in these issues compared to Orthopaedic Surgeons from other sub-specialties. Poor understanding of Podiatric surgical training, impact on private practice and medical protectionism were areas identified by podiatric respondents. Conflicts over job-title, concerns over training, role boundaries and responsibilities were identified by Orthopaedic respondents as being significant restrictors to further integration.

The paper will present the full results of the survey and discuss the suitability and feasibility of closer working practices between Orthopaedic and Podiatric surgeons.

Introduction: Lesser toe deformities which require surgery are often treated using a technique of interphalyngeal joint fusion. This procedure is an effective way of reducing the deformity and pain associated with lesser toe deformity but necessitates internal fixation until fusion is achieved. The Kirschner wire used to provide peri-operative stability is undesirable for a number of reasons, most importantly, the risk of interosseous infection and the lack of patient satisfaction due to the need for a second procedure for the wires removal. The ‘Oxford’ procedure was developed by the senior author (PHC) both in an attempt to remove the need for Kischner wire fixation and to maintain some mobility at the interphalyngeal joint.

Patients and methods: Between January and October 1994, 14 patients underwent ‘Oxford’ procedures on isolated lesser toe deformities. Their mean age was 59 at the time of surgery (range 26 – 79, 3 male and 11 female). Each patient was reviewed in November 1995 and an assessment was made of their post-operative pain levels, function, footwear, cosmetic appearance, time to return to work and any complications they had experienced. In March 2005 (ie: at least 10 years postop) an attempt was made to review these patients and make assessments of their pain in the operated toe, any subsequent surgery in that, or other toes, and the stability of the toe. In addition, an assessment was made of the patients view of the cosmetic outcome and their satisfaction levels. 12 patients were successfully contacted and reviewed.

Results: All 12 patients were satisfied with their long term results in terms of pain relief and cosmesis.

Conclusion: The ‘Oxford’ proceedure for lesser toe deformities has good long term clinical results and avoids k-wire fixation.

Aim of Study: Assess clinical outcome and function of planned marginal excision of low grade liposarcoma of the forearm.

Material and Methods: Between 1997 and 2005 15 of 27 soft tissue sarcomas of the forearm were liposarcoma.

13 presented in the extensor compartment and 2 flexor compartment at the level of the distal radius. All presented with a painless mass. 5 patients with neurological symptoms. 4 involving the post interosseus nerve and 1 radial nerve. MRI was the diagnostic imaging technique of choice, 2 had biopsies where there was atypical imaging features.

Treatment and Results: All treated by planned marginal excision in view of proximity of neurovascular structures. The majority of tumours of the extensor compartment of the forearm were either involving or abutting the post interosseus nerve or neurovascular conduit.

All underwent planned marginal excision preserving juxtaposed peripheral nerve. There were no radial, spiral or PIN nerve palsies. One patient presented with PIN palsy had partial resolution of symptoms and function. I wound infection

Conclusion: Low grade lipoma-like liposarcomas have low metastatic potential. In the forearm a wide margin would mean ablation of critical neurological structures and planned marginal excision results in good function and to date no evidence of local recurrence at 2–9 year follow up.

Introduction: Previous reports have highlighted the impact of emergent crazes such as in-line skating and micro-scooters, with attention being drawn to potential accident prevention and emergent injury patterns.

A modern craze is the Harry Potter series of books. UK sales of the latest book, The Half-Blood Prince, are estimated to reach 4 million. Given the lack of horizontal velocity, height, wheels or sharp edges we were interested to investigate the impact the books had on children’s traumatic injuries.

Methods & Materials: A retrospective review was undertaken of Children aged 7 to 15 attending the Emergency Department of our Level 1 trauma unit over the summer months of a 3 year period.

The launch dates of the most recent two books (Order of the Phoenix and The Half-Blood prince) were identified and the admissions for these weekends were compared to surrounding summer weekends and those dates in previous years.

Data were obtained from MetOffice (www.metoffice.gov.uk) to establish weather conditions recorded for each of the identified weekends. This would enable us to adjust for this as a confounding variable if necessary.

Results: The mean attendance for children aged 7 to 15 years for this period was 65.1 (median 66, standard deviation 13.289, standard error 2.771). For the two intervention weekends the attendance rate was 36 and 37. This represents a significant decrease in emergency department attendances on those weekends (p < 0.05).

MetOffice data suggested no confounding effect of weather.

Discussion & Conclusion: Harry Potter books appear to protect children from traumatic injuries. The Royal Society for the Prevention of Accidents (rospa.org.uk) is dedicated to the identification and prevention of high risk childhood activities and produce guidelines on keeping children safe. To date no research has addressed the option of ‘distraction therapy’ to prevent injuries.

Purpose: To assess the functional outcome of patients who pre-operatively, were known to have sciatic nerve tumour involvement and proceeded to have nerve-preserving planned marginal excision with epineurectomy.

Methods: We identified patients who had surgery between 1997 and 2004, for soft tissue sarcomas in the posterior thigh with known sciatic nerve involvement. During this period it was the practice of the senior authors (MG & HG) to apply a nerve-preserving epineurectomy approach as part of their planned marginal excision of these tumours.

The identified patients had their notes reviewed, and were contacted by post to complete a Toronto Extremity Severity Score (TESS) questionnaire to assess lower limb function in day-to-day life. Details of their presenting features, oncological work-up, surgical intervention and adjuvant therapy was established and correlated to the TESS score.

Conclusion: This study demonstrates that a careful epineurectomy can preserve sciatic nerve function and allow tumour excision with no increase in local recurrence rate. With good soft tissue cover it appears nerve function can be maintained, even in cases where adjuvant radiotherapy is indicated.

Aim: To assess the functional outcomes for patients treated by limb salvage surgery for sarcomas of the upper limb and shoulder girdle.

Materials and methods: Patients who had undergone limb salvage surgery for upper limb sarcoma between 1997 and 2004 were entered into the study. The operation notes were used to obtain details of the surgery. Pathology reports were consulted to identify the type, grade and margins of the tumour. The Toronto Extremity Salvage Score (TESS) questionnaire was used to assess post-operative function, in a postal survey.

Results: A total of 62 patients were identified. Liposarcoma was most common histological diagnosis, and “low” the most common grade (27). Histologically clear margins were achieved in 28 (44%) cases, marginal in 2 (3%), incomplete in 13 (21%) and indeterminate in 20 (32%). 30% had received adjuvant radiotherapy with or without chemotherapy as indicated. A total of 48 (76%) had been treated with excision and primary closure, 7 (11%) with local flaps, and 4 (6%) with endoprostheses. 10 patients had died, and 1 was untraceable. 29 completed TESS questionnaires were returned; with an average follow-up of 33 months post-resection (range 4 to 83). 11 female (38%), 18 male (62%), with an average age at surgery of 55. The average TESS score was 77 +/−10 with a range of 18–100. For the different regions, forearm sarcomas had an average TESS of 81 +/−17, upper arm 76 +/−19 and shoulder 81 +/−14.

Discussion: Surgical excision of soft tissue tumours with limb salvage aims to balance morbidity and mortality. Upper limb amputation has greater morbidity than lower limb and thus the argument for limb salvage should be stronger. A limb-salvage procedure should be considered preferable to amputation provided oncological outcomes are not compromised, and the resulting functional outcome is worth the oncological risk. In this cohort, patients had good functional outcomes, as described by the TESS functional assessment score, with no evidence of compromised oncological outcome during the follow up period.

Introduction: Recent evidence from the Swedish Lumbar Spine Group has confirmed the anecdotal opinions of many spinal surgeons that fusion for persistent back pain can be a very effective treatment. However, it is clear that many more variables operate in determining clinical success than just radiological evidence of solid fusion. The very careful selection of patients for low back surgery is, in the opinion of the authors, the most important predictor of success. This paper addresses this issue and presents data to show why clinical failure can coexist with radiological success.

Methods: Between October 1997 and January 2001, 3600 spinal fusion using Diapason pedicle screw instrumentation and Brantigan anterior interbody fusion cages was performed on 25 patients. During this period 5,850 new outpatients with back pain were assessed in the low back clinic. Patients were selected by the following criteria: Low back pain of two years or more duration; Pain resistant to all non-operative and minimally invasive treatments; Normal psychosocial profile; Normal body mass index; Non-Smokers; Single or two level disease on MRI proven to be painful by provocative discography; No current insurance or workers-compensation claims. Postal follow-up was at a minimum of 2 years post-surgery (mean 47 months) using the Low Back Outcome Score (LBOS) and x-rays taken at the two-year clinic follow-up were independently assessed to determine fusion.

Results: 24 patients returned the questionnaire (96%). Only 20 (83%) patients had ‘good’ or ‘excellent’ results, as defined by the LBOS. However, 92% of patients stated that they would opt to have a circumferential fusion again, if guaranteed the same post-operative result. The same number of patients stated they would recommend the treatment to friend or family member. Analysis of the post-operative radiographs revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in all 25 cases.

Conclusions: Our opinion that patient selection is the most important predictor of satisfactory outcome in spinal surgery is demonstrated in this study by the mismatch between the clinical and radiological results. We have identified the causes of clinical failure in this group of patients as: Multiple sites of musculoskeletal pain confounding the LBOS; Neuropathic leg pain that cannot respond to surgical treatment; More than two previous spinal operations; Excessive pre-operative disability and functional loss that confounds the LBOS; Poor psychosocial profile.

Stringent application of rigid selection criteria might improve outcomes in lumbar spinal fusion so that clinical and radiological results correlate more closely. However, even with adherence to such rigid criteria, the outcome tool (LBOS) may be confounded and a more holistic assessment of outcome, including a more sensitive subjective assessment of satisfaction, might be a better measure.

Introduction: The initial promise of stand-alone threaded anterior interbody fusion cages to treat chronic low back pain has not been maintained. In an attempt to overcome some of the problems associated with threaded fusion devices (endplate subsidence, failure to re-establish lordosis and displacement) a two-part ALIF cage was devised. The device consists of a rectangular frame that accommodates a threaded, open-weave cylinder holding bone graft material. The device addresses the biomechanical issues required for successful ALIF whilst providing a large area for bone in-growth and is a less invasive solution than a formal 3600 fusion.

Methods: From August 2001 to December 2002, 41 patients who fulfilled selection criteria for a single or two-level 3600 spinal fusion for low back and leg symptoms underwent ALIF using Stabilis. All patients had failed to improve with all non-invasive and minimally invasive treatments available to them. Prospective follow-up has continued for all cases using the Low Back Outcome Score and a Patient Satisfaction Score. Plain x-rays were taken at 3, 6 and 12 months post-operatively and the 12-month series included flexion and extension films.

Results: Ten patients (24.4%) have completed more than 12 months follow-up; 18 (43.9%) are between six and twelve months post surgery and the rest (31.7%) have less than six months follow-up. LBOS results for the first 10 showed 9 (90%) as excellent or good. LBOS results for the second group of 18 were excellent or good in 15 (83.3%). All but two of the 28 patients, would be prepared to undergo the procedure again and all would recommend the operation to a friend with similar trouble. Radiographic assessment at 6 months showed 16 patients had at least a partial anterior or posterior sentinel sign. Using motion criteria, all 10 cases at one year were fused on flexion and extension lateral x-rays. No devices migrated anteriorly or posteriorly and no lucent lines have been seen around the implants. Three of the two-level procedures showed some subsidence of the L4/5 implant into the L5 vertebral body, but none were symptomatic. No clear reasons have emerged to explain the clinical failure of 14% of the patients given the radiological success. In only one was there a mismatch in the LBOS outcome measure and the satisfaction rating.

Conclusions: Stabilis is a useful standalone ALIF device that not only addresses the theoretical biomechanical failures of anterior threaded interbody fusion cages, but has been shown in this early clinical and radiological evaluation to be effective, objectively and subjectively. It is likely that in the medium term future, fewer patients will require fusion to treat back and leg pain as the results from lumbar spine arthroplasty become established and non-fusion technologies become accepted. Until that time, experience in the UK and USA suggests that Stabilis is a good alternative to 3600 fusion.

INTRODUCTION: The initial promise of stand-alone threaded anterior interbody fusion cages to treat chronic low back pain has not been maintained. In an attempt to overcome some of the problems associated with threaded fusion devices (endplate subsidence, failure to re-establish lordosis and displacement) a two-part ALIF cage was devised. The device consists of a rectangular frame that accommodates a threaded, open-weave cylinder holding bone graft material. The device addresses the biomechanical issues required for successful ALIF whilst providing a large area for bone in-growth and is a less invasive solution than a formal 360° fusion.

METHODS: From August 2001 to December 2002, 41 patients who fulfilled selection criteria for a single or two-level 360° spinal fusion for low back and leg symptoms underwent ALIF using Stabilis. All patients had failed to improve with all non-invasive and minimally invasive treatments available to them. Prospective follow-up has continued for all cases using the Low Back Outcome Score and a Patient Satisfaction Score. Plain X-rays were taken at three, six and 12 months post-operatively and the 12-month series included flexion and extension films.

RESULTS: Ten patients (24.4%) have completed more than 12 months follow-up; 18 (43.9%) are between six and twelve months post surgery and the rest (31.7%) have less than six months follow-up. LBOS results for the first 10 showed nine (90%) as excellent or good. LBOS results for the second group of 18 were excellent or good in 15 (83.3%). All but two of the 28 patients, would be prepared to undergo the procedure again and all would recommend the operation to a friend with similar trouble. Radiographic assessment at six months showed 16 patients had at least a partial anterior or posterior sentinel sign. Using motion criteria, all 10 cases at one year were fused on flexion and extension lateral X-rays. No devices migrated anteriorly or posteriorly and no lucent lines have been seen around the implants. Three of the two-level procedures showed some subsidence of the L4/5 implant into the L5 vertebral body, but none was symptomatic. No clear reasons have emerged to explain the clinical failure of 14% of the patients given the radiological success. In only one was there a mismatch in the LBOS outcome measure and the satisfaction rating.

CONCLUSIONS: Stabilis is a useful stand-alone ALIF device that not only addresses the theoretical biomechanical failures of anterior threaded interbody fusion cages, but has been shown in this early clinical and radiological evaluation to be effective, objectively and subjectively. It is likely that in the medium term future, fewer patients will require fusion to treat back and leg pain as the results from lumbar spine arthroplasty become established and non-fusion technologies become accepted. Until that time, experience in the UK and USA suggests that Stabilis is a good alternative to 360° fusion.

INTRODUCTION: Recent evidence from the Swedish Lumbar Spine Group has confirmed the anecdotal opinions of many spinal surgeons that fusion for persistent back pain can be a very effective treatment. However, it is clear that many more variables operate in determining clinical success than just radiological evidence of solid fusion. The very careful selection of patients for low back surgery is, in the opinion of the authors, the most important predictor of success. This paper addresses this issue and presents data to show why clinical failure can coexist with radiological success.

METHODS: Between October 1997 and January 2001, 360° spinal fusion using Diapason pedicle screw instrumentation and Brantigan anterior interbody fusion cages was performed on 25 patients. During this period 5,850 new outpatients with back pain were assessed in the low back clinic. Patients were selected by the following criteria: Low back pain of two years or more duration; Pain resistant to all non-operative and minimally invasive treatments; Normal psycho-social profile; Normal body mass index; Non-Smokers; Single or two level disease on MRI proven to be painful by provocative discography; No current insurance or workers-compensation claims. Postal follow-up was at a minimum of two years post-surgery (mean 47 months) using the Low Back Outcome Score (LBOS) and X-rays taken at the two-year clinic follow-up were independently assessed to determine fusion.

RESULTS: 24 patients returned the questionnaire (96%). Only 20 (83%) patients had ‘good’ or ‘excellent’ results, as defined by the LBOS. However, 92% of patients stated that they would opt to have a circumferential fusion again, if guaranteed the same post-operative result. The same number of patients stated they would recommend the treatment to friend or family member. Analysis of the post-operative radiographs revealed that spinal fusion (as defined by the Brantigan and Steffee criteria) was present in all 25 cases.

CONCLUSIONS: Our opinion that patient selection is the most important predictor of satisfactory outcome in spinal surgery is demonstrated in this study by the mismatch between the clinical and radiological results. We have identified the causes of clinical failure in this group of patients as: Multiple sites of musculo-skeletal pain confounding the LBOS; Neuropathic leg pain that cannot respond to surgical treatment; More than two previous spinal operations; Excessive pre-operative disability and functional loss that confounds the LBOS; Poor psychosocial profile. Stringent application of rigid selection criteria might improve outcomes in lumbar spinal fusion so that clinical and radiological results correlate more closely. However, even with adherence to such rigid criteria, the outcome tool (LBOS) may be confounded and a more holistic assessment of outcome, including a more sensitive subjective assessment of satisfaction, might be a better measure.