Aims

The aim of this study was to develop a core outcome set of what to measure in all future clinical research on hand fractures and joint injuries in adults.

Abstract

This study compares the cost-effectiveness of treating dorsally displaced distal radial fractures with a volar locking plate and percutaneous fixation. It was performed from the perspective of the National Health Service (NHS) using data from a single-centre randomised controlled trial. In total 130 patients (18 to 73 years of age) with a dorsally displaced distal radial fracture were randomised to treatment with either a volar locking plate (n = 66) or percutaneous fixation (n = 64). The methodology was according to National Institute for Health and Care Excellence guidance for technology appraisals. .

There were no significant differences in quality of life scores between groups at any time point in the study. Both groups returned to baseline one year post-operatively.

NHS costs for the plate group were significantly higher (p < 0.001, 95% confidence interval 497 to 930). For an additional £713, fixation with a volar locking plate offered 0.0178 additional quality-adjusted life years in the year after surgery. The incremental cost-effectiveness ratio (ICER) for plate fixation relative to percutaneous fixation at list price was £40 068. When adjusting the prices of the implants for a 20% hospital discount, the ICER was £31 898. Patients who underwent plate fixation did not return to work earlier.

We found no evidence to support the cost-effectiveness, from the perspective of the NHS, of fixation using a volar locking plate over percutaneous fixation for the operative treatment of a dorsally displaced radial fracture.

Cite this article: Bone Joint J 2015;97-B:1264–70.

Methods: We examined prospectively collected data from 6782 consecutive hip fractures to identify 327 fractures in female patients aged 65 years and younger. We report on demographic characteristics, treatment and outcome. We compare this group with a cohort of 4810 consecutive hip fractures in older females.

Results: Not surprisingly, younger women had higher levels of mobility and independence than their older counterparts. However, over 20% mobilised with aids, needed help with activities of daily living and/or had significant co-morbidity. A significantly higher proportion of younger patients were smokers. This had a strong influence on the relative risk of “early” as opposed to “late” fracture (Hazard Ratio 4.7, p< 0.01). Mortality was 0.7% at 30 days and 4.2% at one year.

We calculated age-related incidence of hip fracture in the local population and noted the first significant increase at the interval between 40–44 and 45–49, rather than the age of 50, which is when the onset of screening of hip fracture patients for osteoporosis occurs in most health areas. Lag screw fixation was the most common method of operative fixation. General complication rates were low, as were reoperation rates for cemented prostheses. Intracapsular fractures are an interesting subgroup. When displaced, 39% (61/158) had lag screw fixation and 61% (97/158) were treated by arthroplasty. Kaplan-Meier implant survivorship of displaced intra-capsular fractures treated by reduction and lag screw fixation was 82% at two and 71% at five years.

Conclusion: Hip fractures in females to 65 years of age are sustained by a population at risk as a result of patho-physiology. Treatment in this age group, particularly of intracapsular fractures, remains a topic of debate. Understanding the characteristics of these patients, may lead to an improved opportunity, if not for prevention, at least for intervention.

We examined prospectively collected data from 6782 consecutive hip fractures and identified 327 fractures in 315 women aged ≤65 years. We report on their demographic characteristics, treatment and outcome and compare them with a cohort of 4810 hip fractures in 4542 women aged > 65 years.

The first significant increase in age-related incidence of hip fracture was at 45, rather than 50, which is when screening by the osteoporosis service starts in most health areas. Hip fractures in younger women are sustained by a population at risk as a result of underlying disease. Mortality of younger women with hip fracture was 46 times the background mortality of the female population. Smoking had a strong influence on the relative risk of ‘early’ (≤ 65 years of age) fracture.

Lag screw fixation was the most common method of operative treatment. General complication rates were low, as were re-operation rates for cemented prostheses. Kaplan-Meier implant survivorship of displaced intracapsular fractures treated by reduction and lag screw fixation was 71% (95% confidence interval 56 to 81) at five years. The best form of treatment remains controversial.

This is a case series of 25 patients with Multiple Epiphyseal Dysplasia (MED), a genetically determined disorder characterised by abnormal ossification of multiple epiphyses. The Nottingham Skeletal Dysplasia Clinic has run since 1966. In 1994 it combined with the Clinical Genetics Service providing care to patients from throughout the region. We collected data on MED patients with follow up of 1 to 41 years (average 12 years) and described their presenting symptoms, genetic, clinical and radiographic features. We followed the natural history and vast array of treatments.

From the genetic point of view, 90% of patients counselled had typical AD-MED and 10% syndromic MED. Seven families opted to have testing. There were MATN3 mutations in 10% of the cohort, with marked intra-familial variability of phenotype. The average age at presentation was thirteen, with 80% of patients presenting before their sixteenth birthday. A third was seen because of a known family history of MED. Newly diagnosed index patients tended to present later. The most commonly affected joint at presentation was the hip and the most common knee deformity genu valgum. Symptoms progressed with time and joints not clinically affected at presentation became symptomatic later. Sixty percent of patients had further joint involvement within 10 years of diagnosis. Treatment ranged from orthotics to arthroplasty. Half of patients required surgical intervention at least once. Six patients underwent hip arthroplasty at an average age of 37.

MED is a rare diagnosis but has significant impact on the quality of life of those diagnosed, who require the support of a multidisciplinary team from an early age. This is not only to help manage symptoms and preserve function, but also to counsel on the progressive nature and the genetic aspects of the disorder.

Introduction: Few intermediate term studies have presented data on modern total ankle replacement designs. This independent, prospective study provides clinical and radiographic results for 50 Scandinavian Total Ankle Replacements with at least 5 years follow up.

Methods: 50 consecutive STAR total ankle replacements were performed in 46 patients, aged 33–79 (mean 63) between 1999 and 2002 by a single surgeon. These were prospectively followed up on annually for a mean of 6 years (5–8 years).

Results: 34 replacements were performed for osteoarthritis, the remainder for inflammatory arthropathy. 13 ankles had a preoperative varus or valgus deformity of more than 10 degrees. There were 3 deaths, therefore 47 ankles reviewed.

5 revisions were performed; 2 for stiffness (1 tibial component, 1 insert), 2 for stress fractures (tibial component only) and 1 insert fracture. 3 of these cases required further surgery following their first revision (1 fusion for deep infection, 1 insert exchange for edge loading and one arthoscopic debridement plus calcaneal osteotomy for painful varus deformity).

There were no primary revisions for aseptic loosening or deep infection. 3 radiographs demonstrated non-progressive lucent lines behind the tibial component.

Further surgery was required in 8 other ankles (6 calcaneal osteotomies and 2 arthroscopic debridements). Complete correction of pre-operative deformity was ultimately achieved in all but 4 ankles.

The mean postoperative American Orthopaedic Foot and Ankle Society Score was 77.

Discussion: At a minimum follow up of 5 years after Scandinavian Total Ankle Replacement, all but one of our ankles have well functioning prostheses in situ. However, 13/47 ankles required further surgery of some kind, including 5 component revisions (90% survival).

Conclusion: Total ankle arthroplasty is a reliable procedure for ankle arthrosis at intermediate term follow up. It provides good functional results and symptomatic benefit, although additional operative procedures may be required.

We carried out 123 consecutive total ankle replacements in 111 patients with a mean follow-up of four years (2 to 8). Patients with a hindfoot deformity of up to 10° (group A, 91 ankles) were compared with those with a deformity of 11° to 30° (group B, 32 ankles). There were 18 failures (14.6%), with no significant difference in survival between groups A and B. The clinical outcome as measured by the post-operative American Orthopaedic Foot and Ankle Surgeons score was significantly better in group B (p = 0.036). There was no difference between the groups regarding the post-operative range of movement and complications. Correction of the hindfoot deformity was achieved to within 5° of neutral in 27 ankles (84%) of group B patients. However, gross instability was the most common mode of failure in group B. This was not adequately corrected by reconstruction of the lateral ligament.

Total ankle replacement can safely be performed in patients with a hindfoot deformity of up to 30°. The importance of adequate correction of alignment and instability is highlighted.

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study.

Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability.

We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design.

Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p< 0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests.

Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.