Abstract

Aims

The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury.

Aims

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

Aims

To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA).

Implementation of the World Health Organisation checklists have reduced errors, however, the impact of pre-operative briefings on adverse events has not been assessed. A prospective case control study assessing the association between pre-operative briefings and minor, potentially major and major adverse events was performed in two phases. Phase one involved prospective data collection for trauma and orthopaedic lists over 2 weeks. Changes were implemented and following this, the study was repeated (phase two). 41 lists were audited during phase one and 47 lists in phase two. Adequate pre-operative briefings were performed in 10/41 lists (24%) in phase one. There was a significant association between the occurrences of intra-operative adverse events (n=37) when a briefing was not performed (p=<0.01), and when a briefing was performed incompletely (p=0.01). In phase two, after staff re-education and policy change, briefings were found to be adequate in 38/47 lists (81%) with the occurrence of only three minor adverse events. Team familiarity also improved significantly (p=0.02). Inadequate pre-operative briefings are associated with increased minor adverse events and are detrimental to team familiarity. On the basis of our findings we recommend that all surgical units perform pre-operative briefings.

Slipped upper femoral epiphysis (SUFE) is an uncommon condition with potentially severe complications including avascular necrosis (AVN) and chondrolysis. Children with a ‘slip’ are at a significantly higher risk of a contralateral slip. Controversy remains as to when to undertake prophylactic pinning. The primary aim of this study was to assess the Posterior Sloping Angle (PSA, as described by Barrios et al in 2005) as a predictor for contralateral slip in a large, multi ethnic cohort.

All consecutive patients treated for SUFE presenting to Waikato Hospital between January 2000 and December 2009 were identified via medical coding. Patients without radiographs and those with bilateral slips on presentation were excluded. Clinical records were reviewed to document demographic data, slip characteristics and follow up outcomes. Radiographic analysis of the PSA in the unaffected hip was performed by a single author. Statistical analysis was performed using a student's t-test with Microsoft Excel 2003.

182 patients were identified, 50 were excluded [26 bilateral slips, 24 no radiograph available] to total a study population of 132 patients. 93 patients were male [72%]. Mean age was 11.8 years [6.2–15.6 years]. 72% were of Maori ethnicity and 26% were of New Zealand European descent. 90 patients [69%] had a unilateral slip, 42 [32%] had a contralateral slip. 48% were not followed until physeal closure and 50% did not attend at least one scheduled appointment Mean PSA of those with a unilateral slip was 10.8° [2–21°]. Patients who subsequently developed a contralateral slip had a statistically significantly higher mean PSA of 17.2° [6–36°] [p<0.0001]. Children with a contralateral slip were significantly younger 11.1 years than those with a unilateral slip 12.2 years (p<0.0001). No significant differences in PSA were found between Maori and NZ European children.

If a PSA of 14° was used as an indication for prophylactic fixation in this population 35/42 [83.3%] of contralateral slips would have been prevented. 19/90 hips would have been pinned unnecessarily. The number needed to treat demonstrates that 1.79 hips are prophylactically pinned to prevent one slip in this population.

This large retrospective cohort study demonstrates that a PSA of 14° in an unaffected hip after one sided SUFE could warrant prophylactic pinning in an unaffected hip to prevent subsequent slip and the complications associated with this, potentially protecting a population that can be difficult to follow up.

Aim: To assess mid to long-term functional and symptomatic outcome after internal fixation of the distal radius.

Methods: All patients operated upon between June 2004 and October 2007 were retrospectively assessed using the ‘Disabilities of arm, shoulder and hand’ (DASH, range 0–100), and Mayo wrist (range 0–100) functional scoring systems. Fractures were classified according to the AO system. All patients were treated in one unit by the same group of surgeons using standard accepted techniques. Revision operations and patients treated at greater than four weeks after injury were excluded. Radiographic analysis of time to union was also performed.

Results: 201 patients underwent surgical fixation of which, 183 patients were contactable for follow up (9% loss). Only these patients were included in the study. Mean age was 62.5 years. Mean follow up time was 30 months. Mean time to surgery was eight days. 74% had good/excellent Mayo and 75% good/excellent DASH scores. 2% of patients had a poor outcome with both scores. 28 % reported no functional or symptomatic deficit. There was a 14% overall complication rate (6% major). Mean time to union was 8.39 weeks. Time to union increased with advancing AO grade. There was no significant difference in scores with regard to postoperative immobilisation, time to surgery, time to follow up, patient age, surgeon grade or fracture type.

Conclusion: This is one of the largest series of its type and the results compare favourably with other published operative and non-operative treatment modalities. This is a safe, reproducible technique with excellent functional outcome and is recommended as the treatment of choice when surgery is indicated for these fractures.

Aim: To study a staged technique for the removal of the Ilizarov fixator following bony union.

Method: A prospective case series of all fractures treated by the senior author between May 2005 and May 2007 were reviewed. When patients were able to weight bear pain free with radiological evidence of healing, the frames were dynamised initially by loosening the rods across the fracture site, then by removing all rods across the fracture site and finally the frame was removed under general anaesthetic. Patients were followed up for 6 months clinically and radiologically.

Results: Of 39 fractures (38 patients) 37 underwent staged dynamisation. No patients required further, casting, bracing or walking aids after frame removal. There were no incidences of re-fracture, non-union or late mal-union at 6 months follow up.

Conclusion: The proposed method of staged dynamisation is a safe and useful technique for confirming fracture union and guiding frame removal

We aim to assess the long term functional and symptomatic outcome of patients after open reduction internal fixation (ORIF) of the ankle. A retrospective telephone interview of patients (n=113) in years five, six and seven after ORIF of the ankle was conducted. The Olerud-Molander Ankle Score (scale 0–100) and SF-12 Health Survey scores were utilised to assess symptomatic and functional outcome. Fractures were classified in accordance with the Danis-Weber system. All patients were operated upon in the same unit by the same group of surgeons.

Sixty five patients were male and 48 female. The mean age was 56 (range 15–96). Patients with Weber B fractures (n=83) had a mean OMAS of 89.2. Those with Weber C fractures (n=25) had a mean OMAS of 85.4. Five patients had isolated medial malleolar fractures. At five to seven years post-operatively, 67.3% of patients were symptomatic. Of these, 75% complained of swelling; 39% of pain and 30% of stiffness whilst 19.5% of all patients felt they had not returned to their pre-operative functional level. Regardless of fracture type or follow up time, patients under 40 years old, had a significantly higher mean OMAS (90.7) as compared to those between 40 and 65 years old (85.3) (p=0.024). There was no significant difference in the mean OMAS of patients followed up at five or seven years post operatively or between those with Weber B or C fractures.

Patients suffer ongoing symptomatic and functional problems up to seven years after ORIF of the ankle and a significant number do not return to their pre-injury functional state. Patients under 40 years old had a better outcome as compared to older patients, whilst Weber type or year of follow up did not affect outcome. Surgeons should counsel patients pre-operatively regarding possible long term problems when undertaking ankle fracture fixation.