Compartment syndrome (CS) is a well-recognised, serious complication of long bone fractures. The association between CS and tibial shaft fractures is well documented in adult patients and in children with open or high velocity trauma. There is, however, little literature on the risk of developing CS in children with closed tibial fractures. In a number of units these children are routinely admitted for elevation and monitoring for CS. We audited our experience of managing paediatric tibial fractures to ascertain whether it may be safe to discharge a sub-group of these children. We audited all children up to the age of 12 years admitted to our hospital over a 5 year period. We reviewed radiographs and clinical notes to determine fracture pattern, modality of treatment, and complications.Aims
Methods
The purpose of the study was to establish if there is a consensus amongst knee surgeons in U.K. related to rehabilitation protocols following microfracture/drilling procedure performed for treatment of full thickness chondral lesions of the knee. Successful rehabilitation is accepted to be essential for achievement of best results. A questionnaire was produced including questions about use of a CPM machine, use of a brace, weight-bearing status, use of an exercise bike, time allowed for patient to resume running, time allowed for patient to return to contact sports and surgeon’s expectancy of when symptoms will plateau. A simple scenario was put at the beginning of the questionnaire: “ A 23 year-old rugby player sustained a full thickness 1.5 x 1.5 cm chondral fracture on
the medial femoral condyle and the femoral trochlea. The lesion is treated using microfracture or a standard debridement method – post-operatively how is the patient managed?”. Questions were asked with regard to each site. The questionnaire was sent to BASK members. One hundred and twenty surgeons replied. Analysis of responses showed an unexpected variability regarding the rehabilitation for patients having treatment for a full thickness chondral lesion, with no common agreement (less than 50%) even about such aspects as the use of CPM, allowed range of motion, weight bearing status or return to sport. There is a marked disparity amongst knee surgeons in UK regarding the protocol of rehabilitation after treatment for full thickness chondral lesions of the knee. The majority of patients suitable for microfracture are young and active and a successful rehabilitation program is crucial to optimize the results of surgery. There is a need for development of accepted practice guidelines, to standardise the outcome for these patients.
Anterior Cruciate Ligament (ACL) reconstruction is performed widely across the United Kingdom by orthopaedic surgeons many of whom are members of the British Association for Surgery to the Knee (BASK), The choice of graft and fixation devices varies, based on surgeon’s preference, experience and patient needs. No data has been published with regards to choice of graft material or fixation devices in primary ACL reconstruction within the United Kingdom (UK). To find out what current practice is, we undertook a postal questionnaire of BASK members. 62% responded. Of these, 55% of surgeons have been undertaking ACL reconstruction for more than 10 years. Only 39% are performing over 50 ACL reconstructions per year. 71% of surgeons have read the Good Practice for ACL reconstruction booklet published by the British Orthopaedic Association (BOA). For the femur, the most popular devices used were metal screws (49%), rigidfix (17%), endobutton (14%), transfix (8%) and bioscrews (6%). For the tibia it was metal screws (57%), bioscrews (25%) and intrafix (14%) 16% use bone patellar tendon bone graft (BPTB), 18% use hamstrings, while 66% use either. Overall the most popular method seems to be the use of hamstrings or BPTB secured at both ends with metal interference screws without the use of a tensioner. Whether the variation alters clinical result is difficult to prove. With no national registry, comparison of outcomes becomes impossible. Our survey should serve as a baseline for any future research in this area.
Human recombinant bone morphogenic protein type 7 (BMP 7) is now available commercially for clinical use. In our trauma unit it has been used since September 2001 for patients with established intractable non-unions. We present the early results. All consecutive patients receiving BMP 7 were reviewed regularly following treatment. All patients had established non-unions previously treated with a variety of methods. The patients were assessed for clinical evidence of fracture union (using stability and pain). Treatment episodes will be categorised as failures if there is no evidence of fracture union at 1 year following BMP 7 treatment. Plain x-rays were assessed by 2 independent radiologists and categorised into: Radiological evidence of fracture union; encouraging progression towards union; little evidence of fracture healing; atrophic non-union, hypertrophic non-union. A total of 12 separate non-union sites have been treated in 10 patients (all male) to date. The mean age of the patients at follow up was 45 years. The series included 5 tibial non-unions, 3 femoral non-unions, 3 ulna non-unions with a mean of 3.3 treatments (range 1–7 treatments) and had endured symptoms, from initial injury to treatment with BMP 7, with a mean of 8.3 years (range 2 months-10.4 years). To date, the mean follow-up is 18 weeks (range 6–48 weeks). Currently, 2 fractures have clinical &
radiological union, 2 treatments have failed (implant failure and patient opted for amputation), 3 fractures are below 3months follow up, 5 fractures have a radiological classification as “encouraging” progression towards of union ( 4 with clinical union). In a very difficult treatment group, we have encouraging early clinical results. Radiological evidence to compare to initial clinical results will be available shortly.
