The triangular fibrocartilage complex (TFCC) is a known stabiliser of the distal radioulnar joint (DRUJ). An injury to these structures can result in significant disability including pain, weakness and joint stiffness. The contribution each of its components makes to the stability of the TFCC is not well understood. This study was undertaken to investigate the role of the individual ligaments of the TFCC and their contribution to joint stability.

The study was undertaken in two parts. 30 cadaveric forearms were studied in each group. The ligaments of the TFCC were progressively sectioned and the resulting effect on the stability of the DRUJ was measured. A custom jig was created to apply a 20N force through the distal radius, with the ulna fixed.

Experiment one measured the effect on DRUJ translation after TFCC sectioning. Experiment two added the measurement of rotational instability.

Part one of the study showed that complete sectioning of the TFCC caused a mean increase in translation of 6.09(±3) mm. Sectioning the palmar radioulnar ligament of the TFCC caused the most translation.

Part two demonstrated a change in rotation with a mean of 18 (± 6) degrees following sectioning of the TFCC. There was a progressive increase in rotational instability until the palmar radioulnar ligament was also sectioned.

Linear translation consistently increased after sectioning all of the TFCC ligaments, confirming its importance for DRUJ stability. Sectioning of the palmar radioulnar ligament most commonly caused the greatest degree of translation. This suggests injury to this ligament would more likely result in a greater degree of translational instability. The increase in rotation also suggests that this type of instability would be symptomatic in a TFCC injury.

Formation of micro-cracks occurs in bone due to daily activities. Through a mechanism of self-repair, these micro-cracks are detected, and the damaged areas are restored, avoiding further propagation. The Scissors Model suggests that the osteocyte processes that cross the micro-cracks break as consequence of the cyclic displacements of the micro-crack faces, due to fatigue, and this triggers the remodelling processes. A fresh bovine tibia bone was cut in sections oriented 20° from the transversal direction. The cortical bone was sliced using a circular saw and shaped to the dimensions: 20 × 10 × 1 (mm) and the surfaces were polished. µCT images were obtained from all the samples (μCT 40, Scanco Medical, Brüttisellen, Switzerland). From the DICOM files, the geometries were reconstructed and meshed using tetrahedrons, in ICEM CFD. The Elasticity Modulus (E) was determined in Bonemat, by applying an empirical relationship Elasticity-Density from the literature. The parts were then imported into ANSYS APDL to simulate micro-crack propagation in bone. This model will be validated with further experimental work where the micro-crack will be initiated in the prepared samples and propagated due to fatigue loading, and the osteocyte processes will be visualized in the Scanning Electron Microscope (SEM). This investigation aims to study how cyclic loading in bones and failure of osteocyte processes can trigger target the mechanism of bone remodelling. The resulting model can later contribute for the investigation of treatments for bone diseases such as osteoporosis and the response of bone to the presence of orthopaedic implants.

Background

With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre.

Introduction

Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation.

Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression.

The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached.

16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth.

This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. The nature of the Afghanistan conflict has changed considerably since 2007, and wounds from improvised explosive devices (IEDs) have replaced those of small arms fire as the signature injury of the insurgency. The severity of injury from IEDs has increased such that casualties routinely present with high bilateral traumatic lower limb amputations and associated pelvic, perineal, upper limb and facial wounds. These complex injuries affecting multiple anatomical zones necessitate a multi-surgeon team approach in their management. We present recent data for the surgical activity at the JF Med Gp Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010.

During the study period, a total of 4276 cases required 5737 surgical procedures, representing a 2.6-fold increase in activity compared with the previously reported 2-year period. Of these cases, 42% were coalition troops (ISAF) and 6% children. Wound debridement (44%) and relook/delayed primary closure of wounds (10%) remain the most commonly performed procedures. There has been a marked increase in the rates of amputation (8% of procedures, 48% being above-knee), laparotomy (9%), application of external fixation (4.5%), and fasciotomies (3%). Scrotal exploration accounted for 1.9% of procedures, resulting in 17 orchidectomies. During the 2-year study period, we have also observed a considerable increase in the incidence of cases requiring 5 or more surgeons operating simultaneously.

The aim of this study was to examine the progression of osteolytic lesions following liner exchange surgery and relate this to the size of the lesion prior to surgery, and whether the defect underwent curettage and bone grafting during surgery.

Six patients with well-fixed Harris-Galante-1 acetabular components underwent liner exchange surgery for excessive polyethylene wear and osteolysis. The mean interval from primary arthroplasty to revision was 14 years (range 11–17 years). All patients underwent a CT scan pre-operatively to identify the location and size of the osteolytic lesions and during surgery, accessible lesions were curetted and bone grafted. One patient had recurrent dislocations and the acetabular component was revised one year following liner exchange surgery. The remaining five patients had CT scans taken at a mean of five months (range 3–5 months) and 5 years (range 3.4–8.2 years) following surgery. Osteolytic lesion volume with or without bone grafting was measured.

Of the 19 osteolytic lesions detected pre-operatively, the first post-operative CT scan showed that four lesions were fully bone-grafted, ten lesions were partially bone-grafted and five lesions had no bone grafting during surgery. At a minimum of three years following surgery, all fully bone-grafted lesions remained full of bone- graft. Of the ten partially bone-grafted lesions, the osteolytic non-grafted zone decreased in volume in five lesions and five lesions remained unchanged. Of the five osteolytic lesions with no bone grafting, one lesion increased in volume, one lesion decreased in volume and three lesions remained unchanged. No new lesions were detected in any of the hips.

These preliminary results suggest that liner exchange surgery is effective in treating periacetabular osteolysis. Although bone grafting appears to aid in restoring bone stock, it is not essential in halting the progression of osteolysis, which likely results from the ongoing production of polyethylene particles in the joint.

Sensitive and accurate measures of osteolysis around TKR are needed to enhance clinical management and assist in planning revision surgery. Therefore, our aim was to examine, in a cadaver model of osteolysis around TKR, the sensitivity of detection and the accuracy of measuring osteolysis using Xray, CT and MRI.

Fifty-four simulated osteolytic lesions were created around six cadaver knees implanted with either a cemented or cementless TKR. Twenty-four lesions were created in the femur and thirty in the tibia ranging in size from 0.7 cm3 to 14 cm3. Standard anteroposterior and lateral fluoroscopically guided radiographs, CT and MRI scans with metal reduction protocols were taken of the knees prior to the creation of lesions and at every stage as the lesion sizes were enlarged. The location, number and size of the lesions from images obtained by each method were recorded.

The sensitivity of osteolytic lesion detection was 44% for plain radiographs, 92% for CT and 94% for MRI. On plain radiographs, 54% of lesions in the femur and 37% of lesions in the tibia were detected. None of the six posterior lesions created in the tibia were detected on the AP radiographs; however, three of these six lesions were detected on the lateral radiographs. CT was able to detect lesions of all sizes, except for four lesions in the posterior tibia (mean volume of 1.2 cm3, range 1.06–1.47 cm3). Likewise, MRI was very sensitive in detecting lesions of all sizes, with the exception of three lesions, two of which were in the femur and one was in the medial condyle of the tibia (mean volume of 1.9 cm3, range 1.09–3.14 cm3). Notably, all six posterior tibial lesions, which could not be detected using AP radiographs, were detected by MRI.

This study demonstrates the high sensitivity of both CT and MRI (which uses no ionising radiation) to detect simulated knee osteolysis and can therefore be used to detect and monitor progression of osteolysis around TKR. The study also shows the limitations of plain radiographs to assess osteolysis.

Haemorrhage is the main cause of preventable death on the modern battlefield. As IEDs in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the CAT tourniquet to control distal haemorrhage following mid thigh application.

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma.

A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits.

232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases.

Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent.

While computed tomography (CT) provides an accurate measure of osteolysis volume, it would be advantageous in general clinical practice if plain radiographs could be used to monitor osteolysis. This study determined the ability of plain radiographs to detect the presence of and determine the progression in size of osteolytic lesions around cementless acetabular components.

Nineteen acetabular components were diagnosed with osteolysis using a high-resolution multi-slice CT scanner with metal artefact suppression. Mean duration since arthroplasty was 14 years (range 10–15 years) at initial CT. Repeat CT scans were undertaken over a five year period to determine osteolysis progression. On anteroposterior pelvis (AP) radiographs and oblique radiographs of the acetabulum seen on the rolled lateral hip view, which were taken at the same time as the CT scans, area of osteolysis was measured manually correcting for magnification.

Osteolysis was detected on the AP radiographs in 8 of 19 hips (42%), on the oblique radiographs in 6 of 19 hips (32%) and on the combined AP and oblique radiographs in 8 of 19 hips (42%). Throughout the study period, osteolysis was detected on 31 of 76 AP radiographs (41%) and 22 of 75 oblique radiographs (29%). Osteolysis was more likely to be detected on plain radiographs if the lesion volume was greater than 10cm3 in size (p=0.005). On CT, osteolysis progressed by more than 1cm3/yr in 10 of 19 hips (55%). In these ten hips, osteolysis progression was detected on AP radiographs in six hips and on oblique radiographs in three hips. No correlation was found between osteolysis progression measured by CT and that measured on AP (r2=0.16, p=0.37) or oblique (r2=0.37, p=0.15) or AP and oblique radiographs (r2=0.34, p=0.17).

Plain radiographs are poor in monitoring progression in size of periacetabular osteolytic lesions. Plain radiographs may detect lesions more than 10cm3 in size, but are unreliable.

Introduction: Obtaining adequate images can be difficult in ring fixator patients during outpatient follow-up. Following a recent publication, we introduced the spirit level technique as an effective method to ensure better quality images for interpretation, reduce unnecessary x-ray exposure, and improve clinic efficiency.

Method: A comparison was made of radiograph quality, patient inconvenience and x-ray exposure between standard X-ray techniques and those with a frame mounted spirit-level in all patients attending the senior author’s outpatient clinic for routine follow up following Ilizarov and Taylor-Spatial frames.

Prospective data was collected using a paper proforma in frame clinic. Information was gathered on all patients sent for plain radiographs. Radiographers collected data regarding time taken in the X-ray Department and total number of radiographs taken to gain the images required. The senior author recorded if these images were satisfactory and if returned to the department for further imaging. The radiation dose was retrieved from the Radiology computer.

The control group consisted of patients from clinics prior to implementation of the spirit-level device. Following a period of familiarization, data was collected from the study group using the spirit-level.

Results: (Table deleted)

Conclusion: The implementation of a simple frame mounted spirit-level as a guide for the radiographers in the outpatient clinic improves x ray quality, to assess healing, and significantly reduces the number of suboptimal images. The data does not support a significant impact on patient inconvenience.

Introduction: Complex extremity injury remains a challenge to those involved in both its emergent and definitive care. Anecdotal concerns exist regarding exposure of orthopaedic trainees to such cases in the light of recent changes in surgical training. We aim to establish the perceived confidence, exposure to caseload and adequacy of training of United Kingdom (UK) Orthopaedic Specialist Trainees in the management of significant extremity trauma.

Method: A web-based survey was sent to a sample of orthopaedic trainees. 222 responses from 888 trainees were required to achieve a 5% error rate with 90% confidence. 232 responses were received.

Results: Perceived confidence and adequacy of training in wound debridement and fasciotomy is high despite infrequent exposure and training is perceived as adequate. With regards to assessment of limb viability and amputation for extremity injury, exposure is minimal, perceived confidence is lower, particularly in the case of amputation and for this scenario over a third of trainees report their training as inadequate. Perceived confidence in dealing with hand trauma is low and is associated with sparse exposure to cases resulting in a quarter of trainees reporting their training as inadequate. For all scenarios, confidence is seen to increase with time spent in training with the notable exception of post-CCT trainees whom report a lower confidence to their colleagues in the latter years of training.

Discussion: Despite infrequent exposure, it has been demonstrated that perceived confidence and adequacy of training in many aspects of extremity injury is high. Concerns are apparent with the management of hand trauma and amputation surgery. This study is the first of its kind to offer a valuable insight into the current training perceptions and requirements of junior orthopaedic surgeons at a national level.

Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary translations and rotations under measured amounts of weight bearing. The aim of this paper was to measure the mechanical stiffness of distal femoral fractures during healing.

Six patients with a 33A2, 33A3, 33B2 and 33C2 fracture were treated with open reduction, internal fixation using a long bridging plate. All patients had a DLRSA examination at 6, 12, 18 and 26 weeks postoperatively. Each DLRSA examination consisted of RSA radiographs taken without load (pre-load), under different increments of load, and finally, without load (post-load). The direction and magnitude of the interfragmentary displacements in six degrees of freedom were recorded at each examination.

DLRSA examinations were able to monitor the inter-fragmentary displacements of the distal femoral fragment relative to the femoral shaft. The interfragmentary displacement recorded, progressively increased as more load was applied in all patients, at all follow-up time points. The two dimensional (2D) translations under maximum tolerated load, progressively decreased over time in three patients. The 2D translations recorded under 60 kg of load at 26 weeks for these patients was 0.18, 0.21 and 0.27mm. The 2D translations of two patients did not decrease progressively between 6 and 18 weeks but did decrease at 26 weeks to 0.47 and 0.75mm. One patient recorded 2D translations of 4.11, 3.48 and 4.53mm under 30kg at 12, 18 and 26 weeks respectively. In the majority of examinations, post-load radiographs enabled the interfragmentary displacements under load to be identified as elastic in nature.

The DLRSA stiffness data confirmed that at 26 weeks three patients had united; two were delayed but improving; and one was a clear non-union without progression. DLRSA examinations may be used as a clinical research tool. to monitor in vivo the stiffness of healing femoral fractures fixed with “relative stability”.

Computed tomography (CT) provides a sensitive and accurate measure of periacetabular osteolytic lesion volume, however, there may remain a role for plain radiographs in monitoring osteolysis. This study aimed to compare CT and plain radiographs for determining the progression in size of osteolytic lesions around cementless acetabular components.

A high-resolution multi-slice CT scanner with metal artefact suppression was used to determine the volume and progression of osteolysis around 19 cementless Harris Galante-1 and PCA acetabular components. The mean duration since arthroplasty was 14 years (range 10–15 years) at initial CT. Repeat scans of the hip were undertaken over a five year period to determine the progression in size of osteolytic lesions over time. A second blinded observer manually measured the area of osteolytic lesions off anteroposterior pelvis radiographs and oblique radiographs of the acetabulum that were taken at the same time as the CT scan.

All 19 hips had CT detected osteolysis. Osteolysis was detected on one or both of the anteroposterior pelvis or oblique radiographs from at least one time point in eight of 19 hips (42%). Osteolysis was detected on 31 of 76 anteroposterior pelvis radiographs (41%) and on 22 of 75 oblique radiographs (29%) (p=0.140). Osteolysis was more likely to be detected on plain radiographs if the lesion volume was greater than 10cm3 in size compared to those 5–10cm3 and less than 5cm3 in size (p=0.009). In 10 of 19 hips (55%), CT determined that osteolytic lesions progressed in size by more than 1cm3/yr. The mean volume of osteolysis progression was 3.2cm3/yr (range 1.1–7.5cm3/yr). Progression in size of osteolytic lesions was significantly associated with hips with larger osteolytic lesions at the initial CT (p=0.0004). Radiographic measurements detected progression of osteolytic lesions in 5 of the 10 hips (50%) that progressed. No correlation was found between progression in size of osteolytic lesions as measured by CT and progression in size of osteolytic lesions as measured off the anteroposterior pelvis (r2 = 0.16, p=0.37), oblique (r2=0.37, p=0.15) and combined anteroposterior pelvis and oblique radiographs (r2=0.34, p=0.17).

Periacetabular osteolytic lesions are more likely to be detected on plain radiographs if they are more than 10cm3 in size. Plain radiographs may therefore provide some monitoring value as lesions more than 10cm3 are more likely to be progressive. However, plain radiographs should not be relied upon to monitor the progression of these lesions.

Periprosthetic osteolysis is a serious medium to long-term complication of total hip arthroplasty. Interobserver reliability of detecting osteolysis around cementless ace-tabular components is reported to be poor using plain radiographs. Quantitative computed tomography (CT) provides sensitive and accurate measures of osteolytic lesion volume, however, there may remain a role for plain radiographs in monitoring progression of osteolysis. The aim of this study was to use quantitative CT to monitor the progression of osteolytic lesions around cementless acetabular components and to compare plain radiographs and CT in determining the progression of osteolysis.

A high-resolution multi-slice quantitative CT scanner with metal artefact suppression was used to determine the volume of osteolysis around 18 cementless acetabular components. The mean time since arthroplasty was 14 years (range 10–15 years) at the initial CT. Repeat scans of the hip were undertaken over a five-year period to determine progression of osteolysis with time. A second blinded observer examined anteroposterior and lateral plain radiographs taken at the same time as the CT scans and measured the location and area of osteolytic lesions.

CT measurements determined that in ten of 18 hips (56%), osteolytic lesions progressed by more than 1cm3/yr. Progression in size of osteolytic lesions was significantly associated with hips with larger osteolytic lesions at the initial CT (p=0.0005). The mean volume of osteolysis progression was 4.9cm3/year (range 2.8–7.5cm3/yr) for cases with osteolysis volumes greater than 10cm3 at the initial CT, and 0.7cm3/yr (range 0–2.3cm3/yr) for cases with osteolysis volumes smaller than or equal to 10cm3 at the initial CT (p=0.002). Importantly, the rate of osteolysis progression between CT scans varied greatly in some hips. In contrast, using plain radiograph assessment, progression in the area of osteolytic lesions was only detected in 10% of hips.

In conclusion, quantitative CT provides new insights into the natural history of periacetabular osteolysis. Total osteolysis volume greater than 10cm3 is associated with a high risk of progression and progress, on average, at a greater rate than those less than 10cm3. Plain radiographs, including a lateral view, are an unreliable clinical diagnostic tool to predict substantial progression of periacetabular osteolytic lesions.

Introduction Magnetic resonance imaging (MRI) is a valid investigation for the diagnosis of intervertebral disc disease, including infection, but it is expensive and difficult to access conveniently for research studies on live animals under anaesthesia. The aim of this study was to compare the MRI signal changes in spines from living and recently deceased sheep.

Methods MRI was conducted on the lumbar spines of six adult sheep from research studies investigating bacterial discitis, chemical discitis and disc degeneration resulting from annular incision. The sheep was anaesthetised and the lumbar spines were imaged with a Siemens Magneton Vision MRI (Numaris VB33G software) using T1 SGE, T1 FSE, STIR and T2 FSE sequences. The sheep were killed with an intravenous overdose of barbiturate and identical images were obtained commencing five minutes post mortem.

Results For each of the disease processes under consideration the MRI contrast relationships were maintained between all of the anatomical structures of interest. The post-mortem images provided improved clarity, particularly in the STIR and T2-weighted sequences, due to the absence of pulsation from the CSF and aorta, as well as the absence of respiratory artefact.

Discussion The MRI appearances of spinal tissues following death correlate well with those in the live animal confirming the validity of this method of investigation. This is particularly relevant for optimisation of a busy clinical resource for research purposes.