To describe the treatment and morbidity of lower limb (LL) football fractures in regard to returning to football in a known UK population at all skill levels.

All football fractures during 2007–2008 sustained by the Lothian population were prospectively collected with the diagnosis being confirmed by the senior author when patients attended the only adult orthopaedic service in Lothian. Patients living outside the region were excluded from the study. Patients were contacted in August 2010 to ascertain their progress in return to football.

There were 424 fractures in 414 patients. 366 fractures (86%) in 357 patients (86%) were followed up with a mean interval of 30 months (range 24–36 months). Of these 32% were sustained in the LL. 88% of LL injuries returned to football compared to 85% of upper limb (UL) fractures (p=0.4). 60% of LL patients were treated as outpatients. 35% were operated on −26% had ORIF and 9% IM Nailing. The most common LL fractures were Ankle 38%, Tibial Diaphysis 14%, 5th Metatarsal 11%, Fibula 9% and Great Toe 7%. Only one of the fractures was an open injury - Gustillo Class 1 2nd Phallanx Foot. Three of the 12 patients who underwent IM nailing required fasciotomy. One patient in the operative cohort developed a significant infection. The mean time for return to football for conservative treatment was 17 weeks (range 3–104 weeks), and for operative treatment 41 weeks (range 10–104 weeks). 91% of patients treated conservatively returned to football, compared to 84% of the operative cohort (p=0.3). 43% of patients had ongoing symptoms from their injury. 9% of the operative cohort required removal of metal work or further operative intervention. 83% of patients returned to the same level of football or higher following injury. Patients under 30 were 1.4 times more likely to return to sport than those over 30 (p<0.05).

We have previously demonstrated that football is the most common cause of sporting fracture(1), yet little is known about patient outcome following fractures. LL fractures are less common than UL fractures, and there is no difference in the proportion of patients returning to football following LL fractures and UL fractures. Over half of LL fractures are treated as outpatients and the incidence of open fractures is very low. There is no significant difference between the operative and conservative groups in their return to football. In the over 30 age group, sustaining a fracture may act as a catalyst to quit football. This may explain the higher non-return rate compared to the under 30 age group. 43% of patients perceive that they have ongoing problems with their fracture over 24 months post-injury reflecting the considerable morbidity of football-related fractures.

Introduction

In an ageing population the incidence of patients sustaining a neck of femur fracture is likely to rise. Whilst the neck of femur fracture is thought to be a pre-terminal event in many patients, there is little literature following this common fracture beyond 1 year. With improving healthcare and increasing survival rate, it is likely that a proportion of patients live to have subsequent fractures. However little is known about if these occur and what the epidemiology of these fractures are.

The risk of venous thrombo-embolism (VTE) is high in orthopedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out questionnaires to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then OD for 14 or 35 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was Deep Vein Thrombus or Pulmonary Embolism confirmed by Doppler or CTPA. Minor bleed was categorized as dressing soakage or reported wound leakage, major bleed as hematoma requiring revision within 30 days.

509 patients underwent TKR: 200 (39%) received Rivaroxaban only (Group 1), 296 (58%) also received tranexamic acid (Group 2). 13 (3%) patients had no data available. Five patients had a VTE: 4 (2%) in Group 1, 1 (0.3%) in Group 2 [P<0.05]. 39 patients had a minor bleed: 17 (8.5%) in Group 1, 22 (7.4%) in Group 2 [P=0.5]. 2 patients had major bleeds: 1(0.5%) in Group 1 and 1(0.33%) in Group 2 [P=0.69]. There were 30 blood transfusions: 21 (10.5%) in Group 1, 9 (3%) in Group 2 [P<0.0001].

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results, whilst they show a trend towards decreased minor and major bleeding rates, are not significant and require larger studies looking at wound bleeding and leakage.

We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group.

Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8–10 years post surgery.

The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason.

203 patients were found to be < 55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study.

A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28–55 years (median 51). Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval.

Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years. TKR should not be withheld from patients on the basis of age.

Previous Anterior Cruciate Ligament (ACL) reconstruction is currently a bar from entry to the Royal Marines and Royal Navy, whilst the British Army allows recruits to join if asymptomatic 18 months post ACL reconstruction. However current Royal Marines policy is to rehabilitate recruits who sustain an ACL disruption in training. We retrospectively analysed the rehabilitation times and pass out rate of Royal Marines who had an ACL disruption during recruit training over an 8 year period.

12 recruits sustained an ACL disruption during recruit training in the study period, giving an incidence of around 1.5/1000 recruits. 9 Patients underwent ACL repairs in training, with 1 patient leaving and rejoining post repair and later successfully passed out. 2 patients were treated conservatively. Of the 12 ACL sustained in training 8/12 (67%) passed out. None of the patients treated conservatively passed out. The mean time out of training for successful recruits was 51.6 weeks (95% CI 13.1) mean rehabilitation time post ACL reconstruction for successful recruits was 36.7 weeks (95% CI 12.5). Mean time to discharge for unsuccessful recruits 63.2 weeks (95% CI 42.4). In the operative group 1/10 left due to failure to return to training and 1/10 left through unrelated reasons. Current costing for recruit training is £1800 per week per recruit.

ACL injuries are not common in Royal Marine Training, and reconstruction is not a bar to completing Royal Marine basic training. We estimate that it costs around £100,000 per-injured recruit, to maintain a policy of rehabilitating ACL injured recruits in Royal Marines training. Further research into the long-term employability or Royal Marines sustaining an ACL injury in training is required.

We set out to demonstrate the 10-year survivorship of the PFC sigma TKA in a young patient group.

Demographic and clinical outcome data were collected prospectively at 6 months, 18 months, 3 years, 5 years and 8-10 years post surgery.

The data were analysed using Kaplan Meier survival statistics with end point being regarded as death or revision for any reason.

203 patients were found to be ≤55 years at the time of surgery. Four patients required revision and four patients died. Another four patients moved away from the region and were excluded from the study.

A total of 224 knees in 199 patients (101 male and 98 females.) 168 patients had a diagnosis of Osteoarthritis and 28 with inflammatory arthritis. Average age 50.6 years range 28-55 years (median 51).

Ten-year survivorship in terms of revision 98.2% at ten years 95% confidence interval.

Our results demonstrate that the PFC Sigma knee has an excellent survival rate in young patients over the first 10 years.

TKR should not be withheld from patients on the basis of age.

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training.

All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded.

53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000)

Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training.

The DuPuy Sigma total knee arthroplasty (TKA) is a modification of the well-established Press Fit Condylar (PFC) TKA and is used extensively in the UK and worldwide. This study reports the first 10-year clinical and radiological follow-up data for the Sigma PFC.

A total of 235 consecutive Sigma TKAs were performed in 203 patients between October 1998 and October 1999, in our unit. Patients were seen at a specialist nurse-led clinic 1 week before admission and at 6 months, 18 months, 3 years, 5 years and 7-10 years after surgery. Data was recorded prospectively at each clinic visit.

Of 235 knees, 171 (147 patients) were alive at 10 years. Twelve were lost to follow up. Eight knees (3.4%) were revised; four for infection and four underwent isolated change of polyethylene insert. Ten-year survival with an end point of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society score was 62 at 8-10 years compared with 31 out of 100 pre-operatively.

Our results show that the PFC Sigma knee arthroplasty performs well over the first 10 years post-implantation.

The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome.

We used our arthroplasty database, which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) was identified. A control group of patients ≥ 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups. 40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees. Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10-year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004).

We conclude that Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.

The aim of this study was to compare the long-term outcome from total knee replacement (TKR) in young versus old patients in terms of pain and functional outcome.

We used our arthroplasty database which recorded prospectively pain and American Knee Society scores at regular intervals over ten years after TKR. The procedures used a modern, cemented resurfacing type cruciate retaining prosthesis. A cohort of young patients (≤55 years) were identified. A control group of patients > 56 was identified, matching for ASA, body mass index and underlying condition. Change over time was analysed using a factorial repeated measures ANOVA test, which allowed for investigation of difference between groups.

40 Knees in 26 patients were identified. 2 patients died prior to follow up, 2 were revised within the study period. (1 for infection at 2 years and one for change of poly at 7 years) and a further 4 were lost to follow up. 7 knees could not be matched and were excluded. This left a study group of 24 young and 24 older knees.

Pain scores (p=0.025) and American Knee Society “Knee” (p<0.001) and “Function” (p<0.001) scores changed significantly over time. There were however no statistical differences over the 10 year period in pain (p=0.436) and knee performance (0.618) but overall function was higher throughout the period in the younger group (=0.004).

Knee replacement in younger patients produces similar outcomes in terms of pain and function compared with older patients and TKR should not be withheld purely on account of age.

Current health economics forces the clinician to consider the cost of treatment. Currently in Fife Hospitals, all lower limb injuries likely to require operative treatment are admitted from the Accident and Emergency department on the day of injury. The aim of this investigation was to see if non-emergency trauma cases could be managed pre-operatively as outpatients to reduce costs.

We prospectively recorded all patients admitted with lower limb trauma excluding neck of femur fractures, requiring operative treatment over an eleven-week period. The senior author reviewed all patients and a clinical judgment was made as to whether the patient could have been safely managed as an outpatient pre-operatively.

61 patients met the inclusion criteria. Average age 41.8 (Range 8-66). The three most common fractures were 23(38%) ankle fractures, 15(25%) tibial fractures and 8(13%) femoral shaft fractures. 28(46%) fractures were deemed safe to have been managed preoperatively on an outpatient basis. 14/23(61%) ankle fractures were deemed safe to be discharged home. The average pre-operative stay was 1.38 nights (Range 1-4 nights).

By initiating a simple policy of allowing uncomplicated ankle fracture patients to wait at home and return on the morning of surgery it is possible to reduce inpatient occupancy by 64 nights per year in our department. At a cost of £518 per patient per night, this could result in a saving of around £33,000 in unnecessary overnight inpatient stays. In order to achieve this, clear clinical guidance for admitting doctors is necessary and further prospective research should be conducted into the risk/benefit of implementing this policy.

The risk of venous thrombo-embolism (VTE) is high in orthopaedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post-operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out a questionnaire to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then once a day for 14 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was confirmed by Doppler or CTPA as Deep Vein Thrombus or Pulmonary Embolism. Minor bleed was categorised as dressing soakage or reported wound leakage, major bleed as haematoma requiring revision within 30 days.

509 patients underwent TKR: 200(39%) only received Rivaroxaban (Group 1), 296(58%) also received tranexamic acid (Group 2). 13(3%) of patients had no data available. 5 patients had a VTE: 4 (2%) Group 1, 1 (0.3%) Group 2 (P<0.05). 39 patients had a minor bleed: 17 (8.5%) Group 1, 22 (7.4%) Group 2 (P=0.5). 2 patients had major bleeds: 1 (0.5%) Group 1, 1 (0.33%) Group 2 (P=0.69). Blood transfusions 21: (10.5%)Group 1, 9 (3%) Group 2 (P<0.0001).

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results whilst they show a trend towards decrease bleeding rates in both the minor and major bleeds are not significant, requiring larger studies looking at wound bleeding and leakage.

To illustrate the incidence and epidemiology of fractures due to football.

All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed.

There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%.

Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients.

Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport.