Weight-bearing status following non neck of femur (NOF) fragility femoral fracture

Weight-bearing status following non neck of femur (NOF) fragility femoral fracture

Authors:
Alex Denning, Rory Ormiston, Saharish Saleem, Jonathan Quayle

Hospital:
Salisbury District Hospital NHS Foundation Trust

Introduction:
The aging population has increased the incidence of femoral fractures. The BOAST – Care of the Older or Frail Orthopaedic Trauma Patient Guidelines state these patients should be full weight-bearing (FWB) within 36 hours. This standard is often not applied to non-NOF fractures.

Methods:
This single-centre retrospective audit assessed compliance with this guidance. Patients admitted in 2021 that underwent surgery for fragility peri-prosthetic or non-NOF femoral fractures were included. Our primary outcome was prescribed weight-bearing status. Reasons for restricted weight bearing (RWB) were then analysed. Secondary outcomes included time to theatre, LOS and discharge destination.

Results:
25 patients met the inclusion criteria. This included 4 mid shaft fractures, 6 distal femoral fractures and 15 peri-prosthetic fractures (8 THR, 7 TKR). 40% of patients were FWB post-operatively. Retrospective analysis suggested that within the RWB group, fixation was sufficient to allow FWB in 10 patients, 2 patients would have required alternative fixation to allow FWB, 3 patients had appropriately restricted weight-bearing. Neither group required revision fixation. Average LOS was 22.4 days – LOS was 16 days if FWB and 24 days if RWB. Patients were discharged to their pre-hospital residence at similar rates in each group (50% v 52%).

Conclusions:
Despite guidelines advising early intervention with intention to FWB patients, only 40% of patients were prescribed to do so. Patients allowed to FWB post operatively had a shorter LOS. Fixation was appropriate to allow FWB in the majority of cases.

Patient Reported Outcomes After Definitive Open Tibial Fracture Management

Patient Reported Outcomes After Definitive Open Tibial Fracture Management

Authors:
Ryan Higgin, Jon Palmer, Amir Qureshi, Nicholas Hancock

Hospital:
University Hospital Southampton

Aims:
Open tibial fractures are often life-changing injuries and outcomes remain poor despite national management guidelines. The longer-term impact to the patient can be considerable but is frequently overlooked in the literature. This study aims to establish the functional, physical, and psychosocial impact of sustaining an open tibial fracture.

Methods:
We reviewed 69 consecutive Gustilo-Anderson grade IIIB and IIIC open tibial fractures presenting to our MTC between September 2012 and April 2018. Participants were interviewed and sent patient-reported outcome questionnaires a minimum of 12 months following injury. Our primary outcome was the Lower Extremity Functional Scale (LEFS). Secondary outcomes included the Short-Form 36 Healthy Survey (SF-36), Sickness Impact Profile 128 (SIP) and return to occupation. Subgroups were analysed according to age, Injury Severity Score (ISS) and limb amputation.

Results:
Our study response rate was 72% with mean follow up 43 months. The mean LEFS was 42 (IQR 21.5 – 58.5). All total and sub-domain scores within the SF-36 and SIP questionnaires were reduced compared to normative population data. 48% of patients returned to full time employment. Subgroup analysis revealed significantly reduced LEFS, SIP and SF-36 subdomain scores for those with a presenting ISS>14 and those undergoing limb amputation.

Conclusions:
Patients have significant risk of longer-term functional, physical and psychosocial harm after suffering an open tibial fracture. Those sustaining major polytrauma or amputation demonstrated greatest risk of poor outcome. Early identification of these individuals likely to suffer most from their injury would help direct appropriate resources to those with greatest need at the earliest opportunity.

Chest wall soft tissue thickness is associated with humeral shaft nonunion: a radiographic study

Chest wall soft tissue thickness is associated with humeral shaft nonunion: a radiographic study

Authors:
Alex, Choudhary, Kizzie Peters, Henry Colaco, Iain MacLeod

Hospital:
Hampshire Hospitals NHS Foundation Trust

Introduction:
Anecdotally, pendulous breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature.

Aims:
To produce radiographic measurements of chest wall soft tissue thickness and determine association with nonunion and angulation in diaphyseal humerus fractures.

Methods:
217 patients who underwent conservative management for a diaphyseal humeral fracture were identified retrospectively from 2008-2017. Radiographic chest wall soft tissue thickness (STT) measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method. Ratios were also derived, dividing these figures by the mid-humerus diameter. Bivariate and multivariate analysis was used to assess association with nonunion.

Results:
There were 58 (26.7%) cases of nonunion. On multivariate analysis, the middle (OR 1.39, 95% p<0.001) and lower (OR 1.23, p=0.009) STT measurements were independently associated with nonunion. Additionally, the middle (OR 1.85, p<0.001), lower (OR 1.47, p=0.005) and maximum (OR 1.40, p<0.001) STT ratios were independently associated with nonunion. A receiver operating characteristic curve was used to determine threshold values for middle STT of 6.2cm (sensitivity 62.1%, specificity 61.6%) and middle STT ratio of 3.0 (sensitivity 69.0%, specificity 62.3%). A middle STT of ≥6.2cm (OR 2.68, p=0.004) and a middle STT ratio of ≥3.0 (OR 3.73, p<0.001) were each independently predictive of nonunion.

Conclusions:
Chest wall soft tissue thickness is independently associated with humeral shaft nonunion. A middle STT ratio of ≥3 was predictive of nonunion. Threshold values can assist in decision making for these fractures.

Mid-term Clinical and Functional Outcomes of Fibula Nail Fixation for Unstable Ankle Fractures: a 5-year experience

Mid-term Clinical and Functional Outcomes of Fibula Nail Fixation for Unstable Ankle Fractures: a 5-year experience

Authors:
Joe Barrett-Lee, J. Enson, A. Ahmed, R. Jamal, M. Elmahi, S. N. Anjum

Hospital:
University Hospital Southampton

Introduction:
In recent years fibula nail fixation of unstable ankle fractures has gained increased interest, particularly for high-risk cohorts. As the technique becomes more commonplace, monitoring of outcomes in the longer term is vital. We present the mid-term outcomes of patients treated with fibula nailing at our institution over a 5-year period.

Methods:
The study period was from December 2016 to December 2021. Our primary outcome measure was the Manchester-Oxford Foot Questionnaire (MOX-FQ), obtained via telephone interview at a mean of 28.9 months post-operatively. Secondary outcomes were complications, metalwork failure, re-operations, and patient satisfaction.

Results:
68 patients with unstable ankle fractures underwent fibula nailing during the study period. Mean age was 72 years (SD 12.9) and 79% were female. Mean time to surgery was 5.1 days (SD 4.1) and discharge 14.8 days (20.3). 55 medial malleoli were fixed (21 open, 34 percutaneous). 4 patients (5.9%) underwent metalwork removal: 1 medial malleolus plate, 1 fibula nail and medial screws for deep infection, and 2 syndesmotic screws for pain and prominence. There was one medial-sided surgical site infection, which was treated with antibiotics. 45 patients were contactable for telephone follow-up. The overall mean MOX-FQ score was 27.08 (SD 25.83) and metalwork failure was associated with worse MOX-FQ scores (57.29 failure versus 24.93 non-failure, p=0.034). 38 patients (84%) were satisfied with their outcome.

Conclusions:
These Results demonstrate that fibula nail fixation of unstable ankle fractures is associated with a low rate of complications and revisions. Patient-reported outcomes are favourable in most patients.

Intra-Articular Haematoma Block vs Procedural Sedation for Manipulation of Closed Ankle Fracture Dislocations: An Efficacious, Resource Sparing Solution?

Intra-Articular Haematoma Block vs Procedural Sedation for Manipulation of Closed Ankle Fracture Dislocations: An Efficacious, Resource Sparing Solution?

Authors:
John McFall, Mr Togay Koc and Mr Zeid Morcos

Hospital:
Queen Alexandra Hospital

Introduction:
Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space, increasing demands on Emergency Departments to allocate resources and facilities to safely provide PS. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS.

Methods:
Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. Data recorded included the patients’ pain scores, time from first x-ray to reduction and acceptability of reduction. A comparison of temporal variables and resource use was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six-month period March – August 2020.

Results:
During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087).
In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p <0.05; ‘pre’ to ‘post’ p <0.01).
In the IAHB group, 24 (92%) had a satisfactory reduction versus 23 (82%) in the PS group. There was no significant difference in the number of unsatisfactory 1st attempt reductions between the groups.

Conclusions:
Intra-articular haematoma block of the ankle is an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures.

The ‘lockdown approach’ to distal radius fractures reduced the burden on outpatient orthopaedic services with no impact on patient outcome

The ‘lockdown approach’ to distal radius fractures reduced the burden on outpatient orthopaedic services with no impact on patient outcome

Authors:
Lucy Walker, David O’Connor, Simon Richards , Jeremy Southgate

Hospital:
University Hospitals Dorset

Introduction:
In response to the coronavirus pandemic the BOAST guidelines advised treating distal radius fractures (DRFs) non-operatively where possible. The objective of this study was to assess whether the COVID pandemic lockdown within the UK altered the management of DRFs and whether there was any subsequent change in patient outcome or complication rate.

Methods:
A retrospective cohort study was performed at a single orthopaedic centre. Patients presenting with DRFs during the first lockdown was identified through the virtual fracture clinic database. The cohort of patients from the previous year was also identified for comparison. Data was collected on patient demographics, radiological features of the fractures, management, patient outcome and subsequent complications. Comparisons were then made between the cohorts for each year.

Results:
The final cohort comprised of 268 fractures in the pre-COVID cohort and 257 fractures in the COVID cohort. There was no significant difference between the two cohorts regarding the number of patients requiring open reduction and internal fixation. The pre-COVID cohort had a significantly higher number of patients reviewed in face-to-face clinic appointments (p=0.004459) and the mean number of clinic appointments for those patients was significantly higher (p=0.014958). There was no significant difference between the cohorts regarding patient complications with a minimum ten month follow-up period.

Conclusions:
Despite comparative numbers and patterns of DRFs the burden on fracture clinic services was significantly reduced during the COVID-19 pandemic. This reduction in follow-up has not translated into an increased prevalence of complications nor requirement for further surgery.

Is Gallows traction effective before open reduction surgery for Developmental Dysplasia of the Hip?

Is Gallows traction effective before open reduction surgery for Developmental Dysplasia of the Hip?

Authors:
Nic Uren, Julia Judd, Ed Lindisfarne, Kirsten Elliott, Alex Aarvold

Hospital:
University Hospital Southampton

Introduction:
Gallows traction is used before the surgical reduction of dislocate. Despite requiring extended hospital stays, traction theoretically reduces soft tissue tension, allowing an easier surgical reduction and thus fewer complications including re-dislocation and avascular necrosis. This study aims to quantify the effectiveness of Gallows traction at altering the resting position of the hip.

Methods:
All infants less than 12kg treated with hip open reduction surgery undergo pre-operative gallows traction at our institution. Patients have a pre-traction radiograph, repeated pre-operatively in theatre with traction removed. The resting position of the hip before and after traction was compared in eighty consecutive patients using the IHDI classification system. The re-dislocation rate and the prevalence of clinically relevant AVN following our surgical protocol was calculated in a longer-term cohort (mean 8 years) of 100 patients.

Results:
Before traction, 49 hips were IHDI grade IV, 27 hips were grade III, and 4 hips were grade II. Following traction, 24 hips were grade IV, 37 hips were grade III, and 19 hips were grade II. There was a significant improvement in hip position according to IHDI classification (P < 0.001, Wilcoxon signed rank test). The outcomes in the longer-term cohort reported that only 2% of hips re-dislocated, and 94% of hips were a Severin 1 or 2 outcome (i.e. good or excellent).

Conclusions:
This study found that pre-operative Gallows traction decreases the degree of hip displacement. Despite the practicalities of the regime, this study supports its use ahead of hip open reduction surgery.

Evaluation of transition services for children and young people with chronic neuromuscular conditions

Evaluation of transition services for children and young people with chronic neuromuscular conditions

Authors:
B Sagade, C Edwards, A Aarvold, P Ross

Hospital:
University Hospital Southampton

Introduction:
The National Institute for Health and Care Excellence (NICE) has set guidelines serving as a benchmark for high quality transition services for children and young people (CYP) with chronic health conditions. We aimed to assess the services provided by the transition program running at our tertiary care hospital and to identify the unmet needs of health care in adults with neuromuscular disorders (NMDs).

Methods:
A questionnaire was designed through consensus amongst professionals and review of literature. An online survey of parents, caregivers, and patients going through NMDs was conducted to identify lacunae in transition services being provided to them.

Results:
53 families who had been transitioned were invited to participate in the study and 39 responses were received. Only 9 patients (23%) agreed that they received a transition plan for transfer of further care to an adult orthopaedic surgeon. The average score of satisfaction with the transition plan was 4/10. Care of their general health was taken over by their GP in 49% of them, while 28% patients did not have any doctor looking after them. 69% patients did not have any orthopaedic supervision whereas, 53% did not have any inputs from Spine surgeons since transitioning. 33% patients did not have continuing physiotherapy. 41% patients reported some decline and 6 (15%) reported a significant decline in their musculoskeletal health.

Conclusions:
Transition between services is challenging for families with tremendous scope for improvement. Coordination of care between Paediatric and adult services can make transition seamless for patients.

Perthes in Portsmouth: 27 years of experience

Perthes in Portsmouth: 27 years of experience

Authors:
Laura Beddard, Robert Richards

Hospital:
Queen Alexandra Hospital

Introduction:
Various factors have been proposed to influence outcome in Perthes. Choosing which patients to operate on, and when can be a challenge.
We present a prospective cohort study aiming to identify correlation between timing of surgical treatment and outcome.

Methods:
Prospective data was collected from a single centre between 28/11/1994 and 23/12/2021. Demographics, radiographic parameters, and surgical intervention were recorded on a database. Radiographic parameters recorded were Herring and Catterall grading at presentation, maximum fragmentation (Waldenstrom stage II) and Stulberg grade at skeletal maturity.

Results:
105 cases of Perthes were diagnosed in 99 patients. 66 hips have been followed up to maturity, 31 remain under review. The remaining 8 cases had incomplete data.
Children complained of symptoms at a median age of 4 years 8 months and were diagnosed on average 2 months later. The median time from the onset of symptoms to Waldenstrom stage II was 10 months.
32 hips (48%) underwent 52 open procedures. The mean time from symptoms to surgery was 18.4 months. The choice of operative intervention varied with age.
Four hips (12.5%) underwent surgery prior to reaching maximal fragmentation, 5 (16%) underwent surgery within the same month and 23 (72%) underwent surgery after this.
Stulberg grade tended to be higher in hips that underwent surgery after maximal fragmentation, although this was not statistically significant (p=0.35).

Conclusions:
Earlier surgery is likely to lead to better radiological outcomes. Understanding timing between symptoms and maximal fragmentation helps plan follow up and intervention to achieve best outcomes.

Open reduction, capsulorrhaphy & acetabuloplasty (ORCA): A one stop surgical treatment for infant DDH

Open reduction, capsulorrhaphy & acetabuloplasty (ORCA): A one stop surgical treatment for infant DDH

Authors:
Nic Uren, Alex Aarvold, Amanda Rhodes, S Penker, Edward Lindisfarne, Kirsten Elliot, Nicholas Clarke

Hospital:
University Hospital Southampton

Introduction:
This study reports the longer-term outcomes of the Open Reduction Capsulorrhaphy Acetabuloplasty (ORCA) procedure, utilising a minimal outer table acetabuloplasty, which aims to stimulates acetabular growth and avoid later pelvic osteotomies.

Methods:
The outcomes for 100 infants treated with ORCA, with a minimum of four year follow up, were analysed. Pre-operative patient demographics and radiological measurements were recorded. Radiological outcomes including IHDI classification, Acetabular Index (AI) and Severin grade were recorded at pre-defined post-operative intervals. The % of hips requiring further pelvic surgery was calculated. Operated hips were then compared to normal contralateral hips

Results:
The median age at the time of surgery was 15 months. Pre-operative dislocation severity was IHDI grade IV (high dislocation) in sixty cases, grade III in 28 and grade II in twelve cases. Mean pre-operative AI was 40° deg. This showed statistically significant improvements year on year (Repeated measures ANOVA, post hoc Bonferroni correction, p<0.001).
Mean AI at final follow up (range 4-12 years) was 18°, compared to 15° in the normal contralateral hips. 94% of cases have Severin Grade 1 (excellent) or 2 (good) outcome. Only 2% of patients required later pelvic osteotomy for residual acetabular dysplasia, compared to 60% of cases who do so after surgical reduction without pelvic osteotomy.

Conclusions:
This procedure, utilising a minimal acetabuloplasty, appears to be at least as effective as open reduction and any formal pelvic osteotomy. The acetabuloplasty is technically quicker to perform, is far less invasive, and is therefore a simple adjunct for the surgeons.