Radiological outcomes following surgical fixation with wires versus moulded cast for patients with a dorsally displaced fracture of the distal radius: a radiographic analysis from the DRAFFT2 trial.

Aims: The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods: Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient's initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results: Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion: For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function.

Computed tomography review of tarsal canal anatomy with reference to the fitting of sinus tarsi implants in the tarsal canal.

Sinus tarsi implants are used in the treatment of symptomatic hyperpronating flexible flatfeet in children. Although some implants are inserted only into the sinus tarsi, others occupy both the sinus tarsi and the tarsal canal. The stem that is anchored in the tarsal canal depends on interference fit for the initial resistance to slippage. The first part of this computed tomography anatomic study in children was aimed at finding and measuring the dimensions in the narrowest point in the canal that provided the interference fit. The second part of the study assessed the possibility of the implant being loaded with axial body weight in the tarsal canal. All foot computed tomography scans performed consecutively at Birmingham Children's Hospital from January 2008 to December 2011 were reviewed to assess the tarsal canal dimensions on the sagittal views. A total of 52 scans fulfilled the inclusion criteria. The average age was 12.7 years. The narrowest mean anteroposterior diameter of the canal was 7.3 ± 1.12 (range 5.2 to 10.0) mm. The narrowest mean superoinferior diameter was 9.2 ± 1.32 (range 6.3 to 12.7) mm. A total of 50 patients had the narrowest dimension in the anteroposterior plane. A positive linear correlation was found between the anteroposterior diameter and the superoinferior distance (r = 0.51, p < .01). We have concluded that the stem of an arthroereisis implant extending into the tarsal canal is unlikely to be constantly bearing body weight, because it obtains an interference grip in the anteroposterior direction in almost all patients and not in the superoinferior line of axial body weight.

Floating Forearm Injury: Monteggia Variant Fracture With an Ipsilateral Distal Radius and Ulna Fracture.

Monteggia variant fracture is a Monteggia fracture (proximal third ulna fracture with radial head dislocation) with an associated radial head fracture, coronoid fracture or complex pattern of injury. We report a rare case of an 80-year-old lady with a right Monteggia variant fracture with an ipsilateral distal radius and ulna fracture leading to a floating forearm injury. To our knowledge, this is the first case report to describe this injury pattern. We describe the multidisciplinary team approach and detailed surgical technique in managing this rare and complex injury.

Digital templating in hip hemiarthroplasty: Is it possible to accurately predict femoral head size from magnification alone?

Background: Templating is an integral part of pre-operative planning in elective hip arthroplasty to achieve favourable long-term outcomes, but its applications in trauma surgery remain limited. When templating from radiographs without a calibration marker, there is always an element of magnification which must be accounted for. Our aim was to establish our institute-specific magnification and to determine whether using this to predict femoral head size in hemiarthroplasty was more accurate than using set magnifications previously reported in the literature. Materials & methods: Fifty consecutive patients who underwent hip hemiarthroplasty were retrospectively identified, their pre-operative radiographs reviewed and femoral head measured with templating software. Intra- and inter-observer reliability analyses were performed. Using this value, and two set values of 15% and 21% magnification, we attempted to predict femoral head sizes of our original cohort. The results were compared using paired t-test to ascertain if there was any significant difference in accuracy. Results: We established our institute-specific magnification as 17%. Inter- and intra-observer reliability were excellent. However, using this magnification we were only able to correctly predict to within ± one femoral head size in 49% of patients. There was no significant difference in accuracy comparing our institute-specific magnification with other magnifications from the literature. Conclusion: We would not recommend using magnification factor in digital templating software as this could potentially lead to errors in predicting final femoral head size in hip hemiarthroplasty and adversely affect patient outcomes.

Experimental testing of fracture fixation plates: A review.

Metal and its alloys have been predominantly used in fracture fixation for centuries, but new materials such as composites and polymers have begun to see clinical use for fracture fixation during the past couple of decades. Along with the emerging of new materials, tribological issues, especially debris, have become a growing concern for fracture fixation plates. This article for the first time systematically reviews the most recent biomechanical research, with a focus on experimental testing, of those plates within ScienceDirect and PubMed databases. Based on the search criteria, a total of 5449 papers were retrieved, which were then further filtered to exclude nonrelevant, duplicate or non-accessible full article papers. In the end, a total of 83 papers were reviewed. In experimental testing plates, screws and simulated bones or cadaver bones are employed to build a fixation construct in order to test the strength and stability of different plate and screw configurations. The test set-up conditions and conclusions are well documented and summarised here, including fracture gap size, types of bones deployed, as well as the applied load, test speed and test ending criteria. However, research on long term plate usage was very limited. It is also discovered that there is very limited experimental research around the tribological behaviour particularly on the debris' generation, collection and characterisation. In addition, there is no identified standard studying debris of fracture fixation plate. Therefore, the authors suggested the generation of a suite of tribological testing standards on fracture fixation plate and screws in the aim to answer key questions around the debris from fracture fixation plate of new materials or new design and ultimately to provide an insight on how to reduce the risks of debris-related osteolysis, inflammation and aseptic loosening.

Mucinous adenocarcinoma of the lung presenting as pathological humeral fracture: a case report and novel surgical treatment.

We present a 73-year-old woman who presented with a pathological fracture of her right humerus. Further imaging and biopsy indicated a mucinous adenocarcinoma of the lung as the primary neoplasm. This represents the first published case of a mucinous adenocarcinoma of the lung presenting as a metastatic lesion of the humerus. Operative management of pathological fractures of the humerus has typically included either intramedullary nailing or the use of single-plating or double-plating techniques. The authors describe a novel technique using both intramedullary fixation augmented with a locking plate, steel cables and bone cement, with good outcome.

Closed reduction techniques for acute anterior shoulder dislocation: a systematic review and meta-analysis.

BACKGROUND: Anterior shoulder dislocations are the most common type of joint dislocation with the majority treated with closed reduction. Reduction methods can be grouped into their principle mode of action: traction-countertraction, leverage and scapular manipulation. The best method has yet to be identified and our aim was to find the most effective, safe and least painful method of closed reduction for acute anterior shoulder dislocations. METHODS: A search of the online databases of CENTRAL, MEDLINE and Embase was performed to identify randomised control trials (RCTs) comparing closed reduction methods for anterior shoulder dislocations. A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Twelve eligible RCTs were included with a total of 1055 patients. Our meta-analysis showed traction-countertraction methods are marginally less painful than leverage methods by 0.86 points on the VAS scale but leverage methods are quicker by 20 s. Amongst traction-countertraction methods, the Spaso technique was the least painful and quickest, albeit with no difference in overall success rate. A meta-analysis was not possible for comparisons involving scapular manipulation due to the paucity of studies, but within two studies, scapular manipulation was significantly less painful than both leverage and traction-countertraction methods by 1.5 and 2.3 points (VAS), respectively. CONCLUSION: Traction-countertraction methods are less painful but slower than leverage methods with no difference in complication rates. However, there was no difference in overall reduction success rate between any of the groups. LEVEL OF EVIDENCE: I.

Carbon fibre reinforced PEEK versus traditional metallic implants for orthopaedic trauma surgery: A systematic review.

INTRODUCTION: There is no literature review comparing outcomes of fixation using carbon-fibre-reinforced polyetheretherketone (CFR PEEK) compared to metal implants used in orthopaedic extremity trauma surgery. A systematic review was performed to compare CFR PEEK to metal implants for clinically-important fracture outcomes. METHODS: A search of the online databases of PubMed/Medline, EMBASE and Cochrane Database was conducted. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A meta-analyses was performed for functional outcomes in proximal humerus fractures converting the score differences to standard mean difference units. GRADE approach was used to determine the level of certainty of the estimates. RESULTS: Two prospective randomised controlled trials and seven comparative observational studies with a total of 431 patients were included. Of the nine studies included, four compared the use of CFR PEEK against metal plates in proximal humerus fractures. Aggregated functional scores across the proximal humerus studies, there was a small signal of better improvement with CFR PEEK (SMD 0.22, 95% CI -0.03 to 0.47, p = 0.08, low certainty). Greater odds of adverse events occurred in the metal group (OR 2.34, 95% CI 0.73 to 7.55, p = 0.15, low certainty). CONCLUSIONS: Low to very low certainty evidence suggests a small improvement in functional recovery with CFR PEEK in proximal humerus fractures. This may be mediated through a small reduction in major adverse events related to fracture healing and stability. There is currently insufficient evidence to support the widespread use of CFR PEEK implants in fracture fixation. LEVEL OF EVIDENCE: Level IV.

Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates.

HYPOTHESIS: Several studies have shown good results with internal fixation of distal humeral fractures; however, few have focused specifically on anatomic parallel plate fixation using the same implant and postoperative regimen. The purpose of this study was to determine the functional outcome after open reduction and internal fixation of these complex fractures using parallel precontoured anatomic plates. MATERIALS AND METHODS: This was a retrospective single-surgeon series involving 16 patients (12 women, 4 men) treated with a double-column parallel plating technique. Clinical assessment included the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH). Mean age was 43 years (range, 20-78 years). Average follow-up was 35 months. Four fractures were AO type A and 12 were AO type C. RESULTS: Union was achieved in all patients. There was no superficial or deep infection or hardware failure. Two patients required removal of plates for pain and prominence but not all screws could be completely removed. The mean flexion was 132 degrees and extension was 29 degrees . The mean DASH score was 46.1. Grip strength was 56% of the uninjured side. Mean flexion and extension force was 72% and 70%, respectively, of the uninjured elbow. The mean MEPS score was 72.3. DISCUSSION: Anatomically precontoured parallel plates are effective in achieving bony union with low implant failure with acceptable functional outcomes. However, screw extraction can be difficult when the implant is removed.

Operative management of intra-articular distal interphalangeal joint fractures of the hand.

The management of intra-articular fractures of the hand represents a challenge. Large articular fragments require reduction and operative fixation. A number of surgical techniques have been described in literature, with variable results. Distal interphalangeal joint fractures have been fixed by various methods including screw, plate and suture techniques. Generally operative fixation is indicated when more than 30% of the articular surface is involved with or without subluxation of the joint. The aim of surgery is to reduce the fracture fragments anatomically whilst providing osseous stability, and to commence early active movement of the joint to prevent stiffness. In this review we aim to summarise the main management options for intra-articular distal interphalangeal fractures, placing particular emphasis on surgical treatment.

Good result after surgical treatment of Pellegrini-Stieda syndrome.

Ossification of the femoral attachment of the medial collateral ligament (MCL) of the knee with associated pain and restricted movements is rare and is characteristic of the Pellegrini-Stieda (PS) syndrome. Although in mild cases conservative treatment is often successful, patients with more significant bone formation and persistent symptoms require surgical excision. We describe a case of PS syndrome with a description of the surgical technique consisting of excision of the bony lesion and reconstruction of the MCL by using the adductor magnus tendon.

Removal of broken solid femoral nail: a modified bent tip guide wire technique.

A broken solid femoral nail can be challenging to remove. We describe a modified bent tip guide wire technique for extraction of a broken solid retrograde femoral nail from the proximal femur. The broken nail was removed successfully through the original retrograde entry point to allow for an exchange femoral nailing in a patient with a hypertrophic non-union. This novel technique avoids any additional exposure other than that required to remove and insert the nail.

Is the tip of the greater trochanter a reliable reference for the rotation centre of the femoral head in total hip arthroplasty?

A variety of techniques have been used to determine intra-operative leg length during total hip arthroplasty. One method often described is using the tip of greater trochanter as the reference for the rotation centre of the femoral head to align the femoral component. There is little in the literature to support this method of leg length restoration. We analysed standard anterior-posterior pelvic radiographs of 225 patients with osteoarthritis of the hip who were about to undergo total hip arthroplasty. The distance between the tip of the greater trochanter and the rotation centre of the femoral head was measured for the affected hip. The average location of the tip of greater trochanter is 3.4 mm proximal to the centre of the femoral head, with a range from 20 mm proximal to 10 mm distal to the femoral head centre. There is considerable variation in the anatomy of the proximal femur; however, with adequate preoperative templating, the greater trochanter can be a helpful guide to determine the rotation centre of the femoral head of the femoral component and should be used with other conventional techniques to determine leg length intra-operatively.

Assessment of lower limb rotational profile and its correlation with the tibial tuberosity-trochlea groove distance: A radiological study.

OBJECTIVE: The purpose of our study was to determine whether there is a correlation between the lower limb rotational profile and tibial tuberosity-trochlea groove (TT-TG) distance. DESIGN AND PATIENTS: The computed tomography cross-sectional imaging on 50 patients' lower limbs (100 limbs) was investigated at our institution. The TT-TG distance was measured along with rotational measurements including femoral version (FV), tibial torsion and knee joint rotation angle (KJRA). Patients were divided into two groups. Group 1 had a TT-TG ≥ 20 mm which was considered pathological and group 2 with a non-pathological TT-TG (≤19 mm). Rotational angles were compared between groups. Statistical analysis was performed using the t-test and Mann-Whitney U analysis. RESULTS AND CONCLUSIONS: Our results demonstrated a statistically significant difference in the mean KJRA (p = 0.026) between the pathological (mean = 10.6, standard deviation (SD) = 7.79°) and the non-pathological TT-TG groups (mean = 6.99, SD = 5.06°). A higher mean value for FV and tibial torsion was also demonstrated in patients with a pathological TT-TG (18.2 vs. 13.7, 32.8 vs. 30.9, p > 0.05, respectively). In conclusion, there was a statistically significant higher mean value for the KJRA in patients with a pathological TT-TG. Hence, a lateralized tibial tubercle as demonstrated by an increase in the TT-TG distance may be associated with a coexisting lower limb rotational malalignment.

Biomechanical comparison of pull-out force of unicortical versus bicortical screws in proximal phalanges of the hand: a human cadaveric study.

BACKGROUND: Bicortical fixation of proximal phalangeal fractures may damage underlying flexor tendons secondary to drilling and screw protrusion in the dorsal-ventral direction. The aim of this study was to measure and compare the pull-out force of unicortical screws compared to bicortical screws in human cadaveric proximal phalanges to identify optimal configuration for internal fixation. METHODS: Forty proximal phalanges were harvested. Bicortical and unicortical self tapping 1.7mm screws were inserted into paired phalanges at the distal and proximal metaphysis and at the mid-diaphysis placed in the dorso-ventral direction. Pull-out force of unicortical and bicortical screws were measured and compared. FINDINGS: Bicortical screw pull-out force is significantly higher than that of unicortical screws in the dorsal-ventral direction. Pull-out strength of unicortical screws at the mid-diaphysis was significantly higher than the pull-out strength of bicortical screws at the proximal metaphysis (181.8N versus 31.5N, P<0.0001). INTERPRETATION: Diaphyseal fixation is stronger than metaphyseal for both unicortical and bicortical configurations. Unicortical mid-diaphyseal is stronger than bicortical proximal metaphyseal screw pull-out strength. This study provides biomechanical data that may be helpful for individualizing fracture fixation techniques at the proximal phalanx.

Using three-dimensional rapid prototyping in the design and development of orthopaedic screws in standardised pull-out tests.

The majority of orthopaedic screws are designed, tested and manufactured by existing orthopaedics companies and are predominantly developed with healthy bone in mind. The timescales and costs involved in the development of a new screw design, for example, for osteoporotic bone, are high. In this study, standard wood screws were used to analyse the concept of using three-dimensional printing, or rapid prototyping, as a viable stage of development in the design of a new bone screw. Six wood screws were reverse engineered and printed in polymeric material using stereolithography. Three of the designs were also printed in Ti6Al4V using direct metal laser sintering; however, these were not of sufficient quality to test further. Both the original metal screws (metal) and polymeric rapid prototyping screws were then tested using standard pull-out tests from low-density polyurethane blocks (Sawbones). Results showed the highest pull-out strengths for screws with the longest thread length and the smallest inner diameter. Of the six screw designs tested, five showed no more than a 17% variance between the metal and rapid prototyping results. A similar pattern of results was shown between the screw designs for both the metal and rapid prototyping screws in five of the six cases. While not producing fully comparable pull-out results to orthopaedic screws, the results from this study do provide evidence of the potential usefulness and cost-effectiveness of rapid prototyping in the early stages of design and testing of orthopaedic screws.

Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital.

The RCS has published clear and succinct guidelines dictating the necessity for the documentation of legible and timely surgical operative notes and exactly what should be included. A baseline study within the upper limb unit at our trust showed a 71.1% adherence with the RCS guidelines with an average delay of typing of notes after dictation was 11.6 days. This quality improvement project designed and developed a bespoke electronic surgical notes template built within an existing database driven software within the Trust. After implementation of the templates we found no delays in full operative notes being typed and a 100% adherence with the RCS guidelines. This project significantly improved the quality and timely production of electronic surgical notes within a sustainable electronic software solution.

Acetabular rim profile measurement in femoroacetabular impingement patients - biomed 2011.

Morphological variations in hip joint anatomy are a possible mechanism for femoroacetabular impingement (FAI) which leads to hip osteoarthritis. Significant geometric variations of the acetabular rim exist between patients including variations in depths of the postereosuperior depression (PSD) and psoas valley (PV). Computed tomographic scans of 48 FAI patients were segmented to create three-dimensional bone reconstructions. A pelvic plane was established using bony landmarks at the inferior iliac spines and the pubis. Placing a sphere on the articular surface of each acetabulum, the center of rotation was found. A curve was drawn on the acetabular rim to extract equally spaced points (0.67mm) to maximize output for an accurate representation of the profile. The acetabular plane was fit to the points using the least-squares method and translated to the center of rotation. The rim points were converted to cylindrical coordinates in degrees along the acetabulum and depth with respect to the mean acetabular plane. The mean depth of the PSD and PV were 7.27mm (SD 1.99) and 4.65mm (SD 2.12), respectively. The affected FAI hip was the right hip in 25 patients and the left hip in 23 patients. Comparisons were made on a per-patient basis between the acetabulum with FAI and without, and FAI hips had an increased coverage of the femoral head by the acetabulum. The appearance of cam and/or pincer impingement was also noted. The novel method of quantification of morphometric variations in the acetabular rim will further aid in understanding the development of FAI.