The Irish National Joint Registry: where are we now?

BACKGROUND: Ireland is currently in the process of establishing a National Joint Registry. AIM: We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland. METHODS: The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland. RESULTS: We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used. CONCLUSIONS: The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.

Publication rates of presentations at the Irish Orthopaedic Association annual meeting.

BACKGROUND: Presentation of scientific research at national and international meetings is an important forum for the dissemination of knowledge. Subsequent publication of a full-text paper in a peer-reviewed journal is the expected outcome of such presentations. The publication rate from these meetings is highly variable. AIMS: To determine the publication rate of abstracts presented at the Irish Orthopaedic Association's Annual Conference and to determine which factors are associated with progression to full-text publication. METHODS: We reviewed the proceedings from the Irish Orthopaedic Association's National Meeting over a 4 year period. We searched the Pubmed database using author names, institution names, and keywords from each abstract's title, to determine how many presented articles progressed to full-text publication. RESULTS: Sixty-six of 203 were published, 97 % within 5 years of presentation. Laboratory based studies presenting novel or innovative findings were more likely to be published than clinical studies. Clinical studies were more likely to be published if they were prospective and had a longer period of follow-up. Retrospective audits were less likely to be published, even with a large cohort size. Changes in authorship of presented papers were related to a longer delay in time to full-text publication. CONCLUSIONS: Thorough planning of research studies is essential to ensure a timely progression to full-text publication in a peer-reviewed journal. Most studies will be published within 5 years of initial presentation.

The effect of inclement weather on ankle fracture management in an Irish trauma unit.

INTRODUCTION: Ireland is unfamiliar with extreme weather conditions. Such conditions occurred in winter 2009-2010 and 2010-2011, with much of the country being affected by snow and ice. We reviewed the effect that these conditions had on the treatment of ankle fractures in our trauma unit. MATERIALS AND METHODS: The study period was from November until February for four consecutive years from 2008-2009 until 2011-2012. We compared two winters with extreme weather with two winters with regular weather conditions. Information from Met Eireann was compared with demographics from patient records to differentiate ice-related injuries from non-ice-related injuries. Ankle fractures were classified using the Lauge-Hansen classification. We compared waiting times in A&E, waiting times for theatre, delays relating to injury severity, and overall length of stay for both groups. RESULTS: We identified 44 ice-related injuries and 67 non-ice-related injuries. Ice-related injuries trended towards more severe fracture configurations using the Lauge-Hansen classification. Patients sustaining ankle injuries during inclement weather were significantly younger than patients sustaining injuries during regular weather conditions. There were no other significant differences between the two groups. DISCUSSION: Ice-related injuries trended towards a greater severity of fracture configuration. We identified no significant increase in the time to treatment or overall length of stay of patients sustaining ankle fractures during these times. Ice-related injuries did not have greater rates of complications. These results are a testament to the trauma staff in this unit who absorbed the increased workload without compromising patient care.

Research in higher surgical training: which rotation?

BACKGROUND: Orthopaedic higher surgical trainees in Ireland are allocated to one of eight training rotations. Each trainee is expected to publish at least one research paper per year during training. AIM: To assess the research productivity of each training rotation over a 10-year period. METHODS: A PubMed search was performed for each orthopaedic unit affiliated to higher surgical training (HST) in order to identify full-text research papers published between 2001 and 2010. The results were analysed to determine which training rotations are most productive in terms of research. RESULTS: We identified 267 papers published from 16 units over the 10-year period. There were substantial differences in the number of papers published from each unit, and substantial differences between the eight set trainee rotations. CONCLUSIONS: It is essential that each trainee makes an honest assessment of their potential for conducting and producing valuable and relevant research, and chooses an HST rotation that is appropriate to their needs. Publication of research articles is easier to achieve on some HST rotations than on others.

Correlation of intra-articular osseous measurements with posterior cruciate ligament length on MRI scans.

Six patients with a clinical diagnosis of chronic posterior cruciate ligament (PCL) rupture, based on a positive posterior drawer test, had a normal appearance of the PCL on an MRI scan. It is postulated that the PCL had been ruptured but healed in a lengthened state. 12 volunteers with no history of knee trauma underwent an MRI scan of the knee. In this control group (n = 12), there was a close correlation between the lateral femoral condylar width in the sagittal plane and the PCL length, with a ratio of 2:1 (95% confidence interval (CI) = 1.817-2.095). In the clinically abnormal group (n = 6), the ratio was 1.49:1 (95% CI = 1.206-1.782) (p< 0.0005). In conclusion, the ratio of the lateral femoral condylar width in the sagittal plane to the PCL length is a useful index for diagnosing PCL attenuation and lengthening in the presence of a normal morphological MR appearance.

Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus.

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

Nail-gun limb injuries.

We present four cases and a review of the literature regarding nail-gun related limb injury. Nail guns have significant potential to cause limb and other major injuries. In most cases improper use of the nail-gun is the single most important factor in causing such types of injuries. Treatment of these injuries requires careful assessment of the limb and the type of nail involved in order to enable safe extraction. We recommend the introduction of training in the workforce to encourage awareness of the danger of such devices. We also emphasize the continuing requirements for improved workplace safety and adequate safety equipment when working with such dangerous devices.

Scoring systems in trauma.

BACKGROUND: Trauma is a major cause of mortality and morbidity worldwide. Methods of assessing outcome have evolved with management of trauma victims. RESULTS AND DISCUSSION: The wide variety of scoring instruments available to assess the injured patient may be divided into three groups: anatomical, physiological and combined systems. Anatomical systems depend on an accurate description of the injuries sustained. Physiological systems measure the effects of injury on the patient's physiological reserves. Combined systems contain elements of both anatomical and physiological scores. Prospectively, scoring systems help in description, triage, treatment decisions and estimating outcome. Retrospective scoring is helpful in audit, in quality control, in comparing treatment methods or centres, and in identifying unexpected outcomes. Limitations may be inherent in the system or may reflect inaccurate or incomplete data collection.

Carpal malalignment following intra-articular fractures of the distal radius in a working population.

In a review of 52 consecutive intra-articular fractures of the wrist (mean age 41 years), 18 developed one of five carpal malalignment patterns. Seven patients developed a volar intercalated collapse pattern. Although showing some loss of motion and/or grip strength, this group remains relatively pain free on follow-up. Patients who developed dorsal translation (six cases) or a dorsal intercalated collapse pattern (one case) were the most symptomatic, with loss of grip strength, decreased range of motion and pain being prevalent.

Articular fractures of the digits: a prospective study.

We report a prospective study of 92 articular fractures of the digits. The treatment protocol was based on functional stability and acceptable alignment rather than on joint congruity. 54% of patients had good results, with 22% fair and 24% poor results being recorded. These results are similar to reports of treatment of finger fractures in general and suggest that for articular fractures of the digits, stability and alignment are more important factors than joint congruity in determining short-term outcome. Compound fractures and those associated with comminution, significant soft tissue damage and marked displacement at presentation have a worse prognosis.

Operative fixation of unstable pelvic ring injuries in polytrauma patients.

Sixteen polytraumatized patients with a variety of unstable pelvic ring fractures were treated with operative fixation. We have found that an aggressive approach with adequate early stabilization of the pelvis offers many advantages over conservative management particularly in polytraumatized patients.

Lunate Silastic arthroplasty in Kienbock's disease.

The use of Silastic lunate replacement for Kienbock's disease has many advocates. We reviewed the long-term results of eight patients who had this procedure performed. Although good short-term results were obtained, this was not maintained and only two patients were regarded as satisfactory at an average follow-up time of 44 months. Evidence of synovitis was apparent in seven cases. It is now our view that if surgical intervention is necessary for this condition, the best surgical option is probably a scapho-trapezio-trapezoid fusion.

Imaging of intramedullary tumour spread in osteosarcoma. A comparison of techniques.

The level of bone resection for osteosarcoma depends on the pre-operative evaluation of the extent of intramedullary tumour. We compared the accuracy of magnetic resonance imaging (MRI), computerised tomography (CT), and isotope bone scanning with the actual extent of the tumour in the resected specimens from 34 patients with primary osteosarcoma of a long bone. The extent of medullary tumour was defined accurately in 23 of 24 MRI scans (96%) and 24 of 32 CT scans (75%). A flexion contracture of a joint close to the tumour was an important cause for inaccurate measurements from both MRI and CT scans. Isotope bone scanning was inaccurate: its role is now confined to detecting skeletal metastases and skip lesions.

Thrombocytopenia--radial aplasia (TAR) syndrome with associated immune thrombocytopenia.

We report a 10 year old girl with congenital thrombocytopenia with absent radii (TAR) syndrome. Unusually this patient has shown no abnormal bleeding tendency despite numerous orthopaedic procedures. There is evidence of an associated immune component to the thrombocytopenia which has not been previously documented.

Benign synovioma presenting as mechanical abnormality in large lower limb joints.

Benign synovioma is a rare cause of symptomatic instability of joints of the lower limb. We report two cases presenting in this way. Arthrotomy is indicated to ensure adequate excision of these lesions if recurrence is to be avoided.