The changing epidemiology of radial head replacement over a 22-year period in Scotland.

BACKGROUND: Radial head replacement is used to confer joint stability in the management of acute unstable elbow fractures and dislocations associated with instability. We determined the annual incidence of radial head replacement over a 22-year period in a defined population. MATERIALS AND METHODS: Hospital episode statistics were collected prospectively at a national level. This database was retrospectively examined to determine the annual incidence of radial head replacement over the study period in adults over 16 years of age. RESULTS: A total of 615 radial head replacements were performed over the 22 years studied. The overall incidence was 0.65/100,000/year (95% confidence interval, CI, 0.50-0.71). The average adult population during the period was 4,270,593. There was a steady and statistically significant increase in the incidence of radial head replacement over the study period (r 2 = 0.816; p < 0.0001). This incidence was significantly greater in women than men (odds ratio 1.46, 95% CI 1.25-1.72; p < 0.001). The peak incidence in men was 0.87/100,000 population/year in the fifth decade of life while in women the peak incidence was in the seventh decade of life (1.38/100,000 population/year). CONCLUSION: The incidence of radial head replacement has increased steadily over 22 years. We hypothesise that this represents an evolving understanding of the role of radial head replacement in acute trauma in the context of emerging literature during the study period.

Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care.

OBJECTIVES: "Virtual fracture clinics" have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a "top-down" analysis of the cost effectiveness of this virtual fracture clinic pathway. METHODS: National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. RESULTS: The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. CONCLUSIONS: The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings.Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33-36. doi: 10.1302/2046-3758.52.2000506.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

OBJECTIVES: Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. DESIGN: A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. SETTING: An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. PARTICIPANTS: 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. OUTCOME MEASURES: Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. RESULTS: Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. CONCLUSIONS: This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

Outcomes of open arthrolysis of the elbow without post-operative passive stretching.

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.

Open arthrolysis for post-traumatic stiffness of the elbow: results are durable over the medium term.

We present a retrospective study of 25 patients treated by open arthrolysis of the elbow for post-traumatic stiffness. The mean follow-up was for 7.8 years (5 to 10.8). The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 55 degrees (0 degrees to 95 degrees ) to 105 degrees (55 degrees to 135 degrees) was obtained in our patients at one year. This improvement was maintained over the mean follow-up period of 7.8 years (5 to 10.8). Improvement in pain, function and patient satisfaction was recorded in 23 of the 25 patients at final follow-up. On the basis of this study, we believe that the results of open arthrolysis for post-traumatic stiffness of the elbow are durable over the medium term.

A team approach to musculo-skeletal disorders.

INTRODUCTION: The majority of patients with musculo-skeletal problems referred to hospitals in the UK have to wait for months, if not over a year, before finally seeing an orthopaedic surgeon. In Stobhill Hospital, Glasgow, the waiting time for an out-patient appointment was 182 days in 1995, with only 20% of the referrals requiring surgery. The aim of this paper was to reduce the out-patient waiting times based on a co-ordinated team approach. METHODS: An outpatient musculo-skeletal service was developed over a 7-year period at Stobhill Hospital. The traditional consultant-based model, in which the consultant and a trainee saw all new patients referred to the hospital, was gradually replaced with a team approach, based on continuous reconfiguration of the roles of the orthopaedic surgeon and rheumatologist and extending the roles of nurses, physiotherapists and podiatrists. This was achieved by: (i) protocol-based daily triage for all referrals to the most appropriate health professional in the team, by the senior out-patient nursing staff; (ii) allocation of appointments based on clinical priority, with a fast-track for urgent cases; and (iii) improvement of inter-disciplinary communication, facilitating the retraction as well as the extension of traditional roles. RESULTS: Despite the number of GP referrals to the orthopaedic out-patient department at Stobhill nearly doubling in a period of 5 years, the out-patient waiting time decreased by about 50% (90 days from 182 days). This reduction in waiting times improved patient and GP satisfaction levels. We also noticed an improved morale and personal development of the health professionals as they saw patients appropriate to their skills and expertise. CONCLUSION: The team's experience demonstrates the effectiveness of a team approach in tackling what is often seen as the insoluble problem of orthopaedic waiting times. This is based on excellent communication and collaboration, with a clear aim of improving patient care that is evidence based.

The Baumann angle in supracondylar fractures of the distal humerus in children.

Radiologic assessment of fracture reduction in displaced supracondylar fractures of the elbow in children is notoriously difficult. The Baumann angle is often used as a guide to the adequacy of reduction. This is based on the assumption that the Baumann angle has a constant relationship to the carrying angle in a displaced fracture. The effect of rotation on the relationship between these angles has not been studied in detail. Computed tomography (CT) studies have shown that < or = 40 degrees of rotation may still be present after closed manipulation of a supracondylar fracture. A computer programme analysing vectors was designed to study the relationship between the Baumann angle and the carrying angle with predetermined displacements of the distal fragment. The relationship between the Baumann angle and the carrying angle was thus defined and, in contrast to the literature, found to be more complex than previously appreciated. The Baumann angle was found to be an inaccurate indicator of the carrying angle when treating displaced supracondylar fractures.

The role of cheilectomy in the treatment of hallux rigidus.

The aim of this study was to evaluate and compare the outcome of cheilectomy for patients with grades 1, 2, and 3 hallux rigidus according to Regnauld's classification. We evaluated 39 patients at a mean of 3.8 years after surgery for pre- versus postoperative changes in pain, activity level, difficulties with footwear, tiptoe walking, and metatarsophalangeal joint range of motion. We used Wilcoxon paired rank tests to compare outcomes for each grade of hallux rigidus. There was significant improvement (p < 0.05) in pain, activity level, tiptoe walking, and range of motion for all three grades of hallux rigidus. Footwear selection was significantly improved in Grades 1 and 2 patients but not in patients with Grade 3 hallux rigidus.

Supracondylar fractures of the distal humerus in children.

An audit of 32 displaced supracondylar fractures of the humerus in children treated at the Glasgow Royal Infirmary between June 1990 and September 1992 was carried out. Six fractures were classified as Grade 2 (one cortex intact) and 26 were Grade 3 (no cortical contact). All grade 2 fractures were treated non-operatively with good results. Relatively poor results were obtained when displaced fractures were treated non-operatively with manipulation and plaster immobilization. Seven patients underwent manipulation and percutaneous pinning but two developed a cubitus varus deformity. Open reduction and internal fixation with two K-wires gave the best results with no deformity in ten patients. We therefore conclude that this is the optimal method of treatment in a hospital which deals with relatively few completely displaced fractures, with the cosmetic appearance of the scar being minimized by a medial approach.

Primary replacement of the fractured radial head with a metal prosthesis.

Compression testing of cadaver specimens showed that excision of the radial head allowed proximal radial displacement. The insertion of a metallic radial head restored normal mechanics, while a silicone rubber implant did not. We reviewed 31 of 36 comminuted fractures of the radial head, 21 associated with dislocation or ulnar fracture, which had been treated by primary replacement with a Vitallium prosthesis. At a mean follow-up of 4.5 years, there was reliable restoration of stability and prevention of proximal radial migration. There had been no dislocations or prosthetic failures, but two implants had been removed for loosening. The prosthesis is recommended for use as a spacer to stabilise the elbow after severe injuries while the soft tissues heal.

Reliability of the acetabular teardrop as a landmark.

This study investigated the effect of tilt and observer reliability on radiographic measurements of the position of a prosthetic acetabular cup in seven dry bone pelves using the teardrop as a landmark. Coronal or sagittal tilt of more than five degrees was easily recognisable and there was effectively no observer variation in the measurements up to this limit. In addition, 90 out of 100 randomly selected antero-posterior pelvic radiographs from an outpatient department were not significantly rotated and 93 demonstrated a clearly defined teardrop. Measurements about the teardrop on routine radiographs are therefore sufficiently accurate to allow assessment of prosthetic position.

Rupture of flexor digitorum profundus to the index finger after a distal radial fracture.

Attrition ruptures of flexor tendons to the fingers following Colles' fractures are very rare. In the case reported here, a protruding bony fragment caused a delayed rupture of the flexor digitorum profundus tendon to the index finger one year after a fracture of the distal end of the radius. Suture of the distal end of the tendon to the adjacent profundus tendon two years after the fracture produced a successful result.

Long-term effects of excision of the radial head in rheumatoid arthritis.

The effects of synovectomy and excision of the radial head in 40 elbows affected by rheumatoid arthritis have been assessed. In contrast with many reports indicating minimal side-effects of this procedure, a common pattern of deterioration from what was often a satisfactory initial result has been demonstrated. A biomechanical theory of one of the factors responsible for failure has been put forward and the importance of conserving or replacing the radial head emphasised.

Bony lacerations caused by assault.

Eight cases of unstable fractures caused by sharp heavy weapons such as swords or machetes are presented. A modern approach to these injuries is described against the historical background.