A national survey of United Kingdom trauma units on the use of pelvic binders.

PURPOSE: Major pelvic injuries resulting from high-energy trauma require emergency hospital treatment, and part of the initial management includes mechanical stabilisation of the pelvis. Controversies include binder position, use in lateral compression injuries and application during radiological assessment. We present the results of a survey of both emergency department and orthopaedic specialties. METHODS: A telephone survey of all 144 trauma units in the UK accepting adult pelvic trauma patients was carried out in July 2012. The duty registrar for the emergency and orthopaedic departments was contacted and asked to complete a questionnaire. RESULTS: A response rate of 100% was achieved. Pelvic binders were available for use in approximately three quarters of the trauma units surveyed. Eight-five emergency department (59%) and 79 orthopaedic (54.9%) registrars had been given training on pelvic binder application. Fifty-six emergency department (38.9%) and 114 orthopaedic (79.1%) registrars identified the level of the greater trochanters as the most suitable position for the binder. Forty-five emergency department (31.3%) and 58 orthopaedic (40.3%) registrars used pelvic binders in suspected lateral compression injuries. One hundred and twenty-six emergency department (87.5%) and 113 orthopaedic (78.5%) registrars would not release the binder during radiological assessment of the pelvis in a haemodynamically stable patient. CONCLUSION: There is great variability in practice amongst trauma units in the UK. Training must be formalised and provided as a mandatory part of departmental induction. The use of standardised treatment algorithms in trauma units and the Advanced Trauma and Life Support (ATLS) framework may help decision making and improve patient survival rates.

The Bicontact cementless primary total hip arthroplasty: long-term results.

We report on a prospective series of 201 primary uncemented total hip arthroplasties with a Bicontact prosthesis at a mean follow-up of 12.9 years. The mean Harris hip score improved from 41 before surgery to 89 at final follow-up. Two femoral stems, one each for infection and fracture, and 12 cups were revised. The mean number of years to revision post-primary surgery was 8.7 years (six months to 16 years). The cumulative survival of the prosthesis was 95.42% for any cause at ten years and 93.57% at 12 years. Survivorship for aseptic loosening of the femoral stem was 100%. In our series, the Bicontact uncemented total hip arthroplasty stem without hydroxyapatite coating showed excellent survival and the cup survival was comparable to other leading series.

Arthroscopic radial head excision in managing elbow trauma.

PURPOSE: This study describes a case series of 15 patients with radial head fractures who underwent radial head excision using an arthroscopic technique. METHODS: Over a four year period, 15 patients (average age 49.6 years) who had sustained a radial head or radial neck fracture underwent an arthroscopic excision of the radial head. Four patients had an unreconstructable comminuted fracture (early group; EG) and 11 patients had pain and loss of motion with an associated non- or malunion (late group; LG). RESULTS: The mean time to surgery following injury was three weeks (one to five) for the EG and 27 weeks (eight-58) for the LG. The average visual analogue scale (VAS) was 1.7 (zero to four), and the average Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score was 24.7 (16-44). At final follow-up, average supination was 62.0° (range 45-75°) and pronation was 63.3° (range 45-75°). There were no complications. CONCLUSION: This series demonstrates that arthroscopic excision of fractures of the radial head and neck is reliable, reproducible and safe, with similar results to open excision. There may also be additional benefits in the short term with regards to speed of healing and rehabilitation.

Use of articular wrist views to assess intra-articular screw penetration in surgical fixation of distal radius fractures.

The use of volar locking plates for fixation of distal radius fractures is increasing in modern orthopedic practice. They have the advantage of limited dissection, early mobilization, and improved function over previous fixation devices. Standard anteroposterior and lateral radiographs would normally be requested by the orthopedic team, but these may not give an accurate representation of the articular anatomy of the fracture fixation. This study evaluated the effectiveness of a series of radiographs, the articular wrist series, which accurately represent the wrist joint and clarify doubt regarding screw placement or articular congruity. With this method, 2 additional radiographs are taken and are oriented in such a manner as to produce an image parallel to the radiocarpal joint on both anteroposterior (11 degrees elevation) and lateral (23 degrees elevation) projections. Since the introduction of such a system, we have been able to interpret radiographs in this setting much more easily.

The outcome of Morton's neurectomy in the treatment of metatarsalgia.

Morton's neuroma is a common cause of metatarsalgia caused by intermetarsal digital nerve thickening. This study reviews the pathology, presentation, symptoms and signs, and patient satisfaction with surgical treatment. Seventy-eight patients (82 feet) were treated for Morton's metatarsalgia by excision of the interdigital nerve. The patients were followed-up for a mean of 4.6 years (range 0.8-8.1 years) and scored using the Foot Functional Index and the American Orthopedic Foot Ankle Society scoring system. In 74 patients the Foot Functional Index was more than 85 (maximum score 100). Seventy-one patients scored more than 90 on the American Orthopedic Foot Ankle Society scoring system with two patients scoring 100 (maximum score). Postoperatively, 82% reported excellent or good results, 10% had a fair result with restriction of activities or pain and 8% had no improvement at all after surgery while 71% had restrictions with footwear.

Technique tip: tubularizing flat tendons in foot and ankle surgery.

We describe a novel technique of tubularizing flat tendons in tendon transfer procedures, including Jones procedure and Chrisman-Snook reconstruction. The technique strengthens the tendon, facilitates passage and fixation through bony tunnels, and helps protect it from fraying.

The effect of patient position on blood loss in primary cemented total hip arthroplasty.

INTRODUCTION: The total blood loss of 101 cemented primary total hip arthroplasties was studied in a prospective randomised study. MATERIALS AND METHOD: Fifty of them were implanted in the supine position and 51 in the lateral position. The patients were matched for sex, height, weight and ASA grade. Only one surgeon carried out the operations using the same operative technique and identical prosthesis in both groups. RESULTS: The intraoperative blood loss associated with the supine position was 1,156 ml (954-1,265 ml) and 1,129 ml (989-1,310 ml) in the lateral position. There was no difference when comparing the two groups (P = 0.41). CONCLUSION: Patient positioning in supine or lateral during total hip arthroplasty surgery has no bearing on the total amount of blood loss.

Preoperative computerized radiograph measurement of Blumensaat's line as an aid to correct placement of the femoral tunnel in ACL reconstruction.

Numerous studies have shown that the improper placement of the graft in anterior cruciate ligament reconstruction is a major cause of graft failure, capturing of the knee, and notch roof impingement. The ideal femoral position is located in the posterior one quarter of Blumensaat's line as seen on a true lateral knee radiograph. We present a simple method that relies on the use of preoperative radiographic measurement and a calibrated guide to ensure that the femoral tunnel is sufficiently far back along the roof of the notch, using the easily identifiable anterior end of the notch as a reference point.

Outcome scoring system evaluation of knee osteoarthritis in patients awaiting TKA.

One hundred and twenty-four patients with knee osteoarthritis were reviewed at three stages over a mean of 24 months (range: 9-32 months) at the time of referral by the general practitioner, by the orthopedic consultant, and before surgery. At each visit, patients were examined and the American Knee Society score and Oxford Knee Society score were obtained. The functional element of the American Knee Score deteriorated significantly from the time of referral until the time of first orthopedic consultation (P=.005) and from the time of referral to the time of surgery (P=.006). The pain element of the American Knee Society score improved from the time of referral till the time of orthopedic assessment (P=.011). The change in Oxford Knee Society score between the time the patient was put on the waiting list to the time of surgery was not statistically significant (P=.30). This article questions the emphasis on surgical waiting times instead of symptoms and physical function in determining timing of surgery.

Paediatric transverse divergent dislocation of the elbow.

Paediatric elbow dislocations are uncommon injuries, accounting for 3-6% of all elbow injuries in childhood. A divergent elbow dislocation is an even more infrequent injury, where in addition to the elbow dislocation there is divergence of the proximal radius and ulna, either in a transverse (extremely rare) or in an anteroposterior plane, as a result of the distal humerus being forced between the proximal ends of the forearm bones. The lesion results from indirect forces transmitted to the elbow from a fall on the outstretched hand. The authors report a case of transverse divergent elbow dislocation in an 8-year-old boy, treated by closed reduction and immobilisation in a cast. At 6 months follow-up the patient had regained a full range of motion, without instability or pain.

Congenital vesical diverticulum in a 38-year-old female.

A 38-year-old female with a history of psychiatric illness presents with irritative urological symptoms and is diagnosed as having a large congenital vesical diverticulum (Hutch diverticulum). An overview of the aetiology, classification and complications of diverticula together with indications for and management of bladder diverticula is discussed. This is the first documented case of a very large symptomatic congenital diverticulum in a female presenting in the third decade of life and emphasizes the importance of ultrasound in irritative urological symptoms resistant to medication.

Testicular infarction and rupture after blunt trauma--use of diagnostic ultrasound.

We report the case of a 23-year-old male who suffered localised testicular infarction and rupture following blunt trauma. This pathology is rare after blunt trauma and has not been previously described in literature. The appearance on ultrasound resembled malignancy, necessitating orchidectomy. An overview of the pathology of testicular trauma as well as its management is given with particular emphasis on the use diagnostic ultrasound in testicular trauma.

Spontaneous non-traumatic dislocation of the knee.

Ligamentous injuries of the knee occur during sports and where there is extensive injury associated with subluxation or dislocation. We present a case of an obese female who sustained spontaneous non-traumatic posterior knee dislocation when she caught her foot while rising from the sitting down position. There was associated peroneal nerve injury but an angiogram confirmed no vascular compromise. Surgical ligamentous reconstruction was undertaken.

Sharps injury reporting amongst surgeons.

INTRODUCTION: The aim of this study was to evaluate the level of sharps injury reporting amongst surgeons. SUBJECTS AND METHODS: A total of 164 surgeons completed a questionnaire on the reporting of sharps injuries, on the reasons for not reporting and their practise of universal precautions. RESULTS: Out of 164 surgeons, only 25.8% had reported all their injuries, 22.5% had reported some and 51.7% had reported none. The top three reasons for not reporting their injuries included perception of low risk of transmission, not being concerned and no time. Of the respondents, 15.9% practised all three universal precautions of double-gloving, face shields and hands-free technique. CONCLUSIONS: We showed that despite local trust adherence to Department of Health policy, sharps injury reporting rates are inadequate. Further investment into healthcare worker education as well as a facilitation of the process of reporting may be necessary to improve reporting rates.

Outcome of glenoid neck fractures.

The aim of this study was to analyze the outcome of extraarticular glenoid neck fractures with respect to glenoid neck malunion and rotator cuff injury. These fractures are often considered to have a favorable outcome if treated conservatively. More recent studies reveal that the outcome is not uniformly good, but the cause of poor outcomes has not been investigated. Our study identified 9 patients who had sustained a glenoid neck fracture of the scapula within the last 10 years and who were treated conservatively with immobilization and then early active motion. Their functional and anatomic outcomes were analyzed by clinical examination and validated scoring systems, including the Oxford questionnaire and Constant score. Plain radiography and magnetic resonance imaging were correlated to outcome. None of the 9 patients were pain-free, and some had poor Oxford and Constant scores. Pain was associated with glenoid neck malunion and evidence of subacromial bursitis or rotator cuff tendinopathy (or both).