Tönnis angle and acetabular depth ratio: predictors of dislocation following hemiarthroplasty for hip fracture.

BACKGROUND: Despite efforts to mitigate possible modifiable risk factors, dislocations following hemiarthroplasty for hip fracture still occur, with reported incidence rates ranging from 1.5 to 11%. The aim of this study was to investigate whether acetabular dysplasia is a significant contributing factor to dislocation, and since non-modifiable, whether it should affect patient selection for this treatment option. METHODS: This is a multicentre nested case-control study of patients treated at 2 separate centres over a 10-year period from January 2011 to December 2020. All cases of hemiarthroplasty dislocation following hip fracture were identified from local databases, and 4 random controls were selected for every case. Tönnis angle (TA) and Acetabular-depth-ratio (ADR) was measured on the injured side using AP pelvis radiographs. Patients with TA > 10° and/or ADR < 250 were considered to have abnormal acetabular morphology. RESULTS: 35 cases of dislocation were identified and 140 random controls were selected. Cases of dislocation had a larger mean TA (8.8° vs. 5.5°, p < 0.001) and lower mean ADR (254 vs. 289, p < 0.001) than controls. 20 out of 35 (57%) cases were considered to have abnormal acetabular morphology, compared to 19 out of 140 (14%) controls. The odds of dislocation is 8.5 times greater (odds ratio = 8.49, 95%CI = 3.73, 19.39) in patients with abnormal TA and/or ADR. CONCLUSIONS: This study demonstrates that TA > 10° and ADR < 250 are useful criteria to identify patients at greater risk of hip hemiarthroplasty dislocation due to acetabular dysplasia. Special consideration to preoperative planning should be taken in these patients. Future research should focus on methods to minimise risk in this subset of patients, including evaluating total hip arthroplasty with dual mobility component vs hemiarthroplasty.

Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation.

OBJECTIVES: Distal femoral fractures occur in patients with osteoporotic bone and also as a consequence of high energy trauma. The recognised treatment options include closed or open reduction of the fracture and fixation using a locking plate or a femoral nail. Both these fixation modalities have some drawbacks. There is a risk of metalwork failure with single lateral locking plates and limited distal fixation with intramedullary nails. Since January 2018, we started using augmented fixation of distal femoral fractures using a combination of a retrograde femoral nail and a lateral locking plate. This study compares the outcomes of single lateral femoral plating (SLP) and combined nail-plate fixation (NPF). METHODS: This is a single centre retrospective case control study including all patients who sustained distal femoral fractures (OTA 33-A2, 33-A3, 33-C, 33-V3B and 33-V3D) over the study period. Outcomes for SLP were compared to NPF. The principal outcome measure was fracture union. Secondary outcome measures were reoperation rate, mortality and post-operative weight bearing status. RESULTS: 67 distal femoral fractures were included in the study. 19 patients had peri­prosthetic fractures. 40 were treated by SLP, 27 were managed with NPF.  23 (58%) patients in the SLP group were given instructions to non-weight bear or Toe touch weight bear for 6 weeks post-surgery compared to 1 (4%) in the NPF group (p = 0.000004). 7 (18%) patients treated with SLP had metalwork failure due to a non-union compared to none treated with NPF (p = 0.04). 11 fractures in the SLP group failed to unite compared to no non-unions in the NPF group (p = 0.01). These differences were magnified when assessing older (>50 years old) patients. CONCLUSIONS: Augmented fixation of distal femoral fractures using a nail plate fixation provided significantly higher union and enabled early weightbearing compared to single plate fixation. We recommend nail plate fixation for the treatment of distal femoral fractures, particularly in osteoporotic fractures.

The missing piece of the trauma armoury-medial femoral condyle plate.

Fixation of distal femoral fractures is often challenging due to the fracture configuration and associated poor bone quality. Dual plating (lateral and medial) has become an acceptable option to provide improved stability versus a single plate fixation. Though there are several commercially available anatomically designed plates for the lateral femoral condyle, there is no anatomic plate available in UK specifically for medial fixation of distal femur fractures. Our aim is to determine the best suited pre-contoured plate for stabilising the medial femoral condyle (MFC). Right sided femur sawbones were used to determine how well 18 different pre-contoured anatomical plates (Depuy Synthes, Leeds, UK) fit the medial femoral condyle. Some of these had variable angle (VA) option. Lift off, fit and notch penetration were assessed and recorded independently by 4 orthopaedic trauma surgeons. The number and distribution of screws in the MFC that each plate allowed was also determined. To do this the MFC was divided into quadrants: Proximal anterior (PA), distal anterior (DA), proximal posterior (PP) and distal posterior (DP). The ipsilateral anterolateral proximal tibial (VA and 4.5 mm non-VA), PHILOS, posteromedial proximal tibial and ipsilateral lateral extra-articular distal humeral plate offered good sagittal fit, less than 2 mm lift off at the condyles and no diaphyseal lift off. Plate positioning in the PA quadrant offered the best fit. The ipsilateral anterolateral proximal tibial plates (VA) and PHILOS allowed at least 4 screws to be placed in the PA and 2 in the PP quadrant with no notch penetration. The Tomofix provided good fit, but all 4 screws were in PA quadrant, with distal screws causing notch penetration. The non-VA and PHILOS plates did not offer the VA advantage. The ipsilateral anterolateral proximal tibial VA plates provided the best anatomical fit for the MFC with the greatest number of screws in the condylar quadrants with the option of variable angle screw placement.

Orthopaedic Surgeon Brain Radiation During Fluoroscopy: A Cadaver Model.

BACKGROUND: The aims of this study were to quantify exposure of the surgeon's brain to radiation during short cephalomedullary (SC) nailing, to extrapolate lifetime dose, and to determine the effects of personal protective equipment (PPE) on brain dose. METHODS: Two cadaveric specimens were used: (1) a whole cadaveric body representing the patient, with a left nail inserted to act as the scatter medium, and (2) an isolated head-and-neck cadaveric specimen representing a surgeon, with radiation dosimeters placed in specific locations in the brain. The "patient" cadaver's left hip was exposed in posteroanterior and lateral radiographic planes. Measurements were performed without shielding of the head-and-neck specimen and then repeated sequentially with different PPE configurations. An average surgeon career was estimated to be 40 years (ages 25 to 65 years) with the caseload obtained from the department's billing data. RESULTS: The mean radiation dose to the surgeon brain without PPE was 3.35 µGy (95% confidence interval [CI]: 2.4 to 4.3) per nail procedure. This was significantly reduced with use of a thyroid collar (2.94 µGy [95% CI: 1.91 to 3.91], p = 0.04). Compared with use of the thyroid collar in isolation, there was no significant additional reduction in radiation when the collar was used with leaded glasses (2.96 µGy [95% CI: 2.15 to 3.76], p = 0.97), with a lead cap (3.22 µGy [95% CI: 2.31 to 4.13], p = 0.55), or with both (2.31 µGy [95% CI: 1.61 to 3.01], p = 0.15). The extrapolated lifetime dose over 40 working years for SC nailing without PPE was 2,146 µGy (95% CI: 1,539 to 2,753), with an effective dose of 21.5 µSv. CONCLUSIONS: The extrapolated cumulative lifetime radiation to a surgeon's brain from SC nailing based on our institution's workload and technology is low and comparable with radiation during a one-way flight from London to New York. Of note, we studied only one of many fluoroscopy-aided procedures and likely underestimated total lifetime exposure if exposures from other procedures are included. This study also demonstrates that thyroid collars significantly reduce brain dose for this procedure whereas other head/neck PPE such as lead caps appear to have minimal additional effect. This study provides a methodology for future studies to quantify brain dose for other common orthopaedic procedures. CLINICAL RELEVANCE: This study, based on our institutional data, demonstrates that although the lifetime brain dose from SC nailing is low, thyroid collars significantly reduce this dose further. As such, in accordance with the "as low as reasonably achievable" radiation exposure principle, radiation safety programs and individual surgeons should consider use of thyroid collars in this setting.

Assessment of Head Displacement and Disassembly Force With Increasing Assembly Load at the Head/Trunnion Junction of a Total Hip Arthroplasty Prosthesis.

BACKGROUND: Most femoral components used now for total hip arthroplasty are modular, requiring a strong connection at assembly. The aim of this study was to assess the effect of assembly force on the strength of head-trunnion interface and to measure the initial displacement of the head on the trunnion with different assembly forces. METHODS: Three assembly load levels were assessed (A: 2 kN, B: 4 kN, C: 6 kN) with 4 implants in each group. The stems were mounted in a custom rig and the respective assembly loads were applied to the head at a constant rate of 0.05 kN/s (ISO7260-10:2003). Load levels were recorded during assembly. Head displacement was measured with a laser sensor. The disassembly force was determined by a standard pull-off test. RESULTS: The maximum head displacement on the trunnion was significantly different between the 2 kN group and the other 2 groups (4 kN, 6 kN, P = .029), but not between the 4 kN and 6 kN groups (P = .89). The disassembly forces between the 3 groups were significantly different (mean ± standard deviation, A: 1316 ± 223 kN; B: 2224 ± 151 kN; C: 3965 ± 344 kN; P = .007), with increasing assembly load leading to a higher pull-off force. For the 4 kN and 6 kN groups, a first peak of approximately 2.5 kN was observed on the load recordings during assembly before the required assembly load was eventually reached corresponding to sudden increase in head displacement to approximately 150 µm. CONCLUSION: An assembly force of 2 kN may be too low to overcome the frictional forces needed to engage the head and achieve maximum displacement on the trunnion and thus an assembly load of greater than 2.5 kN is recommended.

Review of evolution of tunnel position in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Improving communication with primary care to ensure patient safety post-hospital discharge.

INTRODUCTION: Successful communication between hospitals and primary care is of paramount importance to enable continuity of care and maintain patient safety post-discharge. Discharge summaries are the simplest way for GPs to obtain information about a patient's hospital stay. A quality improvement study was conducted with the aim of increasing the content of discharge summaries for inpatients in the authors' department. METHODS: A prospective review of 60 electronic discharge summaries was conducted over a 6-week period. The content of discharge summaries was reviewed in accordance with local trust guidelines. Targeted, intensive, cost and time-effective educational interventions were then conducted. A post-intervention review of 60 discharge summaries was performed. A further review of 60 discharge summaries was performed after 12 months. RESULTS: Initial results pre-intervention confirmed suboptimal content of discharge summaries. Post-intervention results showed each component of discharge summaries improved in terms of content, with six of eight components having a statistically significant (P<0.05) increase. This was maintained after 12 months. CONCLUSIONS: This study has demonstrated how simple, intensive educational sessions can lead to an improvement in discharge summaries and communication with primary care.

Quality of Plaster Molding for Distal Radius Fractures Is Improved Through Focused Tuition of Junior Surgeons.

OBJECTIVES: Successful nonoperative management of distal radius fractures requires an adequately reduced fracture held in a well-molded cast. The purpose of this study was to determine whether a targeted teaching session to the same group of junior doctors led to objective improvement in fracture reduction and plaster molding and hence a decrease in the redisplacement of these fractures. DESIGN: Retrospective review. SETTING: Level I academic trauma center. METHODS: A retrospective review of all dorsally angulated distal radius fractures treated in plaster that presented to our plaster room over a 4-week period (group 1, n = 52). This was followed by the intervention and a subsequent 4-week prospective review (group 2, n = 36). Radiographs were reviewed before manipulation, after manipulation, and at follow-up by a single senior orthopaedic trainee using predetermined criteria. INTERVENTION: A targeted teaching session on fracture reduction and cast molding to the same group of junior doctors involved in managing all these cases. MAIN OUTCOME MEASURES: Adequate fracture reduction, plaster molding, redisplacement, and further intervention before and after the targeted intervention. RESULTS: In group 1, 85% had adequate fracture reduction but only 36% showed adequate molding. This was improved in group 2%-94% adequate reduction and 65% adequate molding (P = 0.022). The rate of redisplacement was improved from 65% to 44% in group 2. In both groups, the rate of redisplacement was around 20% for adequately reduced and molded fractures, compared with around 90% for adequately reduced but inadequately molded cases (P < 0.001). The rate of further intervention improved from 27% to 8% (P = 0.052). CONCLUSIONS: We recommend that specific teaching focusing on fracture reduction and molding techniques is included in orthopaedic juniors' induction teaching or as a separate session. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Data protection among junior medical staff: a questionnaire study.

OBJECTIVE: There have been numerous reports of loss of confidential information amongst UK public agencies. The aim of the study was to examine current standards of practice and knowledge of junior medical staff with respect to management of patient identifiable information. METHODS: An anonymous multiple choice questionnaire was completed by 50 junior medical staff in each of 2 separate district general hospitals in the UK. RESULTS: Sixty-two percent of physicians surveyed held patient identifiable information electronically, outside of normal NHS use. Thirty percent of physicians used portable memory sticks, of which, 68% were not password protected. Ninety percent of physicians used patient ward lists in paper format with 18% frequently using a domestic waste bin for disposal. Thirty-five percent of physicians were aware of the Caldicott principles, and 58% were aware of the Data Protection Act as applied to their duties. CONCLUSIONS: Despite having statutory duties toward the management of patient identifiable information, many physicians are not aware of their responsibilities and obligations. This is unlikely to be an isolated local issue. More emphasis needs to be placed on data management in hospital induction procedures for new employees, and security measures, such as encryption software, should be made more widely available.

An isolated articular surface fracture of the distal patella: an unusual and previously unreported paediatric injury.

Paediatric patella fractures are uncommon, accounting for less than 1% of all paediatric fractures. This case report describes a previously undocumented patella fracture in a child, with a clear mechanism of injury. We present a case of a previously healthy 14-year-old boy who fell directly onto his right knee after coming off his pushbike. He sustained an isolated fracture involving the articular surface of the distal part of the patella with minimal displacement. The patient was managed conservatively in a Richard splint for three weeks, followed by a knee brace with gradually increasing degrees of flexion. He was instructed to be nonweight bearing for two weeks and then partial weight bearing for six weeks. At the final followup, after 9 weeks, the patient had full return of function and standard radiographs show the fracture to be healed. This case report has demonstrated how direct compression to the paediatric patella can cause a fracture isolated to its articular surface. It has detailed the natural progression of this injury to radiographic union, using a conservative management strategy. The authors believe that this case report provides an interesting insight into the variation of paediatric patella fractures and their contrasting management strategies.

What are the predictors that affect the excellent long-term benefits of redo coronary artery bypass grafting?

OBJECTIVE: Recurrent angina refractory to medical therapy in patients having undergone prior coronary artery bypass grafting (CABG) is an indication for repeat surgical revascularisation. The primary aim of this retrospective study was to determine the benefit of redo surgery over the longer term with regards to survival and freedom from cardiac symptoms/events. Our secondary aim was to identify risk factors that compromise surgical efficacy of redo revascularisation. METHODS: Patients were identified through case note review. Survivors were interviewed by telephone according to a defined protocol. Actuarial freedom from cardiac symptoms/events and survival were determined. A composite outcome for cardiac symptoms/events was used and defined as angina class> or =2 or NYHA> or =2 or myocardial infarction or need for percutaneous intervention. Univariate and multivariate analysis was performed. Survival was assessed using a Kaplan-Meier method, and determinants of survival with the Cox proportional hazards model. RESULTS: Between January 1st, 1996 and February 1st, 2004, 101 consecutive patients underwent redo CABG at our institution under the care of a single surgeon. There were 91 men and 10 women, 64% (65/101) had an age> or =70 years. 30-Day mortality was 1.2% (2/101). Mean time to follow-up was 5.3+/-3.8 years. Poor left ventricular function and pre-operative NYHA> or =2 status were independent predictors of decreased survival with hazard ratios (HR) of 2.12 (1.042-4.31) and 3.98 (1.39-11.39) respectively. The use of a radial artery graft at re-operation was an independent predictor of peri-operative death OR=18 (1-346). Actuarial survival at 1, 5 and 8 years was 90.1%, 84.4% and 76.9% and freedom from cardiac symptoms/events was 100%, 95% and 68% respectively. CONCLUSION: This study shows acceptable short- and long-term survival and freedom from symptoms/events in patients undergoing redo coronary artery bypass grafting at a single institution. The apparent association between radial arterial grafts and impaired early clinical outcome warrants further investigation.

Trapezium fracture - a common technique to fix a rare injury: a case report.

Trapezium fractures are rare injuries which should not be missed. We report a case of a 27-year-old right hand dominant man who sustained a closed vertical trapezium fracture and first carpometacarpal joint dislocation which was treated with closed reduction and percutaneous Kirschner-wire fixation, a technique familiar to all orthopaedic surgeons. Satisfactory functional outcome was achieved at final follow-up.

Osteoma cutis masquerading as an ingrowing toenail: a case report.

Osteoma cutis of the foot is extremely rare and there are very few reported cases. The incidence of in-growing toenail in the United Kingdom is estimated to be 10,000 new cases per year and many are treated non-operatively. We present a case where osteoma cutis was masquerading as an in-growing toenail, and wish to highlight the condition as a differential diagnosis for this condition. There have been case reports of bony cutaneous lesions of the foot, both benign and malignant and so these are especially important to consider in the differential diagnoses where non-operative management is being considered.

Pyrethroid resistance mediated by enzyme detoxification in Listronotus maculicollis (Coleoptera: Curculionidae) from Connecticut.

In 2009, pyrethroid resistance was confirmed for seven "annual bluegrass weevil" Listronotus maculicollis Kirby (Coleoptera: Curculionidae) adult populations from southern New England. The mechanisms responsible for conferring this resistance were unknown. In this study, topical application bioassays with bifenthrin and bifenthrin combined with synergists affecting three detoxification systems were conducted on four field-collected adult populations of L. maculicollis from Connecticut to determined whether cytochrome P450 monooxgenases (P450s), glutathione S-transferases (GSTs), and/or carboxyl-esterases (COEs) mediated metabolic detoxification. Because a susceptible L. maculicollis laboratory strain does not exist, the most susceptible field-collected population (New Haven) provided a baseline against which all other populations were compared. In the population with the lowest resistance (Norwich), only detoxification by P450s was significant. Detoxification in the population with the second highest level of resistance (Stamford) involved both P450s and GSTs. Detoxification in the population with the highest level of resistance (Hartford) involved P450s, GSTs, and COEs. This study suggests that enzyme-mediated metabolic detoxification plays an important role in annual bluegrass weevil pyrethroid resistance.

Pyrethroid resistance in populations of Listronotus maculicollis (Coleoptera: Curculionidae) from southern New England golf courses.

Topical application bioassays of bifenthrin and lambda-cyhalothrin were conducted on field-collected populations of Listronotus maculicollis Kirby (Coleoptera: Curculionidae) from eight southern New England golf courses, six in Connecticut, one in Massachusetts, and one in Rhode Island. Concentrations versus mortality regression lines were estimated to compare the LD50 values and resistance ratios for each insecticide and each population. The LD50 ranges for bifenthrin and lambda-cyhalothrin were 1.80-244.67 ng per insect and 0.52-159.53 ng per insect, respectively. The field-collected strains showed low to high levels of resistance to bifenthrin (6.1-135.9-fold) and lambda-cyhalothrin (28.7-306.8-fold). This is the first report of insecticide resistance in this species. The loss of pyrethroid efficacy is making control of Listronotus maculicollis more challenging.