• 6-Year clinical results and survival of Copeland Resurfacing hemiarthroplasty of the shoulder in a consecutive series of 279 cases.

      Dekker, Andrew; Joshi, N; Morgan, Marie; Espag, Marius; Tambe, Amol; Clark, DI (2020-03)
      Background: Medium-term clinical results and survival of the Copeland resurfacing hemiarthroplasty of the shoulder (CRHA) in a large consecutive group are presented with a comparison of outcomes for underlying pathologies. Methods: A consecutive series of patients undergoing CRHA over 14 years was retrospectively analysed with no exclusions. Patients had a minimum 2-year follow-up by an independent assessor. Functional outcome was assessed using the Oxford Shoulder Score (OSS) and Constant-Murley Score (CMS). Pain and satisfaction was assessed using a visual analogue score. Results: 279 CRHAs were performed in 242 patients between 2002 and 2016. The mean follow-up was 6 years. The indication for surgery was osteoarthritis (OA) in 212, inflammatory arthropathy (RA) in 35, rotator cuff tear arthropathy (CTA) in 22 and avascular necrosis (AVN) in 2. For the OA group, 5-year survival was 90%, 10-year survival was 83% and mean survival was 13.2 years (95% CI 12.5-13.9). The mean OSS was 35.0 and mean CMS 49.9. CRHA for CTA had significantly poorer (p < 0.001) 5-year survival (55%), 10-year survival (41%) and mean survival (5.9 years, 95% CI 4.7-7.2). Mean OSS was 23.6 and mean CMS 30.3, which was poorer than for OA (p < 0.001). A subgroup analysis of OA patients found significantly better survival (p = 0.013) in those aged over 65 years but no difference in functional outcome. Conclusion: CRHA remains a reasonable option for OA in patients with an intact rotator cuff and with sufficient bone stock, especially in those aged over 65 years. With poorer functional outcomes and survival, CRHA should not be offered in those with CTA. Level of evidence: Level III (retrospective comparative study).
    • A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study).

      Bateman, Marcus (2015-07)
      OBJECTIVES: To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. DESIGN: Multi-centre pragmatic unblinded parallel group randomised controlled trial. SETTING: UK National Health Service. PARTICIPANTS: Patients with a clinical diagnosis of rotator cuff tendinopathy. INTERVENTIONS: The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment. MAIN OUTCOME MEASURES: The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months. RESULTS: A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 (n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49).By six and twelve months there remained no significant difference between the groups. CONCLUSIONS: This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment.
    • A simple and safe technique for reconstruction of the acromioclavicular joint.

      Rushton, Paul; Gray, James; Cresswell, Timothy (2012-01)
      Surgical reconstruction of the dislocated acromioclavicular joint often requires exposure and instrumentation of the coracoid. This carries risks to the surrounding neurovascular structures. We present a safe and simple technique of primary fixation of the acromioclavicular joint, relying on mechanical principles and biological repair, without the need for metalwork. By avoiding the coracoid we hope this approach will appeal to the general orthopedic surgeon. We have found that this technique is suited to both acute and chronic acromioclavicular joint dislocation.
    • Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease.

      Majeed, H; Bommireddy, Rajendranadh; Klezl, Zdenek; Calthorpe, D (2012-01)
      INTRODUCTION: Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS: Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS: A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS: The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.
    • Achilles Tendon Rupture: Can the Tendon Gap on Ultrasound Scan Predict the Outcome of Functional Rehabilitation Program?

      Mubark, Islam; Abouelela, Amr; Arya, Swati; Buchanan, Donald; Elgalli, Mosab; Parker, Jennifer; Ashwood, Neil; Karagkevrekis, Charalampos (2020-09)
      Background and objectives: There is a growing use of functional rehabilitation programs for the treatment of Achilles tendon rupture. Factors such as patient age and level of activity have been used to guide the decision. One of the debated indications is the gap size between the ruptured ends of the tendon. This study aims to define any correlation between the amount of the initial gap between tendon ends and patients outcome treated with the functional rehabilitation program. Method: A prospective case series study of all patients with acute Achilles tendon rupture treated non-surgically with the functional rehabilitation program between 2016 and 2018. The tendon gap was measured with an ultrasound scan on the initial presentation. Patients were followed for a minimum of 12 months and assessed for Achilles Tendon Rupture Score (ATRS), plantarflexion strength, and re-rupture rate. Results: A total of 56 patients completed one-year follow-up, and 2 patients had re-ruptures. The mean plantar flexion gap was 13.7 mm. The mean ATRS at 12 months was 85.12. There was no statistically significant correlation between the final ATRS and the mean rupture gap. Conclusion: The outcome following non-operative functional rehabilitation treatment of rupture Achilles tendon did not correlate with the size of the tendon gap, and authors recommend that decision on functional rehabilitation should not be based on these criteria.
    • Acromioclavicular joint disruptions: A comparison of two surgical approaches 'hook' and 'rope'

      Athar, Sajjad; Ashwood, Neil; Hamlet, Mark; Salt, Emma (2018-01)
      INTRODUCTIONAcromioclavicular joint injuries are common shoulder girdle injuries most commonly resulting from a direct blow to the acromion with the arm adducted. Type-I or type-II acromioclavicular joint injuries can be managed with sling immobilization, early shoulder motion, and physiotherapy. The management of type-III injuries remains controversial and is individualized. Type IV and V injuries should be treated surgically. A myriad of surgical techniques for the management of acromioclavicular joint injuries have been reported.METHODSWe present a comparative study of 76 patients treated with two most common modalities of treatment for AC joint disruption and that is Hook plate stabilisation (n=52) or arthroscopically assisted tight rope stabilisation (n=24). The primary objective was to establish whether hook plate stabilization was superior compared to arthroscopic tight rope fixation in reducing pain and increasing function in the short-term and long-term for patients with AC joint disruptions III-IV. We also wanted to assess how quickly patients returned to their work/job. It was a prospective study, we included all the patients operated between 2008 and 2015 for AC joint disruption by the two shoulder surgeons of our department. All patients followed a strict physiotherapy protocol and were assessed at 6 weeks, 3 months and 12 months. We used the Harm and cost criteria of assessment and the patient specific functional outcome scores.RESULTSBoth modalities of treatment have high patient satisfaction rate, return to work is faster in tight rope group but after a year both group of patients returned to their premorbid state. Removal of hook plate is not mandatory and lysis of acromion is rare (1% in our series).CONCLUSIONDespite the fact that both methods yielded similar results and have statistically similar number of complications, the type of postoperative complications was different between groups. The plate group had more postoperative pain and worse function but both aspects improved after plate removal. The rope group had more complex complications including deep infection and recurrence of deformity and fracture. These differences should be taken into consideration when consenting the patient regarding possible treatment.
    • The acute management of ankle fractures (Augment) study: A prospective trainee led national collaborative audit of the Boast 12 guidelines

      Davies-Jones, Gareth; Latif, Javed (2021-01)
      Background: Ankle fractures are one of the most common fractures in adults aged 20-65 years. The British Orthopaedic Association (BOA) and British Orthopaedic Foot and Ankle Society (BOFAS) jointly produced Standards for Trauma (BOAST) BOAST 12, with the aim of reducing morbidity by standardising care of these injuries. The primary aim of the AUGMENT study was to determine the extent and clinical effect of variation from BOAST 12. Methods: AUGMENT was a multi-centre prospective trainee led audit of consecutive patients presenting with an ankle fracture within a four-week period. Data were collected on patient demographics, comorbidities, management and 12-week outcome. The BOAST 12 standards were divided into four subgroups; documentation, imaging, management and follow-up. Percentage compliance with each subgroup was analysed. A multivariate logistic regression analysis was used to determine impact of overall compliance on likelihood of discharge in follow-up period. Findings: 971 patients were included across 52 sites. The overall rate of BOAST 12 compliance was 41.7%. Variations in practice were observed in clinical documentation, especially of neurovascular status, (40.7%) and VTE assessment (61.5%). Patient management compliance with all 16 of the BOAST 12 standards was associated with a higher rate of discharge during the 12-week follow-up period (p = 0.005). Conclusion: AUGMENT has demonstrated that the management of ankle fractures is variable across the UK. Over half of patients had aspects of their care that were not BOAST 12 compliant. When compliance was observed, it was associated with earlier discharge from orthopaedic care.
    • Advancing spinal fellowship training: an international multi-centre educational perspective.

      Kumaria, A; Bateman, AH (2019-08)
      PURPOSE: The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery. METHODS: Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training. RESULTS: Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training. CONCLUSIONS: Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.
    • An epidemiological study of rotator cuff pathology using The Health Improvement Network database.

      White, Jonathan; Titchener, Andrew; Fakis, Apostolos; Tambe, Amol; Hubbard, R; Clark, David (2014-03)
      Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.
    • Aneurysmal Bone Cyst in the Cervical Spine

      Ashwood, Neil; Jayakumar, Nithish; Mulay, Sanjay (2019-10)
    • Anterior cruciate ligament reconstruction complicated by pyoderma gangrenosum.

      Bagouri, Elmunzar; Smith, Jon; Geutjens, Guido (2012-11)
      We report a case of pyoderma gangrenosum as a complication of an anterior cruciate ligament reconstruction in a patient with inflammatory bowel disease, which was misdiagnosed initially as a post-operative wound infection. An early dermatology opinion and skin biopsy should be considered in cases of suspected infection where thorough surgical debridement and antimicrobial therapy has failed to improve the clinical picture.
    • Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bone-graft harvest.

      Mathew, Philip; Garcia-Elias, Marc (2013-03)
      The most common complication after distal radius fractures is union with deformity. When symptomatic, distal radial malunions may require operative intervention. Numerous approaches to the distal radius have been described. Most volar approaches involve sectioning the brachioradialis and opening the first extensor compartment to permit adequate exposure. When bone graft is required, this may necessitate a separate incision and further add to the morbidity. We present an alternative anterolateral surgical approach to the distal radius, which allows for excellent exposure, and minimal trauma to the tendons while permitting harvest of local bone graft through the same incision.
    • Arachnoiditis following caudal epidural injections for the lumbo-sacral radicular pain.

      Nanjayan, Shashi; Swamy, Girish; Yallappa, Sachin; Bommireddy, Rajendranadh (2013-12)
      Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.
    • Arterial Injury to the Profunda Femoris Artery following Internal Fixation of a Neck of Femur Fracture with a Compression Hip Screw.

      Craxford, Simon; Gale, Michael; Lammin, K (2013-12)
      We report the case of an 82-year-old woman who developed extensive proximal thigh swelling and persistent anaemia following internal fixation of an extracapsular neck of femur fracture with a dynamic hip screw (DHS). This was revealed to be a pseudoaneurysm of a branch of profunda femoris artery on angiography. Her case was further complicated by a concurrent pulmonary embolism (PE). She underwent endovascular coil embolisation of the pseudoaneurysm. An IVC filter was inserted and the patient was fully anticoagulated once it had been ensured that there was no active bleeding. In this case, we review the potential for anatomical variations in the blood supply to this region and discuss treatment options for a complicated patient. We recommend that a pseudoaneurysm should be part of a differential diagnosis for postoperative patients with anaemia refractory to blood transfusion so as not to miss this rare but potentially serious complication.
    • Arthroscopically diagnosed scapholunate ligament injuries associated with distal radial fractures: a 13- to 15-year follow-up.

      Lindau, Tommy (2015-06)
      PURPOSE: To evaluate the natural history of untreated complete or partial scapholunate (SL) ligament tears associated with displaced distal radius fractures. METHODS: Between 1995 and 1997, 51 consecutive patients aged < 60 years with displaced distal radius fractures were examined arthroscopically to assess for concomitant soft tissue injuries. Thirty-two of 51 patients had an SL ligament tear, 10 had a complete tear (Lindau grade 3), and 22 had a partial tear (Lindau grades 1 and 2). Thirty-two patients had AO type-C fractures, 3 had type-B fractures, and 16 had type-A fractures. In 2010, 47 of the 51 patients were still alive, and they were invited for an interview, clinical examination, and radiography. RESULTS: Thirty-eight of the 51 original patients participated in the long-term follow-up. Mean grip strength was 83% relative to the contralateral hand in patients with a complete tear, as compared with 92% in patients with partial or no SL tears (nonsignificant). Median Disabilities of the Arm, Shoulder, and Hand questionnaire score was 2 (range, 0‒55) for complete SL tears, compared with 9 (range, 0‒70) for the others (nonsignificant). No differences were found regarding visual analog scale pain or wrist motion/forearm rotation. None of the patients developed a static SL dissociation or a SL advanced collapse wrist. CONCLUSIONS: No major differences were found in the subjective, objective, or radiographic outcome after a complete (grade 3) or partial (grade 1 or 2) SL untreated tear associated with displaced distal radius fracture. It should be noted that none of the patients had a grade 4 SL tear, which may have a different outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
    • Assessment of Orthopaedic Lecture Teaching by Foundation Doctors

      Athar, Sajjad; Ashwood, Neil; Galanopoulos, Ilias; Karagkevrekis, Babis (2018-11)
    • Assessment of scapholunate instability and review of evidence for management in the absence of arthritis.

      Lindau, Tommy (2013-09)
      Scapholunate ligament tear is a common wrist injury and may lead to degenerative arthritis of the wrist in the long term. We review the assessment and classification of scapholunate instability and discuss the findings from our search for evidence for the management of scapholunate instability in the absence of arthritis. Strong evidence (level 1 or 2) for management is lacking and published recommendations are largely experience-based. The choice of procedure in the absence of arthritis depends on the extent of the tear, quality of the ligament remnants, and reducibility of the joint. Prospective, randomized studies with validated outcome measures are needed to establish the efficacy of intervention on symptoms and function and its effect on the risk of future arthritis.
    • Asymptomatic non-union of capitate 14 years postfracture

      Hamed, Yosef; Ashwood, Neil; Galanopoulos, Ilias (2013-06)
      We report the unusual complication of non-union 14 years following a capitate fracture in a right-hand dominant man. Our patient fell and sustained an injury to his left wrist 14 years ago. At that time he had a swollen painful left wrist. His symptoms subsequently settled and he went back to his normal activities. He lost some power for bench-pressing and had slightly restricted range of motion but remained essentially pain-free. He presented 14 years later with another wrist injury when the original non-union was revealed.
    • Atypical presentation of sacrococcygeal pilonidal disease: presentation and surgical management.

      Alwadiya, Ahmed; Abouelela, Amr; Al Ghunimat, Abdallah; Ashwood, Neil; Kotecha, Amit (2020-09)
      Sacrococcygeal pilonidal disease presentation varies greatly between being asymptomatic, acute abscess and chronic sinus. Acute abscess constitutes almost half of the initial presentation of such disease. To our best knowledge, acute abscess presentation hasn’t been reported as a result of acute trauma in the literature. In this paper, we report a case of atypical presentation of sacrococcygeal pilonidal disease after a fall on the back a week earlier. Surgical management of the abscess, incidental finding of the pilonidal disease and lessons learned from such case is discussed in detail.