Recent Submissions

  • Feasibility of using a GENEActiv accelerometer with triaxial acceleration and temperature sensors to monitor adherence to shoulder sling wear following surgery

    Barakat, Ahmed (2024-01-29)
    Background: Self-reported adherence to sling wear is unreliable due to recall bias. We aim to assess the feasibility and accuracy of quantifying sling wear and non-wear utilising slings pre-fitted with a GENEActiv accelerometer that houses triaxial acceleration and temperature sensors. Methods: Ten participants were asked to wear slings for 480 min (8 h) incorporating 180 min of non-wear time in durations varying from 5-120 min. GENEActiv devices were fitted in sutured inner sling pockets and participants logged sling donning and doffing times. An algorithm based on variability in acceleration in three axes and temperature change was developed to identify sling wear and non-wear and compared to participants' logs. Results: There was no significant difference between algorithm detected non-wear duration (mean ± standard deviation = 172.0 ± 6.8 min/participant) and actual non-wear (179.7 ± 1.0 min/participant). Minute-by-minute agreement of sensor-detected wear and non-wear with participant reported wear was 97.3 ± 1.5% (range = 93.9-99.0), with mean sensitivity 94.3 ± 3.5% (range = 86.1-98.3) and specificity 99.1 ± 0.8% (range = 93.7-100). Conclusion: An algorithm based on accelerometer-assessed acceleration and temperature can accurately identify shoulder sling wear/non-wear times. This method may have potential for assessing whether sling wear adherence after shoulder surgeries have any bearing on patient functional outcomes.
  • Radiological criteria for acceptable alignment in paediatric mid-shaft forearm fractures: a systematic review

    Chong, Han Hong (2023-11)
    Introduction: Forearm fractures are common in children. The remodelling capacity of growing long bones in children makes these potentially forgiving injuries, recovering with good outcomes despite minimal intervention. Clinicians rely on radiological characteristics that vary with age to guide treatment decisions and minimise adverse sequelae. The purpose of this review was to consolidate the evidence base of radiological indications for intervention in paediatric mid-shaft forearm fractures. Materials and methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed for this review. Citable research output reporting radiological criteria for mid-shaft forearm fractures in paediatric patients (age ≤16 years) was screened and analysed to ascertain acceptable radiological criteria for non-operative management. Results: A total of 2,059 papers were initially identified; 14 were selected following screening. Sagittal angulation >15°, coronal angulation >10°, and/or >50% (or >1cm) translation were the most common radiological indications for intervention in children aged 0 to 10 years. For children over 10 years of age, the most common radiological indication for intervention was sagittal angulation >10°, coronal angulation >10°, and/or >50% (or >1cm) translation. Conclusion: This study revealed a scarcity of high-quality evidence to guide management and significant variation in outcome reporting throughout the published literature. Since Noonan and Price's 1998 recommendations, there has been no significant evolution in the evidence-base guided threshold for intervention in paediatric mid-shaft forearm fractures. There remains a pressing need for a robust multicentre observational study using the patient-reported outcome measurement information system (PROMIS) to address this complex and controversial area of uncertainty in paediatric trauma management.
  • Consensus guidelines on the management of musculoskeletal infection affecting children in the UK

    Abraham, Alwyn (2023-07-01)
    Aims: The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems. Methods: A Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children's Orthopaedic Surgery (BSCOS). Statements were only included ('consensus in') in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded ('consensus out') if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation. Results: A total of 133 children's orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached 'consensus in', 0 'consensus out', and 11 'no consensus'. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as 'consensus in', resulting in a total of 40 approved statements. Conclusion: In the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe.
  • Five-year outcomes for patients with a displaced fracture of the distal tibia

    Kulkarni, Ashwin (2023-07-01)
    Aims: To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods: The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results: There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion: This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year.
  • Proximal humerus fractures: a review of current practice

    Pandey, Radhakant; Raval, Parag; Singh, Harvinder; Nanjayan, Shashi (2023-08-10)
    The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.
  • Supraspinatus muscle atrophy in relation to aging with or without shoulder pathology: A radiographic study

    Ahad, Abdul; Haque, Aziz; Muhammad, Jan; Pandey, Radhakant (2023-05-27)
    Introduction: Supraspinatus muscle atrophy is commonly associated with shoulder disease, but the effect of ageing on atrophy is not well understood. It was the aim of this study to investigate this effect using MRI scans in older patients. Methods and materials: A retrospective review of MRI scans in patients aged >70 years was performed between Jan 2016-Dec 2018.Both normal and abnormal scans were included in the analysis which included quantifying muscle atrophy of the supraspinatus using Thomazeu's occupation ratio. Results: There were 39 normal shoulder MRI scans with a mean age of 75 years (range: 70-88) and 163 abnormal scans with a mean age of 77 years (range: 70-93). The mean supraspinatus occupation ratio for normal MRI scans was 0.57 (range: 0.33-0.86) and abnormal scans 0.35 (range: 0.17-0.90). Occupation ratio was maintained with advancing until the age of 85 years before undergoing a significant declin following this. Conclusion: This study has shown that the occupation ratio is significantly reduced with shoulder disease, but normal shoulders do not undergo significant atrophy of supraspinatus tendon with increasing age. An occupation ratio of <0.32 is unlikely to occur in normal shoulders and this awareness may be useful when planning shoulder surgery, specifically shoulder arthroplasty.
  • A man with panda eyes after a fall

    Butt, Umar (2022-09-08)
    Most commonly caused by trauma, basal skull fractures present with a range of clinical signs. These include periorbital ecchymosis, as seen in this case, as well as rhinorrhea, otorrhoea and post-mastoid ecchymosis. Suspected cases must be managed with appropriate imaging and medical or surgical treatment as indicated.
  • Alteration of anterior cruciate ligament orientation in knees with trochlear dysplasia: description of a novel angle on MRI

    Esler, Colin; Rennie, Winston (2022)
    Aim: To assess changes in anterior cruciate ligament (ACL) geometry and inclination in trochlear dysplasia (TD) and analyse their significance. Materials and methods: Ninety-nine consecutive knees with TD and 23 normal knee magnetic resonance imaging (MRI) examinations were included as controls (n=122). Varying degrees of TD were classified into four distinct groups (A-D) according to the Dejour classification. MRI images were reviewed independently to measure four ACL angles. Interobserver and intra-observer agreements with statistical significance were determined for TD and various angles. Results: A significant association was found between TD and two measured angles compared with the control group (sagittal ACL and anteromedial ACL angles, p<0.001 for each). The results indicate that TD can predispose to more vertical ACL inclination as measured in the coronal plane on MRI. No association was found with the Blumenstat angle. Conclusion: The present study found significant associations with TD and steeper sagittal ACL, which have been implicated in ACL failure. A novel angle (anteromedial ACL angle) is described which has significant association with TD and is specific for the anteromedial bundle as measured in the coronal plane. Careful consideration of ACL fibre orientation in the coronal plane on MRI is suggested in knees with TD and the use of this newly described angle in assessing ACL reconstruction (ACLR) grafts.