Orthopaedics

Surgical Fixation of Three- and Four-Part Proximal Humeral Fractures Using the Proximal Humeral Interlocking System Plate (2022)

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Type of publication:Journal article

Author(s):Saber AY; Said UN; Abdelmonem AH; Elsayed H; Taha M; Hussein W; *Al-Hashimi K; El-Omar O; Elbeshbeshy M

Citation:Cureus, 2022 May 26; Vol. 14 (5), pp. e25348

Abstract:Introduction The management of proximal humeral fractures ranges greatly from conservative management to surgical treatment. For those fractures requiring surgical treatment, internal fixation is the primary method. The aim of internal fixation is to achieve rigid fracture fixation until union occurs, return of shoulder range of motion, and minimise intra-and postoperative complications. The aim of this study was to evaluate the results of the Proximal Humeral Interlocking System Plate (PHILOS) used for the treatment of three-and four-part proximal humeral fractures. Materials and methods This study included 30 patients with a mean age of 54 years (range 20-80 years). Results were checked post-operatively with standard radiographs and clinical evaluation according to the Constant-Murley shoulder score. All patients were followed up for 12 months. Results Union was achieved in all patients with a mean neck/shaft angle of 130° (range 108°-150°). The mean Constant-Murley score at the final follow-up was 82.28 (range 67-96) correlating with good results. No patients developed an intraoperative or postoperative vascular injury, wound complications, or avascular necrosis of the humeral head. Conclusion Our study has shown that the surgical treatment of three- and four-part proximal humeral fractures with the use of the PHILOS plate leads to a good functional outcome. It has also demonstrated the PHILOS plate and is an effective system for fracture stabilisation provided the correct surgical technique is used with awareness of potential hardware complications.

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The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain (2022)

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Type of publication:
Journal article

Author(s):
Perry DC; Arch B; Appelbe D; Francis P; Craven J; Monsell FP; Williamson P; Knight M; BOSS collaborators (including *Rhee, J of Shrewsbury and Telford Hospital NHS Trust)

Citation:
The Bone & Joint Journal, 2022 Apr; Vol. 104-B (4), pp. 510-518

Abstract:
Aims: The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip. Methods: This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants. Results: Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years. Conclusion: Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery.

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Soft tissue extensor mechanism tendon ruptures of the knee (2021)

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Type of publication:Journal article

Author(s):Rhind J.-H.; *Lancaster P.; *Ahmed U.; *Carmont M.

Citation:British Journal of Hospital Medicine; Sep 2021; vol. 82 (no. 9); p. 1-9

Abstract:Ruptures of the extensor mechanism of the knee are serious injuries requiring prompt diagnosis and treatment. They can be divided into soft tissue and bony causes. Soft tissue tendon injuries can be either partial or complete. Rupture of the quadriceps tendon is an uncommon injury and is more frequent in patients over the age of 40 years. Patella tendon ruptures are even rarer and are more frequent in patients under the age of 40 years. Causes can be direct or indirect. Complete ruptures of the quadriceps tendon or patella tendon benefit from early surgical management, while partial ruptures may be managed non-operatively. This article gives an overview of the presentation, assessment and management of soft tissue extensor mechanism tendon ruptures for core surgical, acute care common stem and emergency medicine trainees.

Presentation of bone tumours: clinical findings and initial management of patients (2021)

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Type of publication:
Journal article

Author(s):
*Green N.M.; Abas S.; Sajid S.; Cribb G.L.

Citation:
Orthopaedics & Trauma; Jun 2021; vol. 35 (no. 3); p. 108-114

Abstract:
Bone tumours are uncommon diagnoses and there is often a delay from first presentation to a healthcare professional (HCP) to definitive diagnosis and management. Patients may present to secondary care in a number of ways. Patients may present acutely with pathological (or impending) fractures, patients may present as urgent 2-week referral from primary care or patients may present with incidental findings on radiological investigations. A thorough history and examination is essential, followed by radiological investigations. Common clinical findings include pain, which is usually the main reason for patient presentation to an HCP. Other reasons include limp or loss of function of limb, swelling or lump, or pathological fracture. As part of the work-up, it is important to ask about constitutional symptoms, past history of malignancy and family history of known syndromes. Plain radiographs are vital for diagnosis. The patient's age is important for the differential diagnosis. The location, morphology and how the tumour is affecting the bone, periosteum and soft tissues are key to the diagnosis. For patients presenting with bone lesions, it is essential to follow the bone sarcoma referral guidelines so that patients are promptly diagnosed and treated.

Rothia mucilaginosa: a case of septic arthritis in a native knee and review of the literature (2021)

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Type of publication:
Journal article

Author(s):
*Daoub, Ahmed; *Ansari, Hamza; *Orfanos, George; *Barnett, Andrew

Citation:
BMJ case reports; Jan 2021; vol. 14 (no. 1)

Abstract:
Rothia mucilaginosa is a Gram-positive aerobic coccus usually found in the oral and respiratory tract. Septic arthritis is an uncommon condition, but is an orthopaedic emergency. A rare case of knee septic arthritis due to R. mucilaginosa is presented. Patient management and outcomes are discussed, and learning points from this case are outlined to help manage any further cases that may arise.

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Do the heel-rise test and isometric strength improve after Achilles tendon repair using Dresden technique? (2022)

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Type of publication:
Journal article

Author(s):
De la Fuente, Carlos; Henriquez, Hugo; *Carmont, Michael R; Huincahue, Javiera; Paredes, Tamara; Tapia, María; Araya, Juan Pablo; Díaz, Nicolás; Carpes, Felipe P

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Jan 2022, 28(1) pages 37-43

Abstract:
BACKGROUND Achilles' tendon ruptures result in impaired plantar flexion strength and endurance. It is interesting to know the plantar flexion strength, the number of heel-rise repetitions, and the maximal calf circumference following Achilles' tendon ruptures repair. METHODS Both the injured and non-injured legs of thirty male patients with Achilles' tendon ruptures treated with the percutaneous Dresden technique were compared with the ankle function of 30 healthy participants. Rehabilitation involved partial weight-bearing for three weeks and then increased to full weight-bearing and ankle exercises. RESULTS The injured legs had weaker plantar flexion strength (1.64 ± 0.17 Nm/kg) compared with the non-injured legs (1.91 ± 0.24 Nm/kg; p = 0.002) and the healthy participants' legs (1.93 ± 0.32 Nm/kg; p < 0.001). The non-injured leg had greater ability in doing heel-rise repetitions (39.4 ± 6.1 rep.) compared with the injured legs (37.2 ± 5.7 rep.; p < 0.023) and the healthy participants' legs (31.0 ± 13.0 rep.; p < 0.001). CONCLUSIONS The injured leg had not recovered full isometric strength but had improved heel-rise repetition.

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No difference in Achilles Tendon Resting Angle, Patient-reported outcome or Heel-rise height Index between Non- and Early-weightbearing the First Year after an Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont M; Brorsson, A.; Karlsson, J.; Nilsson-Helander, K.

Citation:
Muscles, Ligaments & Tendons Journal (MLTJ); Oct 2020; vol. 10 (no. 4); p. 651-658

Abstract:
Background. Patient-reported outcome scores and comparable re-rupture rates in randomized controlled trials have not shown a definitive benefit for operative treatment after acute Achilles tendon rupture. This, together with the increasing rupture rates in the older age group has led to non-operative treatment being increasingly used. Objective. This study aimed to determine the variation in Achilles Tendon Resting Angle (ATRA) together with patient reported and functional outcome, with non-operative management of the ruptured Achilles tendon using two different regimes, which have been shown to offer low re-rupture rates. Methods. This is a non-randomised cohort comparison of Achilles tendon rupture patients managed with Non-Weight-Bearing (NWB) for 6 weeks vs. Early Weight-Bearing (EWB). The NWB-group received a cast in plantar flexion for 2 weeks followed by 6 weeks in a controlled ankle motion boot with incremental diminishing plantar flexion. The EWB-group received an initial anterior protective plaster slab in plantar flexion followed by 6 weeks of weight-bearing on the meta-tarsal heads, with an anterior shell restricting dorsiflexion. Results. At 12 months after the injury there were no differences in any of the variables between the two treatment groups. The NWB-group compared to the EWB-group reported at mean (SD) for ATRA -9.8° (4.6°) versus -11.4° (5°), p=0.32, for Achilles tendon Total Rupture Score (ATRS) 87 (10) versus 79 (19), p=0.43 and for Heel-Rise Height Index (HRHI) 71% (19%) versus 59% (13%), p=0.13. Conclusions. The two methods of non-operative treatment studied lead to increased relative ATRA following injury, however, patients report only minor limitation in terms of outcome. Patients had almost a third less heel-rise height compared with the non-injured ankle.

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Clinical Orthopaedic Teaching programme for Students (COTS) (2020)

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Type of publication:
Journal article

Author(s):
Kumar P.R.; Stubley T.; Hashmi Y.; *Ahmed U.

Citation:
Postgraduate Medical Journal; 2020 [epub ahead of print]

Abstract:
Introduction: There is a huge variation in the depth and breadth of content taught regarding orthopaedic examinations. Undergraduate students are often confused by the variability in examination teaching, therefore increasing concerns for upcoming objectively structured clinical examinations (OSCEs). Doctors, despite being expected to teach, rarely receive formal preparation, with only a handful of institutions providing necessary training. The Clinical Orthopaedic Teaching programme for Students (COTS) was designed to equip medical students with the knowledge to perform orthopaedic examinations and to synergistically provide senior students with the necessary experience for the future teaching required of them. Method(s): Six fortnightly sessions were delivered, each focusing on a specific joint examination. Student and tutor recruitment were voluntary. Pre-session and post-session multiple-choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors. Result(s): From 61 student responses, 98.4% of students stated that COTS met the learning outcomes, with content relevant for their medical curriculum. 96.7% supported COTS' near-peer teaching (NPT) style for OSCE preparation. Based on a five-point Likert scale, students displayed a mean improvement in confidence (1.7+/-1.2, p<0.001) and MCQ scores (1.3+/-1.2, p<0.001). All 10 tutors perceived an improvement of their teaching skills and confidence to teach (1.0+/-0.9, p=0.016). Conclusion(s): COTS shows that an NPT style can be used to effectively teach orthopaedic examinations, with benefits for students and tutors. With our aim to refine and upscale this programme, we publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities.

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The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture (2021)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; *Littlehales J.; Brorsson A.; Karlsson J.; Nilsson-Helander K.; Barfod K.W.; Ginder L.

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Oct 2021; vol. 27 (no. 7); p. 760-766

Abstract:
Background: During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. Method(s): A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. Result(s): The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9 (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6 (11.2), (18.5-56.5) versus 55.5 (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651). Conclusion(s): The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.

Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R.; Zellers, Jennifer A.; Brorsson, Annelie; Nilsson-Helander, Katarina; Karlsson, Jón; Grävare Silbernagel, Karin

Citation:
Orthopaedic Journal of Sports Medicine; Mar 2020; vol. 8 (no. 3); p. 1-8

Abstract:
Background: Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management. Purpose: To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair. Study Design: Cohort study; Level of evidence, 3. Methods: From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI. Results: A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was –4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P <.001) and greater intraoperative ATRA (B = 0.005; P =.053) as predictors of more symmetrical 12-month HRHI (R 2 = 0.19; P <.001; n = 120). Conclusion: Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.

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