Consultant Orthopaedic Surgeon Research Articles

Efficacy of Platelet-Rich Plasma Versus Steroids In Patients of Tennis Elbow

Objective: To compare the efficacy of Platelet Rich Plasma versus Steroids among patients managed for Tennis elbow at our Orthopaedic unit. Study Design: Quasi-experimental study. Place and Duration of Study: Orthopaedic Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan 2021 to Jul 2022. Methodology: Patients with Tennis Elbow diagnosed by a consultant orthopaedic surgeon were included in the study. They were randomly allocated treatment with platelet-rich plasma and steroid injections. The team assessed them after three months of treatment using the Disabilities of Arm, Shoulder, and Hand score. Different factors, including mode of treatment, were associated with significant improvement in these patients at the end of three months. Results: Out of 250 patients with tennis elbow included in the final analysis, 193(77.2%) were male, and 57(22.3%) were female. Patients were divided into two groups for comparison, and Group-1 had significant improvement, while Group-2 had no improvement. Out of the total, 117(46.8%) patients received platelet-rich plasma, while 133(53.2%) patients were managed with corticosteroids. The presence of comorbid illnesses and the use of platelet-rich plasma was statistically significantly found in a group with significant improvement in Disabilities of Arm, Shoulder, and Hand score (p-value<0.05) as compared to a group of patients without significant improvement. Conclusion: Most patients had significant improvement in symptoms at the end of three months. In our study, patients who were managed with platelet-rich plasma and had no comorbid illness had more chances of significant improvement at the end of three months.

An interview with Miss Samantha Tross

Miss Samantha Tross discusses her career, being the first Black woman to become a consultant orthopaedic surgeon in the UK and what advice she would give to future trainees.

FROM THE TOP TO THE BOTTOM: UTILITY OF THE NOTTINGHAM HIP FRACTURE SCORE IN PREDICTING DISTAL FEMUR FRAGILITY FRACTURE MORTALITY

The Nottingham Hip Fracture Score (NHFS) is validated to predict mortality after fragility neck of femur fractures (NOF). Risk stratification supports informed consent, peri-operative optimisation and case prioritisation.With the inclusion of fragility distal femur fractures (DFF) in the BPT, increasing attention is being placed on the outcome of these injuries. Developing on the lessons learnt over the past decades in NOF management is key.This study assesses the validity of the NHFS in predicting mortality after fragility DFFs.A multi-centre study of 3 high volume fragility fracture units was performed via a retrospective analysis of prospectively collected databases.Patients aged 60 years-of-age who presented with AO 33.A/B/C native DFF, or V.3.A/B periprosthetic DFF over an 86-month period between September 2014 and December 2021 and underwent surgical treatment were eligible for inclusion. Open and/or polytrauma (ISS >15) were excluded.All operations were performed or supervised by Consultant Orthopaedic Surgeons and were reviewed peri-operatively by a 7-day MDT.Patients with a NHFS of gt;=5 were stratified into a high-risk of 30-day mortality cohort, with all others being œlow-risk.285 patients were eligible for inclusion with 92 considered to be low-risk of 30-day mortality, these tended to be younger female patients admitted from their own homes.30-day mortality was 0% in the low-risk cohort and 6.2% (12/193) in the high-risk group. 1-year mortality was 8.7% (8/92) and 35.7% (69/193) in the low and high-risk groups respectively.Area Under the Curve (AUC) analyses of Receiver Operator Characteristic (ROC) curves demonstrated the greatest ability to predict mortality at 30-days for the high-risk cohort (0.714).The NHFS demonstrates a good ability to predict 30-day mortality in those patients with a NHFS =5 after a surgically managed fragility DFF. With comparable mortality outcomes to those documented from fragility NOF.

The current standard of the shoulder trauma series in Ireland – A national audit

Objectives/aimsThe primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of. MethodsA national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email. ResultsThe number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n ​= ​599) and 21.17% (n ​= ​167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n ​= ​181) of cases. The survey response rate was 70.8% (n ​= ​17). 88.2% (n ​= ​15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n ​= ​16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n ​= ​16) are in favour of establishing a national protocol. ConclusionThe current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

Mcmurray Test for Diagnosis of the Meniscal Tears

Aim: Meniscal tears are the most common injury of the knee. Tears of medial meniscus are seen more frequently as compared to lateral meniscus. Most often tears result from sports injuries where there is a twisting motion on the partially flexed, weight-bearing knee. As majority of our population resides in peripheries where access to arthroscopy and imaging modalities is difficult so we need a clinical test for evaluation of medial meniscal tears. And then this technique can be opted in our practice for early diagnosis of meniscal tears in order to take proper management for reducing morbidity of these particular patient, if its diagnostic accuracy comes out to high. Objective: To determine the diagnostic accuracy of McMurray test in diagnosing medial meniscal tears, taking arthroscopy as gold standard. Materials and Methods: This Cross-sectional validation study was carried out in Orthopedic Department of Medical Teaching Institute Lady Reading Hospital Peshawar from July 2021 to June 2023.In this study a total of 149 patients were observed. McMurray test was performed by the a single and same consultant and was looked for medial meniscal tear (present/absent).After this arthroscopy was done in each patient by the consultant orthopedic surgeon who has examined the patient and presence or absence of medial meniscal tear was noted. McMurray test results were compared with arthroscopy result. Results: In this study mean age was 30 years with SD ± 11.35. Eighty five percent patients were male and 15% patients were female. Diagnostic accuracy of MacMurray Test findings taking arthroscopy as gold standard was analyzed as the sensitivity was 76.55%, specificity was 75%, Positive predictive value was 99.10%, Negative predictive value was 8.10%. So, the overall diagnostic accuracy was 76.51%. Practical Implication: As in our setups majority of population resides in peripheries where access to arthroscopy and magnetic resonance imaging is difficult so there is a need of clinical test for diagnosing medial meniscal tears. And this technique can be opted in routine practice for early diagnosis of medial meniscal tears in order to take proper management for reducing morbidity of these particular patients after determining the sensitivity and specificity of the test. Conclusion: This study concludes that the McMurray test had sensitivity 76.55%, specificity 75%, Positive predictive value 99.10%, Negative predictive value 8.10% and the diagnostic accuracy 76.51% in diagnosis of meniscal tear keeping knee arthroscopy as gold standard. Keywords: Arthroscopy, Knee, McMurray test, Meniscal tear, Magnetic resonance imaging.

KNEE ARTHROSCOPY: SHOULD KNEE ARTHROSCOPY SIMULATION BE PART OF THE TRAINING CURRICULUM IN THE UK?

IntroductionKnee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.MethodsAt a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.ResultsComparing pre and post experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were also noted in time taken to complete and distance covered in metres, of the simulated exercises on repeat performance (p<0.05).ConclusionOverall, with only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience.

Congenital hyperextension of the knee without dislocation in a child: A case report

Congenital hyperextension of the knee, also known as congenital genu recurvatum, is a rare medical condition with an incidence of 1:100,000 deliveries. It is typically diagnosed clinically at birth, aided by radiological findings. Treatment with serial casting and close follow-up has been demonstrated to provide most favourable results. A Tanzanian 15-years-old primigravid girl with a normal gynaecological history was enrolled into a clinical trial evaluating the immunogenicity of different doses of two human papillomavirus vaccines (clinicaltrials.gov identifier NCT02834637). Fifty-five weeks after she received the second dose of the bivalent vaccine, Cervarix®, she delivered a female infant by spontaneous vaginal delivery following normal labour, at an estimated gestational age of 41 weeks. The infant had a notable right knee deformity but was otherwise well. Five days later, the baby was examined at the research clinic and noted to have a right knee hyperextension with limited flexion. X- rays reviewed by a consultant orthopaedic surgeon revealed congenital hyperextension of the right knee without dislocation. The baby girl recovered fully after three months of serial casting.

KNEE ARTHROSCOPY: SHOULD KNEE ARTHROSCOPY SIMULATION BE PART OF THE TRAINING CURRICULUM IN THE UK?

AbstractIntroductionKnee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.MethodsAt a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement.ResultsComparing pre and post-experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were noted in time taken to complete, distance covered in metres and roughness of instruments used on the simulated exercises on repeat performance (p<0.05).ConclusionWith only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience.

DIAGNOSTIC ACCURACY OF MAGNETIC RESONANCE IMAGING (MRI) FOR MENISCAL KNEE INJURIES TAKING ARTHROSCOPY AS THE GOLD STANDARD

The accurate non-invasive diagnosis of meniscal tears is challenging. Magnetic resonance imaging (MRI) is commonly employed, but previous studies have reported inconsistent findings regarding its diagnostic accuracy. This study aimed to determine the diagnostic accuracy of MRI for detecting meniscal injuries in the knee joint using arthroscopy as the gold standard. The cross-sectional study was conducted at the Department of Orthopedics, Jinnah Hospital Lahore, from October 17, 2021, to April 16, 2022. Ethical approval was obtained from the hospital's Ethical Review Board, and all eligible patients were enrolled after providing informed consent. MRI scans were performed on all patients to assess meniscal injuries, followed by arthroscopy performed by a consultant Orthopedic Surgeon in the department. The collected data were analyzed using SPSS version 20. 131 patients were included in the study, with a mean age of 35.06 ± 8.32 years. The majority of the patients were male (79.4%). The mean body mass index (BMI) was 23.37 ± 4.05 kg/m², and the mean duration of illness was 5.20 ± 2.6 months. The sensitivity and specificity of MRI for diagnosing medial meniscal injuries were found to be 77.4% and 44.9%, respectively. For lateral meniscal injuries, the specificity was 66.7%, and the specificity was 65.3%. MRI demonstrated good sensitivity in detecting meniscal injuries when arthroscopy findings were considered the gold standard. However, its specificity was low for detecting these lesions. Therefore, MRI may be used as a screening tool for these patients, but arthroscopy remains the gold standard for definitive diagnosis.

Systematic triage and treatment of earthquake victims: Our experience in a tertiary hospital after the 2023 Kahramanmaras earthquake.

The aim of this study was to evaluate the benefits of our triage system in acceleration of intervention for the musculoskeletal injuries and clinical follow-ups of trauma patients admitted to our center after the Kahramanmaras earthquake. Between February 6th, 2023 and February 20th, 2023, a total of 439 patients (207 males, 232 females; mean age: 37.1±19.1 years; range, 1 to 94 years) with earthquake-related musculoskeletal injuries after the Kahramanmaras earthquake were retrospectively analyzed. Data including age, sex, referral city information, removal time from the rubbles, physical examination findings, clinical photos, fasciotomy and amputation stumps and levels, and X-ray images and computed tomography images of all patients were shared and archived in the WhatsApp (Meta Platforms, Inc.® ATTN/CA, USA) group called 'Earthquake' created by orthopedic surgeons. To complete the patient interventions as soon as possible and to ensure order, the patients were distributed with the teams in order through this group by the consultant orthopedic surgeon. The treatments were applied and recorded according to the skin and soft tissue conditions, and fractures of the patients. All treatments were carried out with a multi-disciplinary approach. Of the patients, 16.2% were children. Lower limb injuries constituted 59.07% of musculoskeletal injuries. Upper limb, pelvic, and spinal cord injuries were observed in 21.9%, 12.7%, and 6.25%, respectively. Conservative treatment was applied to 183 (41.68%) patients. The most common surgical intervention was debridement (n=136, 53.1%). External fixation was applied in the first stage to 21 (8.2%) patients with open fractures. The mean removal time from the rubbles was 32.1±29.38 h. A total of 118 limb fasciotomy operations were applied to the patients. Fifty limb amputations were performed in 40 patients at the last follow-up due to vascular insufficiency and infection. Based on our study results, we believe that a triage system using a good communication and organization strategy is beneficial to prevent treatment delay and possible adverse events in future disasters.

THE UTILITY OF 3D PRINTING FOR PREOPERATIVE CREATION OF PATIENT-SPECIFIC IMPLANTS FOR SHOULDER ARTHRODESIS

Anatomically specific fixation devices have become mainstream, yet there are anatomical regions and clinical conditions where no pre-contoured plates are available, such as for glenohumeral arthrodesis. In a case series of 4 glenohumeral arthrodesis patients, a consultant orthopaedic surgeon at GCUH implemented 3D printing technology to create reconstructions of each patient's shoulder girdle to pre-contour arthrodesis plates. Our aim was to quantify the cost-benefit & intra-operative time savings of this technique in glenohumeral arthrodesis.We hypothesized that the use of 3D printing for creating patient specific implants through pre-operative contouring of plates will lead to intra-operative time and cost savings by minimising time spent bending plates during surgery.This study analysed 4 patients who underwent shoulder arthrodesis by a single consultant orthopaedic surgeon at GCUH between 2017-2021. A CT-based life-size model of each patient's shoulder girdle was 3D printed using freely available computer software programs: 3D Slicer, Blender, Mesh Mixer & Cura.Once the patient's 3D model was created, plate benders were used to contour the plate pre-op, which was then sterilised prior to surgery. Arthrodesis was performed according to AO principles of fixation. The time spent pre-bending the plate using the 3D model was calculated to analyse the intra-op time and cost-saving benefits.For the 4 cases, the plate pre-bending times were 45, 40, 45 & 20 minutes (average 38.8 mins). The intra-op correction time to make small adjustments to the plate was 2 min/ case. 3 plates needed minor (3 degree) adjustment to fine-tune scapula spine contouring. 1 plate needed a 5 degree correction to fine-tune hand position. On average, the pre-bending of the plate saved approximately 38.8 mins intra-op/ case. These shorter anaesthetic and operating times equate to approximately $2586 saving/ case, given an estimate of $4000/hour of theatre costs.We conclude that pre-bending plates around 3D-printed life-size models of an individual's shoulder girdle prior to surgery results in approximately 38.8 mins time saving intra-op when used in shoulder arthrodesis. This is a viable and effective technique that will ultimately result in significant operative time and financial savings.

A Retrospective Study of Missed Fractures and Injuries in Orthopedics

Introduction: Common Orthopedics injuries may result in long-term disability when they are treated lately. Simple fractures may require surgeries when they are missed and neglected. Most musculoskeletal injuries are seen in emergencies, some injuries may be missed when life-threatening conditions require attention, especially in poly-trauma patients. Certain injuries are difficult to recognize and some fractures may not visible in initial x-rays. A high index of suspicion is required to diagnose such cases. Methods: We conduct a retrospective study in which missed fractures, dislocations, and injuries were diagnosed and noted by consultant Orthopaedic surgeons from 2013 to 2022. Results: There were 76 missed diagnosed cases noted from 2013 to 2022. The patient’s ages range from 2 years to 63 years. Altogether 42(55.3%) were missed fractures, 23 (30.3%) were missed dislocations, and 11(14.5%) were tendon and ligament injuries cases. The common reason for the error was related to radiological error found in 62 (81.6%) cases. Misreading of X-rays was seen in 22 (28.9%) cases, poor quality x-rays in 17 (22.4%) cases, improper x- rays in 10 (13.2%) cases, and failure to order for x-rays in 16 (21.1%) cases. Conclusions: Good history and clinical examinations are essential. Proper x-rays should be taken and poor-quality x- rays should not be accepted but repeated. Most injuries missed on radiographs are not difficult to diagnose. Re-evaluation of patients should be done in an emergency, and with poly-trauma patients.

Arthroscopy and orthopedic residency: a cross-sectional study of training structure in a resource-constrained environment.

orthopedic residency training was established in the West African sub-region a few decades ago, but sub-specialty in arthroscopy has only become established in the last decade. This study was aimed at evaluating available arthroscopy training resources and their impact on skill acquisition by orthopedic residents. this was a cross-sectional study involving the use of a structured online survey of consultant orthopedic surgeons and orthopedic resident doctors. Details relating to the structure of training and challenges with training and recommendations for improved training were enquired. one hundred and two responses were received. There were 95% males (73) and 5% (4) females among the residents and 92% (23) males and 8% (2) females among the responding consultants. Of the residents, 47% (36) were registrars while 53% (41) were senior registrars. Seventy-six percent (77) were residents and twenty-five (24%) were consultants. Didactic lectures were the most impactful available training adjunct. Only 3% (2) of the residents had access to dry laboratory sessions with no specified number of practice hours attached. There was no computer simulation laboratory or cadaveric laboratory training facility for arthroscopy training in any of the training centres. Ninety-two percent (23) of the responding consultants would prefer a 6-12-month rotation in arthroscopy for residents. Fifty-three percent (41) of the residents had regular opportunities to participate in arthroscopic surgeries. orthopedic residency in arthroscopy in Nigeria is emerging and can be improved upon by increasing the available training resources and trained personnel.

Frequency of recurrent dislocation after conservative management of acute traumatic shoulder dislocation

Dislocations of the shoulder are a serious and expensive issue. Younger males are more likely than older men to experience shoulder dislocations, with overall incidence rates ranging between 23.91 and 23.12 per 100,000 person/years. After initial closure reduction and sling immobilization of the traumatic anterior shoulder dislocation, this study will give us the most recent and accurate information about the severity of recurrence of dislocation. Aim: The goal is to determine the frequency of recurrent shoulder dislocation occurs following conservative treatment. Place and Duration: In the Orthopaedics Department, Khyber Teaching Hospital, Peshawar for six months duration from 28/6/2012 to 28/12/2018. Methods: A total of 172 patients were observed during this study. All patients had conservative treatment, which included manual shoulder reduction and three weeks of immobilization with a sling. In order to reduce bias, all treatments were carried out by a consultant orthopedic surgeon with at least seven years of experience, assisted by a senior postgraduate resident. To check for the recurrence of the dislocation, all patients were instructed to maintain regular follow-up for the following three months.

The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK.

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry.Cite this article: Bone Joint J2022;104-B(9):1073-1080.

Expert clinical consensus in the delivery of hydrodilatation for the management of patients with a primary frozen shoulder : a modified Delphi study.

AimsTo achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation.MethodsWe conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional.ResultsBetween 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating).ConclusionIn the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation.Cite this article: Bone Jt Open 2022;3(9):701–709.

Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty.

Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up. Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing. From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28years postsurgery (median 5years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC. This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC. A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.

Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery.

Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.

ARTHROSCOPIC PREVALENCE OF RAMP LESION IN PATIENTS PRESENTING WITH ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR OF THE KNEE JOINTS

Objective: To measure the arthroscopic frequency of RAMP lesion in patients presenting with Anterior Cruciate Ligament tear of the knee. Methodology: This cross-sectional study was conducted at the Department of Orthopedic Surgery, Khyber Teaching Hospital Peshawar from 06 Aug, 2019 to 06 Feb, 2020. The patients were prepared for Arthroscopy under Spinal anesthesia by consultant orthopedic surgeon who had a further fellowship in arthroscopy and sports medicine, having a minimum of three years experience post-fellowship. All procedures were performed by the same surgeon. Standard two ports (anteromedial and anterolateral) arthroscopic technique was adopted and the inside of knee was thoroughly examined for any RAMP lesion in the posteromedial corner as per operational definition. The positive cases were recorded and one with no RAMP lesion was labelled as negative. Results: 19(17.1%) patients were recorded with RAMP lesions, diagnosed on knee arthroscopy undergoing Anterior Cruciate Ligament reconstruction of the knee. Conclusion: The RAMP lesion is a common meniscal injury that can occur at the time of anterior cruciate ligament rupture or as a result of knee laxity associated with anterior cruciate ligament insufficiency. The prevalence of RAMP lesions in this study was 17.1%. Patients younger than 30 years of age and male patients had a higher prevalence of RAMP lesions. Keywords: Anterior Cruciate Ligament, RAMP Lesions, Arthroscopy

Subtrochanteric fractures treated with dynamic condylar screw

Objectives: To assess the functional outcome of dynamic condylar screws to treat subtrochanteric fractures in adult patients.
 Methods: The prospective descriptive study was conducted at the department of orthopedic surgery, Dr. Ruth KM Pfau civil hospital Karachi, Pakistan, from March 2016 to October 2019. A total of 47 patients of 18 to 60 years of either gender with subtrochanteric fractures treated with dynamic condylar screw were included in the study. After consent and counseling, patients were operated on by a consultant orthopedic surgeon and fixed with a dynamic condylar screw. Postoperatively patients were regularly followed at 2nd, 6th, 12th, 16th, 20th weeks, and onwards monthly for at least one year. Functional outcomes such as infection, union, failure of fixation were observed in all patients. SPSS software version 23 was used to analyze data. Mean and SD was reported for numeric variables, whereas frequency and percentage were reported for categorical variables. A Chi-square test was used to assess the association between variables.
 Results: The mean age was estimated as 37.53±12.31 years. Most of the patients were male (74.5%), and 25.5% were females. About 27 patients had a fracture on the right side (57.4%) and 20 on the left side (42.6%). Out 47 cases, 3 were lost to follow, 33 patients showed excellent outcomes, 6 cases had a good outcome, 3 cases had fair outcomes, and 2 cases had poor functional outcomes. During the follow-up, 42 cases showed union, 3 lost to follow-up, 1 died, and 1 patient had implant break. About 2 patients had infections in post- operative duration because of fracture.
 Conclusion: Subtrochanteric femur fractures are challenging to operate, especially in our society where extensive trauma becomes more frequent. Dynamic condylar screws showed overall acceptable results. It is simple, locally made, readily available, and cheap, with almost the same result as other implants around proximal femur fractures.