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Introduction:Clavicle fractures represent 2.5% of fractures in adults and almost 44% of shoulder injuries. The treatment is usually non-surgical with good results; however, significantly displaced fractures can be associated with high non-union rate and therefore many would advocate surgical fixation. This is traditionally carried out by direct approach over the clavicle but an infraclavicular approach has also been used for clavicular fixation. The aim of this study was to identify the main indications for surgical intervention at our unit and patient satisfaction following surgery. We also wanted to compare the direct and the infraclavicular surgical approaches in relation to the outcome of surgical intervention.Materials and Methods:Retrospective study looking at all the clavicle fractures managed surgically over 5 years at our department. Information relating to surgical indication, surgical approach, complications, outcome, patient satisfaction, and oxford shoulder score were collected.Results:A total of 35 patients were identified, the majority were males (n = 25) and most (n = 29) were working at the time of injury. The commonest indication for surgery was displacement with shortening (n = 16). The infraclavicular approach was used in the majority of patients (n = 21), the rest (n = 14) had direct incision. Evidence of radiological and union was achieved in all patients after an average of 13 (8-24) weeks. There were no major complications but minor complications were reported in 28% and 19% of cases with direct and infraclavicular approaches, respectively. Plates were removed from six symptomatic patients; infraclavicular (n = 2) and direct approach (n = 4). Four asymptomatic plates were removed on patients’ requests. All patients returned to work (after an average 2.6 months), had good oxford shoulder score between 12-20, regardless of the surgical approach used. All patients except one would recommend it to a friend.Conclusion:Our study showed excellent surgical outcome for displaced clavicle fractures supported by the high union rate, good oxford shoulder score, high return to work rate, and good patient's satisfaction. The number of minor complications and symptomatic metal work removal was less in the infraclavicular approach.

A fully hydroxyapatite (HA) coated collared stem, when used in elderly age group for elective THR, has only 2% risk of intraoperative periprosthetic fracture. There's a 4% risk of radiologically significant subsidence (i.e. ≥2 mm), however, it has not proven to be clinically significant in our study. Dorr canal type had no bearing on either risk of periprosthetic fracture or subsidence. Collared stems did not have a statistically significant difference in risk of subsidence and peri-prosthetic fracture in comparison to un-collared stem, although there was a non-significant trend in favour of collar use.

Compartment syndrome of the leg and forearm are well described in the literature. However, compartment syndrome of the hand is rare and in children it is even rarer. Atraumatic hand compartment syndrome has not to our knowledge been previously reported. We describe a case of an atraumatic compartment syndrome of the hand in a child who underwent an urgent fasciotomy. The child was diagnosed with hereditary angiooedema. We highlight a rare but serious complication of a hereditary disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition, thereby reducing delays in reaching a prompt diagnosis.Paediatric compartment syndrome is a rare condition. Compartment syndrome of the leg and the forearm are much more common and are well described in literature. The average annual incidence is given as 7.3/100,000 for men and 0.7/100,000 in women.1 The incidence of compartment syndrome of the hand is not documented although there are a limited number of anecdotal reports. Trauma, for example in the form of crush injuries, venomous animal bites, 2 vascular injuries and burns, 3-5 is the most common underlying aetiology behind these case reports. There is one report of Henoch-Schönlein purpura 6 causing an acute compartment syndrome of the hand. We describe the first reported case of an acute hand compartment syndrome caused by hereditary angiooedema. case historyA 13-year-old Asian, right hand dominant girl presented with progressive left hand swelling (Fig 1) and a 5-day history of fever and malaise. There was no significant history of trauma, fall or any animal or insect bites. She had suffered from previous episodes of idiopathic swelling over the last two years on a monthly basis affecting both hands and legs as well as her head and face. She was otherwise fit and healthy.The patient was referred to the orthopaedic service five days into her illness. She was haemodynamically stable and apyrexial with gross, painful, oedematous swelling of the left hand. Digital perfusion was not impaired and she had paraesthesia in a median nerve distribution. Radiographs were normal and blood tests including a full blood count and inflammatory markers were also normal.A clinical diagnosis of compartment syndrome was made and the patient was taken to emergency theatre for a fasciotomy (Fig 2). Intraoperatively, a tight carpal tunnel was released. Necrotic fascia and muscle was found in the mid palmar space. The thenar eminence was normal and the recurrent palmar branch of the median nerve was preserved. Intermetacarpal spaces were also released, which again showed evidence of a necrotic brown exudate. A sample of this fluid was sent for microscopy and culture and went on to show no evidence of any organisms. In addition, the patient's blood and urine cultures were also negative. Postoperatively, the left limb was kept elevated and intravenous antibiotics were administered prophylactically after surgery until the result of the microbiology sample was known.At the 12-week foll...

Relevance: This study is considered as a research theme. Purpose: To investigate the most common differential diagnosis for anterior knee pain. Methods/analysis: A Delphi method has been used for this study. An expert panel of clinicians and academics were interviewed and surveyed to obtain their opinion regarding differential diagnosis for anterior knee pain. Semi-structured interviews of qualitative data (obtained in a previous survey) were used for initial round, which was conducted on ten expert academic researchers and clinicians from across the world and this was followed by a ranking analysis of qualitative data generated. All experts panel has more than seven years experience as clinicians and academic researchers. Reported here is one aspect of the themes identified in the overall study. Results: The first question asked of the experts was "What is the most common differential diagnosis? Can you characterize them?" the findings show that Plica syndrome was the most common differential diagnosis according to the expert panel 5 (out of 10), followed by patellar tendinitis and menisci problem and neurological referral like femoral or saphenous nerve 3 (out of 10), other differential diagnosis such as fat pad syndrome, degenerative osteoarthritis and hip joint itself have been scored 2 of 10. While other differential diagnosis scored just 1 of 10 for bursitis, Iliotibial band syndrome, collateral ligament injury, Chondromalacia, the patella itself and popliteal syndrome. Two experts indicated that there is no specific test that clinicians can do. After data analysis and quantifying of the findings by using thematic analysis, the researcher designed the ranking survey. In the ranking survey, nine experts were asked to rank the most frequent differential diagnosis for anterior pain they see in the clinic from their experience. The researcher considered the first three options ranked by the expert panel, the results show that patellofemoral joint was the most frequent to be seen by the experts in the clinic for 7 of the 9, 5 as primary. Patellar tendinitis was reported as common by 7 of the 9, while fat pad syndrome scored 4 times, once as primary ranking. The other question was "Can you rank the most difficult differential diagnosis to treat?, the experts indicated that both degenerative osteoarthritis or chondromalacia and fat pad syndrome were ranked in the top three by 6 out of 9

Purpose: Clavicle fracture is a common orthopaedic injury. Recent studies suggest a better outcome following open reduction and internal fixation for displaced midshaft clavicle fractures. Standard AP view is used in most hospitals to diagnose and treat midshaft clavicle fracture. The aim of our study was to identify if the second view (30 • caudal tilt) changes the treatment of clavicle fractures.Methods: A prospective study was conducted between March and June 2009. 17 patients attending the fracture clinic with midshaft clavicle fracture were reviewed by 5 orthopaedic trainees with X-rays. The fractures were classified according to Edinburgh Classification and treatment plan was decided after reviewing 1 and 2 views of the clavicle.Results: 84 treatment responses were available for 17 patients with midshaft clavicle fractures. 66 responses (79%) decided conservative treatment and 18 (21%) operative treatment after reviewing 1 view of the clavicle fracture. 34 responses (41%) were changed after reviewing the 2nd view and operative treatment was offered to 47 patients (56%). Fracture classification was also changed for 45 (54%) responses after the 2nd view. 84% responses preferred 2 views of the clavicle for diagnosis and treatment of midshaft clavicle fractures.Conclusions: We looked at the treatment offered to the patients with midshaft clavicle fractures by orthopaedic trainees in the fracture clinic of a teaching hospital after reviewing 1 and 2 views of clavicle X-rays.We found that the treatment changed significantly after reviewing the 2 views. We strongly recommend 2 views of the clavicle to decide the treatment of midshaft clavicle fractures.Proximal humeral fractures previously had been relegated to surgical scrap heap. Over the last two decades, significant interest has been evolved in the surgical fixation of unstable and displaced fractures of the proximal humerus. PHILOS plate fixation is relatively new and effective way to treat these complex fractures.Aim of study: To asses the radiological outcome following fixation of proximal humeral fracture using PHILOS plate.Method: Retrospective review of X-ray from patient with proximal humeral fracture treated with PHILOS plate. Thirty nine (39) patients were reviewed from 2007 to 2010. Patient age, sex, medical background information gathered. Mean follow up time was (6 months). Initial and follow up X-ray reviewed and complications such as screw penetration, avascular necrosis (AVN), non union and malunion were looked at.Outcome: Female to male ratio was 3:1. Majority of the fracture was three part (24, 61.5%) with two cases of fracture dislocation (5.1%).Screw penetration was the main complication following this surgery (8, 20.5%). There were two cases of AVN and (20.3%) malunion (Varus). Majority of complication happened when the fracture was not satisfactory reduced intraoperatively.Conclusion: Fracture proximal humerus can be challenging and there is still controversy regarding optimal management of these injuries. PHILOS plating is relatively new ...

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Relevance: With an ageing population the number of total hip replacements has increased by over 20% in the past 5 years (National Joint Registry, UK). The need to ensure patient management pathways are effective and efficient is becoming increasingly apparent.Purpose: Enhanced recovery programs (ERP) have been championed for over a decade for improving patient outcomes following elective surgery. The program described in this report is used within a UK NHS hospital and is a multi-modality treatment within which physiotherapy plays an integral component by providing pre-and post-operative intervention in both an in-patient and community setting. The service has become all-inclusive to patients regardless of medical, surgical or social status. One concern regarding ERPs is the risk of increased complications and hospital readmissions due to premature hospital discharge. The aim of this study is to evaluate an ERP following total hip arthroplasty in terms of hospital length of stay and readmission rate.Methods/analysis: A retrospective analysis was conducted of length of stay (LOS) in 1943 consecutive patients following THA surgery (primary, revision & post neck of femur fracture) at a UK general district hospital between April 2010 and April 2015. Further analysis for 28-dayreadmission was completed in 825 consecutive patients between April 2012 and April 2014.Results: LOS has reduced consistently from 4.36 to 3.27 days for primary THA, from 6.88 to 4.58 days for revision THA, and from 8.47 to 6.15 days for THA post neck of femur fracture. Relevant readmission within 28-days was 2.55%, occurring more so post revision THA, with hip dislocation and medical issues the most common causes. For those patients who were readmitted mean initial LOS was 7.34 days and time to readmission was 11.47 days.Discussion and conclusions: Our ERP incorporates a collaborative multi-disciplinary approach and has seen a 16 to 25% reduction in LOS following THAs in the last five years. The most recent years LOS figures are comparable with other reported ERP outcomes following THA across Europe. Reducing LOS is known to have positive effects on improving patient satisfaction, reducing hospital acquired illnesses and importantly ensuring cost-savings. Key concepts within this ERP including pre-operative education and community visits for inspections of wounds and exercise rehabilitation are provided by a dedicated home-support physiotherapy team. High readmission rates for ERP following hip and knee arthro-plasty have been reported however in this report the rate is substantially lower and comparable with readmission rates for non-ERPs. Readmissions do not appear to be linked to premature hospital discharge as the initial LOS for those readmitted was twice the overall average and the time to readmission was nearly a fortnight post discharge.Impact and implications: The need to develop services that enhance patient outcome, satisfaction and reduce the financial burden of an ageing population on the NHS is becoming increasingly important. The...