Compression testing of cadaver specimens showed that excision of the radial head allowed proximal radial displacement. The insertion of a metallic radial head restored normal mechanics, while a silicone rubber implant did not. We reviewed 31 of 36 comminuted fractures of the radialhead, 21 associated with dislocation or ulnar fracture, which had been treated by primary replacement with a Vitallium prosthesis. At a mean follow-up of 4.5 years, there was reliable restoration of stability and prevention of proximal radial migration. There had been no dislocations or prosthetic failures, but two implants had been removed for loosening. The prosthesis is recommended for use as a spacer to stabilise the elbow after severe injuries while the soft tissues heal.

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Background and purpose Total elbow replacement (TER) is used in the treatment of inflammatory arthropathy, osteoarthritis, and posttraumatic arthrosis, or as the primary management for distal humeral fractures. We determined the annual incidence of TER over an 18-year period. We also examined the effect of surgeon volume on implant survivorship and the rate of systemic and joint-specific complications.Methodology We examined a national arthroplasty register and used linkage with national hospital episode statistics, and population and mortality data to determine the incidence of complications and implant survivorship.Results There were 1,146 primary TER procedures (incidence: 1.4 per 105 population per year). The peak incidence was seen in the eighth decade and TER was most often performed in females (F:M ratio = 2.9:1). The primary indications for surgery were inflammatory arthropathy (79%), osteoarthritis (9%), and trauma (12%). The incidence of TER fell over the period (r = –0.49; p = 0.037). This may be due to a fall in the number of procedures performed for inflammatory arthropathy (p < 0.001). The overall 10-year survivorship was 90%. Implant survival was better if the surgeon performed more than 10 cases per year.Interpretation The prevalence of TER has fallen over 18 years, and implant survival rates are better in surgeons who perform more than 10 cases per year. A strong argument can be made for a managed clinic network for total elbow arthroplasty.

ObjectivesCollaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance.DesignA retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change.SettingAn ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system.Participants2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol.Outcome measuresTime for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance.ResultsWhere plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment.ConclusionsThis process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

Background Fifth metacarpal fractures are common and comprise a significant proportion of traditional orthopaedic fracture clinic workload. We reviewed the functional outcome and the satisfaction of patients managed with a new protocol that promoted Bself-care^and resulted in the discharge of most of these patients from the emergency department with no further follow-up. Methods A retrospective study was performed of patients discharged with a fifth metacarpal fracture between April 2012 to October 2012. A postal questionnaire was sent to each patient, followed by a telephone call. Patient-reported outcome measures (EQ-5D, QuickDASH) and patient satisfaction were assessed. Of the 167 patients eligible for the study, 5 were excluded. Of the remaining 162, 64 were uncontactable or declined to participate. The mean follow-up time was 21.6 months (SD 1.9, range 18.1 to 24.7). Results The median EQ-5D health index score was 0.87 (IQR 0.74 to 1.00), and the median QuickDASH score was 2.3 (IQR 0 to 6.8). Seventy-nine (80.6 %) patients were satisfied with the outcome of their injury, while 83 (84.9 %) reported being satisfied with the process. There was no difference between those with a fracture or those without a fracture in EQ-5D (p=0.307) or QuickDASH (p=0.820).Conclusion Fifth metacarpal fractures can be managed effectively through an Emergency Department protocol without any formal orthopaedic follow-up. This pathway lead to excellent patient-reported outcome measures and patient satisfaction. This protocol has reduced unnecessary hospital attendances for patients and increased the time available for clinicians to deal with more challenging injuries.

Objectives“Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway.MethodsNational Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign.ResultsThe total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs.ConclusionsThe virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings.Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. DOI: 10.1302/2046-3758.52.2000506

The use of passive stretching of the elbow after arthrolysis is controversial. We report the results of open arthrolysis in 81 patients. Prospectively collected outcome data with a minimum follow-up of one year were analysed. All patients had sustained an intra-articular fracture initially and all procedures were performed by the same surgeon under continuous brachial plexus block anaesthesia and with continuous passive movement (CPM) used post-operatively for two to three days. CPM was used to maintain the movement achieved during surgery and passive stretching was not used at any time. A senior physiotherapist assessed all the patients at regular intervals. The mean range of movement (ROM) improved from 69° to 109° and the function and pain of the upper limb improved from 32 to 16 and from 20 to 10, as assessed by the Disabilities of the Arm Shoulder and Hand score and a visual analogue scale, respectively. The greatest improvement was obtained in the stiffest elbows: nine patients with a pre-operative ROM < 30° achieved a mean post-operative ROM of 92° (55° to 125°). This study demonstrates that in patients with a stiff elbow after injury, good results may be obtained after open elbow arthrolysis without using passive stretching during rehabilitation.