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volume 5 | issue 3 | june 2016 | issn 2048-0091

in your field consent: where are at a glance

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Management of
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A global view in orthopaedics

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Volume 5 Issue 3
ISSN 2048-0091

In this issue Feature

1 EDITORIAL
2 FEATURE
2 Diabetic foot ulcers: Just chop
02
it off?
Diabetic foot ulcers: Just
8 GLOBAL VIEW
chop it off?
A quick glance at recent
orthopaedic developments
around the world
ROUNDUP360
Specialty summaries
10 Hip & Pelvis Medico-Legal

38
12 Knee
15 Foot & Ankle
17 Wrist & Hand
21 Shoulder & Elbow
24 Spine Consent: where are we
26 Trauma in 2016?
29 Oncology
31 Childrens orthopaedics
33 Research
36 Cochrane Corner
38 MEDICO-LEGAL FEATURE
38 Consent: where are we in 2016?
42 DIARY360
Meetings and dates Specialty summaries

10
for your diary

Next issue
FEATURE
New alignment strategies in TKA

A Bone & Joint Publication

BRITISH EDITORIAL SOCIETY OF BONE & JOINT SURGERY
 A global view in orthopaedics

EDITORIAL BOARD Journal Office Journals our Editorial Board read

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Arthritis and Rheumatism
Emma Vodden, Head of Editorial Publishing Services
Dr Jason Brockwell, Hong Kong, China Arthroscopy: The Journal of Arthroscopic and Related Surgery
Michael Searle, Head of Operations Bone & Joint Journal (formerly JBJS[Br)
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Emma Barnes, Head of Marketing & Sales Bone & Joint Research
Dr Antonia F. Chen, Philadelphia, USA British Journal of Sports Medicine
Kate Picard, Editorial Production Manager British Medical Journal
Mr Adrian Chojnowski, Norwich, UK
ISSN 2048-0091 Cartilage
Mr Michael Cross, New York, USA Chinese Journal of Orthopaedics
Clinical Journal of Sport Medicine
Mr Avi Das, Nottingham, UK Bone & Joint360 ISSN 2048-0091 is published bi-monthly in the Clinical Orthopaedics and Related Research
UK by the British Editorial Society of Bone and Joint Surgery at
Mr Sebastian Dawson-Bowling, London, UK Developmental Medicine & Child Neurology
22Buckingham Street, London WC2N 6ET
European Journal of Cancer
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E-mail: editor360@boneandjoint.org.uk European Journal of Surgical Oncology
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Subscription rate 49.00 (59.00). The 2016 US annual subscription
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editorial2016

Editorial

Ben
Ollivere
Editor-in-Chief
editor360@bone
andjoint.org.uk

The demise of reading: a problem

reflected in open access journals?

R
ight at the birth of orthopaedic sur-
gery, innovations and new treatments 25 000
were communicated through letters
to societies and in treatises, and rather 20 000
long textbooks describing experiences of treat-
ments. In fact, the oldest known records of 15 000
orthopaedic treatments described in the Edwin
Smith papyrus from Ancient Egypt are true to 10 000
this formula of simple series of descriptive cases,
a method also used by the fathers of orthopae- 5000
dic surgery in their own treatises in the 19th
century. Academic medical writing, and specifi-
0
cally orthopaedic writing, became more formal- 1

101
105
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
1
5
9

ised with the advent of scientific societies which

soon started circulating newsletters that rap-
idly became journals with the addition of peer
review, and more modern scientific methods.
This model has remained mostly unchanged
and provides regular updates of current scientific
methods to members of professional bodies.
However, the electronic revolution has changed
this somewhat. The most readily available source
of up-to-date information is no longer the
monthly visit of the postman bearing the latest
version of The Bone & Joint Journal. The rapid rise
of open access journals and online publishing
has exponentially expanded the numbers of
orthopaedic publications year on year (Fig. 1),
with around 20 000 publications last year com-
pared to 5000 just nine years ago. We all know
that the quality of these excess publications is not
improving. On the one hand, the ease of access
in the digital age ensures it is easy to sift through
information and identify that which is most rele-
vant, but on the other, it can make it increasingly
easy to miss important publications.
However, there is a real danger with the
move away from the printed journal. Important
Fig. 1 Orthopaedic publications by year.
messages are still printed in high-impact and
leading journals. Game-changing papers are
unlikely to appear in internet-only journals of
orthopaedics, and if they do, they are unlikely to
be read and even less likely to change practice.
Scientific research isnt just entirely about
finding things out like all of medicine, it is
about improving patient care. I was heartened to
read the report of how the DRAFFT study1
changed clinical practice in the BJJ (and reported
here in 360) this month. However, I cant help
thinking that the impact this study has had may
be as much to do with the massive publicity
effort that Professor Costa and his team in Oxford
have put into publicising the result. Although a
large study, the simple message that K-wires are
as effective as volar plates is not necessarily any
more important than that of David Stanley and
colleagues who reported in the same issue that
elbow arthroplasty is successful in supracondylar
fracture of the distal humerus over a 10-year
follow-up.2 Without the funded PR machine
behind the DRAFFT study, a similarly important
take-home message relies on the exposure
given to it by the journal in which its published.
As the national regulatory authorities are
becoming increasingly involved in revalidation
and keeping up-to-date, I hope this will return
the importance of the leading journal, be that
a subspecialty or general journal. After all, the
best and most competitive research gets pub-
lished in the largest journals, and as such it is
essential to keep reading them.
References
1.Costa ML, Jameson SS, Reed MR. Do large pragmatic ran-
domised trials change clinical practice? : assessing the impact of
the Distal Radius Acute Fracture Fixation Trial (DRAFFT). Bone Joint J
2016;98-B:410-413.
2. Prasad N, Ali A, Stanley D. Total elbow arthroplasty for non-
rheumatoid patients with a fracture of the distal humerus: a mini-
mum ten-year follow-up. Bone Joint J 2016;98-B:381-6.

2016 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.53.360447

Bone & Joint360 | volume 5 | issue 3 | june 2016

research-article2016
Feature
Diabetic foot ulcers:
Just chop it off?
Introduction
Diabetes is increasingly common, and is associ-
ated with significant patient morbidity, mortal-
ity and high socioeconomic costs (Table I). Due
to the increasing prevalence of diabetes, almost
all clinicians will treat patients who suffer from
it, or will treat a direct complication of diabetes.
One of the most serious complications affecting
2 orthopaedic surgeons is the diabetic foot ulcer
(DFU). The aim of this review is to update clini-
cians on the optimal management of the DFU.
Aetiology of DFU
Diabetes is a metabolic disease characterised by
hyperglycaemia as a result of defects in insulin
secretion or action. In the long-term this leads
to damage and dysfunction of organs, specifi-
cally the eyes, kidneys, heart, nerves and blood
vessels.4 A break in the skin on the foot in the
presence of diabetes is known as a diabetic foot
ulcer (DFU), and is the leading cause of hospi-
talisation in patients with diabetes (Fig. 1).5,6
There are multiple risk factors for the devel-
opment of a DFU (Table II).5 The most common
reasons are related to neuropathy, vasculopa-
thy or a combination of both.7-9 The vast major-
ity of DFU seen in clinics or presenting as
emergencies have combined pathology, and
only 10% of DFU are due to isolated vasculopa-
thy or peripheral vascular disease (PVD).10
Neuropathy
Diabetes is thought to cause damage to the vasa
nervorum resulting in an ischaemic insult and a
progressive irreversible sensory, motor and auto-
nomic neuropathy. Most presentations of sensory
Bone & Joint360 | volume 5 | issue 3 | june 2016
neuropathy are insidious until the onset of com-
plications. The sensory deficit usually occurs
below the knee, is denser distally and is bilateral.
Sensory deficit results in numbness of the feet
with burning, pain or paraesthesia being less
common.9 Autonomic neuropathy leads to stiff,
dry and scaly skin, which may crack due to loss of
normal skin flexibility, predisposing to softtissue
infection. Motor neuropathy is rarer, but in the
feet usually affects the intrinsic and extrinsic mus-
cle balance giving claw or hammer toes. These
lesser toe deformities can cause pressure points
and subsequent ulceration. Motor neuropathy
can also present as isolated mononeuritis. This
usually affects the peroneal nerve and results in
foot drop. Sensory and autonomic neuropathy
leads to high foot pressures, foot deformities, and
gait instability which leads to increased plantar
pressures and the subsequent risk of developing
ulcers.11-13
Vasculopathy
Arteriosclerosis is more common, more aggres-
sive and more diffuse than in non-diabetics. The
vasculopathy in diabetic patients affects the
large and small arteries as well as the microcir-
culation, with more diffuse circumferential
lesions that are harder to treat in isolation. This
is significant in the foot with regards to the DFU,
but also explains why diabetic patients have
higher risks of cardiovascular complications
such as ischaemic heart disease.
In summary, the primary aetiology of a DFU
is excessive pressures on softtissues in a neuro-
pathic foot, which is exacerbated by poor vascu-
larity and deformity.
Management of DFU
There are clear guidelines, recently updated by
NICE14 for the optimal management of the DFU,
but for those presenting as an emergency,
standards of practice can vary. The infected
emergency DFU can be life-threatening; the
term foot attack has been coined and appro-
priately highlights that management needs to
be more aggressive.1
There is a wealth of evidence and interna-
tional consensus which demonstrates how a
multidisciplinary approach reduces amputation
rates, lowers costs and leads to a better quality
of life for patients with DFU.9,14-20 The key NICE
recommendation is that every patient with a
DFU is referred promptly to the multidiscipli-
nary team (MDT; Table III) and the patient
should have a named clinician in charge of their
care, which can either be the diabetologist or
the surgeon. The benefits of the MDT approach
are clear in that diabetes is a multi-system dis-
ease and all comorbidities that will affect
wound-healing need to be addressed. The MDT
approach is preventative, reducing the risk by
up to 85% of further DFU and amputation
occurrances.19 In the presence of an emergency
or foot attack, the best practice recommenda-
tion from NICE is that immediate stabilisation
and drainage of pus should be performed by
the admitting team, before referral within 24
hours to the foot MDT service.14
Assessment of the DFU
A thorough history focussed on the duration of
diabetes and its associated complications, time
since the development of the ulcer and presence
 Martin Raglan FRCS, MSc, MBBS
Nottingham University Hospitals NHS Trust, UK
Brigitte Scammell DM, FRCS
Arthritis Research UK Pain Centre, University of Nottingham, UK

Email: b.scammell@nottingham.ac.uk

Table I. Diabetes-related statistics in the UK detailed assessment is required.28,29 If the ulcer

Diabetes: key facts1
In 2014, there were 3.3 million people with diabetes in the UK
By 2025, this will increase to 5 million
25% of patients with diabetes will suffer from a diabetic foot ulcer2
70% of lower limb amputations are secondary to diabetic foot ulcer1
70% mortality rate following amputation at 5 years; only lung and pancreatic cancer have worse mortality3
Total cost of diabetes care in the UK in 2014 was 23.7 billion1
Fig. 1 Necrotic diabetic foot ulcer of calcaneum.
of sensation will help guide treatment and
should be taken into account along with the
HbA1C level, which is the best indicator of blood
sugar control over a 90-day span. High HbA1C
correlates to high blood sugar levels, which
result in decreased neutrophil function, sup-
pression of the inflammatory response and
greater susceptibility to acute infection.5,21
Examination should focus in on those prob-
lems particularly seen in diabetic feet, pressure
areas, callosities and Achilles tendon tightness,
which leads to equinus deformity and increased
forefoot pressure, predisposing to ulceration. The
SINBAD (site, ischaemia, neuropathy, bacterial,
infection, area and depth)14 pneumonic is a sim-
ple but effective way to evaluate ulcers; and these
should be classified according to the Brodsky
ment clinical examination. However they all suffer
classification, which aids in directing treatment
(Table IV). The most accurate assessment for neu-
ropathy (or rather protective sensibility) remains
the use of the 10 g Semmes-Weinstein monofila-
ment or the use of 128 Hz tuning fork.22,23 There
are commercial variants such as the Vibratip,
which have been shown to be equally effective.24
Thorough vascular assessment is also necessary,
and palpable pulses only has a 70% sensitivity in
predicting peripheral arterial disease.25 Simple
bedside tests such as the ankle brachial pressure
index (ABI), which suggests peripheral arterial
disease (PAD) if the ABI is less than 0.8 can be
helpful; however calcification of the arteries in
diabetics can give a falsely reassuring ABI result.
Transcutaneous oxygen tension greater than 30
mm Hg and toe pressures greater than 45 mm Hg
are more sensitive and predictive of arterial dis-
sal micro-organism. In our experience they often
ease and DFU healing,26 however these tests are
time-consuming and expensive so have not been
widely accepted into modern clinical practice.
If there is a suspicion of PVD then early refer-
ral is made to a vascular surgeon, with assess-
ment via either digital subtraction angiography
or, more commonly, Duplex ultrasound. In
select cases a popliteal-to-distal-artery bypass
has been shown to be effective in lower limb
revascularisation, with an 82% limb salvage rate
at three years, and many patients wil benefit
from angioplasty where suitable lesions exist.27
Imaging
All patients with a DFU should have weight-bearing
foot and ankle radiographs taken to evaluate any
gross fractures or deformities as a result of Charcot
arthropathy. However with a sensitivity of between
60% and 75% for osteomyelitis, sometimes more
overlies a bony prominence with radiological
changes then osteomyelitis can be assumed, and
pencilling of the metatarsal and phalanges occurs
in diabetes and is more likely to be as a result of
hyperaemia than an infective process.29 More
expensive and specialist imaging such as triple
phase bone scans and MRI can be used to compli-
from poor specificity and sensitivity and struggle in
differentiating between infection and Charcot
arthropathy.9
Charcot neuroarthropathy is a disease pro-
cess that results in increased osteoclastic activ-
ity, leading to bone resorption, fragmentation
and deformity. In the acute phase it is difficult to
distinguish between an infection and Charcot
arthropathy. Diagnosis is based on clinical find-
ings more heavily than imaging as MRI cannot
distinguish between infective oedema and
oedema secondary to destructive Charcot.30
3
Microbiological assessment
DFU infections are generally polymicrobial, and
due to previous antibiotic use may harbour resist-
ant organisms. Superficial swabs of the ulcers are
often carried carried out; however we feel they are
of limited value due to colonisation by commen-
do not reflect micro-organisms isolated from deep
infection. Ultimately, accurate microbiology can
only be obtained by either a bone biopsy of sus-
pected osteomyelitic lesions, or from deep-tissue
samples during surgical debridement. Initial anti-
biotic treatment regimes should be broad until
accurate cultures are obtained and we would
advise deep-tissue sampling or bone biopsy in
established cases of osteomyelitis, allowing tar-
geted antibiotic regimes.31 This is supported in
part by NICE, which advocates early referral to the
DFU MDT if antibiotics have not worked over a
period of 14 days, to allow for earlier diagnosis
and assessment.14
Treatment
Medical management of uncontrolled diabetes
and sepsis in the first instance is key to a success-
ful outcome. If there is spreading infection or an

Bone & Joint360 | volume 5 | issue 3 | june 2016

 Table II. Risk factors for the development of diabetic foot ulcers5
General/systemic
Uncontrolled hyperglycaemia
Duration of diabetes
Peripheral vascular disease
Blindness/ visual impairment
Chronic renal disease
Old age
Table III. Members of the multidisciplinary team (MDT)
MDT membership
Diabetologist
Podiatrist
Diabetes nurse specialist
Plaster tech with skill in casting
General practitioner
Table IV. Treatment guide for DFU based on the depth-ischaemia classification9
Classification Definition
Grade
0 At-risk foot
1 Superficial ulceration
2 Deep ulceration
4 3 Extensive +/- pus
Ischaemia
A Not ischaemic
B Ischaemia without gangrene
C Gangrene
accompanying abscess (a foot attack) then the
DFU should be treated as an emergency and
urgent decompression of the ulcer performed
before transfer of care, ideally within 24 hours, to
a team with a specialist interest in this treatment.
In our experience, delaying urgent surgical
decompression while admitting teams discuss
management is associated with increased mor-
bidity and mortality in these diabetic patients.
Wagner first classified and rationalised DFU
treatments; his system was subsequently modi-
fied by Brodsky, which gives a numerical assess-
ment for depth of ulcer (0-3) and an alphabetic
grade for the vascular assessment (A-C; see
Table IV).
Grade 0 and Grade A: Loss of protective sensa-
tion. There is a loss of protective sensation so
Bone & Joint360 | volume 5 | issue 3 | june 2016
Local
Peripheral neuropathy
Structural foot deformity
Trauma
Callus
Limited joint mobility
Improperly fitted shoes
Vascular surgeon
Microbiologist
Orthopaedic surgeon
Orthotist
Treatment
Education, accommodative footwear, regular
clinical assessment
Off-loading with total contact cast
Surgical debridement, off-loading, targeted
antibiotics
Surgical debridement, +/- amputation, off-loading,
targeted antibiotics
Nil
Vascular assessment and consider vascular
reconstruction before debridement
Vascular reconstruction +/- amputation
the foot is at risk, but there is no ulceration and
no ischemia. Treatment consists of patient edu-
cation, regular examination and accommoda-
tive footwear such as a total contact insole,
which is contoured to the shape of the foot. The
simple measure of foot education in patients
has been shown to be the best precautionary
measure, preventing up to 50% of DFU
occurrences.32,33
Grade 1: Loss of protective sensation, and sub-
sequent ulceration. The ulcer is superficial with
no signs of infection and no exposed bone or
tendon. Treatment consists of offloading with a
total contact cast (TCC), removable cast walkers
(RCW) or specialist foot wear. TCC is the most
effective offloading technique for DFU, with
good evidence demonstrating a faster and
better healing of tissues time when compared
to standard treatments.34 TCC is a minimally
padded cast closely moulded to the shape of
the foot, enclosing the toes. This minimises
direct pressure on the ulcer by distributing the
pressure over the entire surface of the foot, and
prevents toes rubbing against the cast.34 The
cast is changed weekly to allow for reduction in
oedema and assess the skin for any risk of pres-
sure sores developing. Up to 90% of ulcers will
heal within six weeks following this regime.34-36
Ideally patients would minimise weight-bearing
on the DFU to optimise healing; however in the
elderly or severely neuropathic this is likely to be
optimistic, with patients unable to comply or to
judge if they are weight-bearing due to their
neuropathy.
Grade 2: Deep ulceration with exposed bone,
tendon or joint. These ulcers are at risk of deep
infection and are unlikely to improve with
offloading devices. They often require surgical
debridement of devitalised or exposed tissue
with appropriate dressings and offloading.
Grade 3: Extensive ulceration with abscess;
presence of infection that can be localised or
systemic. These are surgical emergencies (foot
attack) and require urgent surgical debride-
ment or partial amputation. Intravenous antibi-
otics alone will not work, as they cannot drain
pus and are ineffective against the micro-
organisms protective biofilm, especially with
the poor concentration of antibiotics delivered
due to the compromised microvasculature.
Alongside grading based on the depth of the
ulcer, consideration is also given to ischaemia.
DFU that are ischaemic or vasculopathic but not
infected (Grade B) may benefit from vascular
reconstruction with angioplasty or bypass,
before formal surgical debridement.
Debridement
Debridement decreases bacterial counts, stimu-
lates production of local growth factors and
reduces pressure on the wound bed that facili-
tates healing. Debridement can be surgical,
enzymatic, autolytic, mechanical and biologi-
cal. Surgical debridement is the most effective
in reducing complications from DFU, and short-
ens ulcer healing time.37,38
Surgical debridement consists of the com-
plete excision of all dead, devitalised and
infected tissue in theatre; in our institution it is
often undertaken with regional anaesthesia.
Copious lavage and repeat microbiological
sampling to determine the level of infection in
the residual wound is essential. Careful antibi-
otic treatment driven by laboratory results opti-
mises outcomes and closure of the ulcer, as this
has been shown to speed up ulcer healing time.
In our institution we pack any defects with anti-
biotic-loaded calcium sulphate, which we have
shown shortens the length of hospital stay and
speeds up ulcer healing.31 Non-adherent dress-
ings are applied and wounds are initially
checked at weekly intervals. A low threshold for
repeat surgical debridement has also been
shown to reduce duration and speed ulcer
healing.38
In our experience, DFU located in the fore-
foot responds well to prompt, aggressive surgi-
cal debridement of the infected tissue, including
even ray or toe amputation as required. Reliable
limb salvage (and even retention of foot length)
can be achieved. Difficulties arise when the
ulcers are located in the mid- or hind-foot. The
aims still remain the same salvage the foot and
eliminate infection. If the ulcer has resulted in
midfoot osteomyelitis and the infection cannot
be controlled then a Symes or below-knee
amputation can be considered as a two-stage
procedure, providing there is appropriate soft-
tissue coverage.
Debridement in the midfoot and Charcot
collapse results in altered biomechanics, a
higher rate of recurrence of ulceration and prox-
imal migration of amputation level. Hindfoot
ulcers affecting the calcaneum can be the hard-
est to manage due to the lack of soft-tissue cov-
erage. Sometimes a partial calcanectomy (with
negative pressure wound therapy to minimise
the dead space and plastics coverage) can be
successful in salvaging the foot. With these par-
tial foot amputations, there are ankle-foot
orthoses that can be applied to aid in
weight-bearing.
The aim of surgical debridement, and the
MDT approach in managing the DFU is to sal-
vage the foot and limb whilst minimising the rate
of amputation. Primary amputation should be
the last resort after all other salvage techniques
have been explored; however in certain patients
a below-knee amputation may offer a better
functional outcome than repeated attempts at
limb salvage and reconstruction, although there
are no clear consensus guidelines for this. This
decision is individualised and multifactorial to
match the patients lifestyle, medical, physical
and psychological comorbidities.
There is increasingly a role for elective pro-
phylactic surgery in the management of DFU,
with the aim of correcting deformities that
increase plantar pressures and predispose to
repeat ulceration. Although this does carry a
higher risk of infection and complications when
compared with standard foot and ankle elective
surgery, the benefits can be considerable.
Corrective procedures can range from simple
exostectomy; the removal of prominent pres-
sure-causing bone lumps; to full deformity
reconstruction via triple arthrodesis or tendon
lengthening and tendon transfer. Surgery can
be performed using minimally invasive tech-
Fig. 2 A forefoot ulcer.
niques to minimise complications, and recent
results are encouraging.39
Adjunct therapies
Biodegradable fillers
Stimulan is a synthetic, purified form of calcium
sulphate, which allows a wide range of antibiot-
ics to be added into the mixture. It is then placed
into soft-tissue or bone defects after ulcer
debridement (as shown in Figs 2 and 3). It is
biodegradable and has a more consistent elu-
tion of antibiotics delivered at high concentra-
tions to the local soft-tissues. In our series,31 it
has performed better as filler than gentamicin Fig. 3 Ulcer post-debridement and application
beads and we have not seen any problems with of Stimulan.
hypercalceamia, likely due to the smaller
amounts being used when compared with revi-
sion joint arthroplasty, and the lack of wound thought that this improves wound tissue 5
leakage problems. hypoxia, enhances perfusion, reduces oedema
and promotes ulcer healing.45 It has also been
shown to stimulate vasculogenic stem cells
Negative pressure wound therapy
from the bone marrow, recruiting them to the
(NPWT)
skin wound.45 However, HBOT is expensive and
This is not a substitute for the surgical debride- there is no evidence that it is superior to current
ment of DFU. It can be used to help heal chronic treatments. It is not mainstream treatment.
wounds by removing oedema, chronic exudate,
reducing bacterial colonisation, enhancing the
Bioengineered skin (BES)
formation of new blood vessels, and increasing
cellular proliferation and wound oxygenation These are synthetically-produced biological
as a result of applied mechanical force.40-42 dressings that act as a delivery system for growth
Meta-analysis has shown that NPWT reduces factors and extracellular matrix components that
healing times, and increases the number of promote wound healing and are meant to speed
wounds healed.43,44 In our experience it works up ulcer healing. They have been used for un-
best post- surgical debridement of calcaneal infected, full-thickness ulcers without bone or
ulcers to asssit in closing up the dead space, tendon exposure. Current BES products available
before either definitive plastics coverage or include Apligraf (Organnogenesis Inc., Cantom
wound healing by secondary intention. The MA), Derma graft (Advanced Bio Healing Inc., La
main disadvantage of NPWT is the material cost Jolla, CA) and Oasis (Cook Biotech, West Lafayette,
compared with conventional wound dressings. IN). These biological dressings have been shown
to accelerate DFU healing by the active secretion
Future therapies of growth factors, and providing the cellular sub-
Hyperbaric oxygen therapy (HBOT) involves strate and molecular components necessary for
intermittent administration of 100% oxygen in healing and angiogenesis.46 The main disadvan-
daily sessions in a hyperbaric chamber. It is tages of BES are the cost; and that they cannot be
Bone & Joint360 | volume 5 | issue 3 | june 2016
 used in ischaemic DFU in the presence of infec-
tion or without surgery. However they may be a
promising avenue for future treatment.
Conclusion
DFU is a complicated diagnosis, expensive to
treat and increasingly common. It presents a
host of challenges and problems to the treating
clinician. The primary goal of treatment is to
limit the risk of amputation, and further compli-
cations. This is best achieved with a multi
disciplinary approach. The main components of
management include patient education, good
blood sugar control, prompt surgical debride-
ment, appropriate antibiotics, offloading with a
total contact cast, and (where appropriate) elec-
tive prophylactic surgery to minimise future
recurrence.
It is important to recognise that the acute
presentation of an infected DFU requires
prompt surgical drainage of pus, and the term
foot attack should be used to promote an
understanding of the urgency. Once initial
debridement has been carried out, local path-
ways should exist for the prompt transfer
(within 24 hours) to the specialist MDT.
On-going management should focus on pre-
vention, then dealing with complications, other-
wise the financial costs of managing ongoing
6 complications could potentially overwhelm
local healthcare budgets.
References
1.No authors cited. Diabetes UK: Key facts and stats. https://
www.diabetes.org.uk/About_us/What-we-say/Statistics/ (date last
accessed 20 November 2015).
2.Sing N, Armstrong DA, Lipsky BA. Preventing foot ulcers in
patients with diabetes. JAMA 2005;298:217-28.
3. Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are dia-
betes related wounds and amputations worse than cancer? Int Wound J
4;2007:4286-7.
4.No authors cited. Position statement. Diabetes Care 2004;27:
suppl 1 s4. http://care.diabetesjournals.org/content/27/suppl_1/
s4.full (date last accessed 20 April 2016).
5. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the
management of diabetic foot ulcer. World J Diabetes 2015;6:37-53.
6. Iraj B, Khorvash F, Ebneshahidi A, Askari G. Prevention of dia-
betic foot ulcer. Int J Prev Med 2013; 2013;4:373-6.
7. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J.
The global burden of diabetic foot disease. Lancet 2005;366:1719-24.
8. Alvavi A, Sibbald RG, Mayer D, et al. Diabetic foot ulcers:
part II. Management. J Am Acad Dermatol 2014;70:e1-21.e2124.
9. Robinson A, Pasapula C, Brodsky J. Surgical aspects of the dia-
betic foot. J Bone Joint Surg [Br] 2009;91-B:1-7.
Bone & Joint360 | volume 5 | issue 3 | june 2016
10. Prompers L, Huijberts M, Apelqvist J, et al. High preva-
lence of ischaemia, infection and serious comorbidity in patients
with diabetic foot disease in Europe. Results from Eurodiale study.
Diabetologica 2007;50:18-25.
11.Sawacha Z, Gabriella G, Cristoferi G, et al. Diabetic gait and
posture abnormalities: a biomechanical investigation through three
dimensional gait analysis. Clin Biomech (Bristol, Avon) 2009;24:722-8.
12.Formosa C, Gatt A, Choklaingham N. Diabetic foot complica-
tions in Malta: prevalence of risk factors. Foot 2012;22:294-7.
13. Malgrange D. Physiopathology of the diabetic foot. Rev Med
Intner 2008;29:Suppl 2:S231-S7.
14.No authors listed. Diabetic foot problems: prevention and
management (NG19). https://www.nice.org.uk (date last accessed 21
September 2015).
15.No authors listed. International best practice guidelines:
wound management in diabetic foot ulcers. Wounds International
2013. http://www.woundsinternational.com/media/issues/673/files/
content_10803.pdf (date last accessed 20 April 2016).
16.Bakker K, Apelqvist J, Schaper NC. On behalf on the
International Working group on Diabetic Foot Editorial Board. Practical
Guidelines on the management and prevention of the diabetic foot.
Diabetes Metab Res Rev 2012;28(suppl 1):225-31.
17.No authors listed. International consensus on the diabetic foot
and practical guidelines on the management and the prevention of
the diabetic foot. Diabetes Metab Res Rev 2000;16 (Suppl 1):S84-92.
18.No authors listed. International Diabetes Federation clinical
guidelines task force. Global guidelines for type 2 diabetes. Brussels:
IDF, 2012. http://www.idf.org/ (date last accessed 20 April 2016).
19. Krisnan S, Nash F, Baker N, et al. Reduction in diabetic amputations
over 11 years in a defined population: benefits of multidisciplinary team
work and continuous prospective audit. Diabetes Care 2008;31:99-101.
20.No authors listed. Canadian Diabetes Association clinical prac-
tice guidelines for the prevention and management of diabetes in
Canada. Can J Diabetes 2008;32(suppl 1):S1-S201.
21. McMurry JF. Wound healing with diabetes mellitus. Better glu-
cose control for better wound healing in diabetes. Surg Clin North Am
1984;64:769-78.
22. Meijer JG, Smit AJ, Lefrandt JD, et al. Back to basics in diag-
nosing diabetic polyneuropathy with the tuning fork. Diabetes Care
2005;28:2201-5.
23. Gin H, Rigalleau V, Baillet L, Rabemanantsoa C. Comparison
between monofilament, tuning fork and vibration perception tests
for screening patients at risk of foot complications. Diabetes Metab
2002;28:457-61.
24. Bracewell N, Game F, Jeffcoate W, Scammell BE. Clinical
evaluation of a new device in the assessment of peripheral sensory
neuropathy in diabetes. Diabet Med 2012;29:1553-55.
25.Criqui MH, Fronek A, Klauber MR, et al. The sensitivity, speci-
ficity and predictive value of traditional clinical evaluation of periph-
eral arterial disease: results from noninvasive testing in a defined
population. Circulation 1985;71:516-22.
26. Apelqvist J, Castenfors J, Larsson J, et al. Prognostic value of
systolic ankle and toe blood pressure levels in outcome of diabetic foot
ulcer. Diabetes Care 1999;22:147-51.
2016 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.53.360435
27. Verhelst R, Brunea M, Nicolas A-L, et al. Popliteal-to-distal
bypass grafts for limb salvage. Ann Vasc Surg 1997;11:505-9.
28. Gold RH, Tong DJF, Crim JR, Seeger LL. Imaging the diabetic
foot. Skeletal Radiol 1995;24:563-71.
29. Yuh WT, Corson JD, Baraniewski HM, et al. Osteomyelitis
of the foot in diabetic patients: evaluation with plain film, 99mcTc-
MDP bone scintigraphy and MR imaging. AJR Am J Roentgenol
1989;152:795-800.
30. Moore TE, Yuh WT, Kathol MH, el-Khoury GY, Corson JD.
Abnormalities of the foot in patients with diabetes mellitus: findings
on MR imaging. AJR Am J Roentgenol 1991;157:813-816.
31. Raglan M, Dhar S, Scammell B. Is Stimulan (synthetic calcium
sulfate tablets impregnated with antibiotics) superior in the manage-
ment of diabetic foot ulcers with osteomyelitis compared with the
standard treatment? Bone Joint J 2015;97-B(Suppl 14):1.
32. Mensing C, Boucher J, Cypress M, Weinger K, et al. National
standards for diabetes self-management education. Diabetes Care
2005;28 Suppl 1:S72-9.
33. Iraj B, Khorvash F, Ebneshahidi A, et al. Prevention of dia-
betic foot ulcer. Int J Prev Med 2013;4:373-6.
34. Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact
casting in treatment of diabetic plantar ulcers. Controlled clinical trial.
Diabetes Care 1989;12:384-8.
35. Boulton AJ. Pressure and the diabetic foot: clinical science and
offloading techniques. Am J Surg 2004;187:17S-24S.
36.Rathur HM, BOulton AJ. The diabetic foot. Clin Dermatol
2007;25:109-20.
37. Lebrun E, Tomic-Canic M, Kirsner RS. The role of surgical
debridement in healing of diabetic foot uclers. Wound Repair Regen
2010;18:433-8.
38.Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgi-
cal debridement: a retrospective study on clinical outcomes in chronic
lower extremity wounds. Wound Repair Regen 2009;17:306-11.
39. Miller R. Minimally invasive surgical techniques for diabetic foot
and ankle pathology. Bone Joint J 2015;97-B(Suppl 14):2.
40.DeFranzo AJ, Argenta LC, Marks MW, et al. The use
of vacuum-assisted closure therapy for the treatment of lower
extremity wounds with exposed bone. Plast Reconstr Surg 2001;108:
1184-91.
41.Espensen EH, Nixon BP, Lavery LA, et al. Use of subatmosh-
peric (VAC) therapy to improve bioengineered tissue grafting in dia-
betic foot wounds. J Am Podiatr Med Assoc 2002;92:395-7.
42. Venturi ML, Attinger CE, Mesbahi AN, et al. Mechanisms and
clinical applicactions of the vacuum-assisted closure (VAC) device: a
review. Am J Clin Dermatol 2005;6:185-94.
43. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H. A sys-
tematic review of topical negative pressure therapy for the acute and
chronic wounds. Br J Surg 2008;95:685-92.
44.Sadat U, Chang G, Noorani A, et al. Efficacy of TNP on lower
limb wounds: a meta-analysis. J Wound Care 2008;17:45-8.
45. Gill AL, Bell CN, et al. Hyperbaric oxygen: its uses, mechanisms
of action and outcomes. QJM 2004;97:385-95.
46. Bennett SP, Griffiths GD, Schor AM, et al. Growth factors in
the treatment of diabetic foot ulcers. Br J Surg 2003;90:133-46.
 FRCS (T&O) REVISION COURSES
Queens Medical Centre, Nottingham
STATISTICS 18 September 2016
BASIC SCIENCE 19-21 September 2016
Statistics Course includes MCQ tests, problem solving and group viva.
Topics include data and distribution of data; key statistical principles; epidemiology;
error, bias and randomisation; sensitivity and specificity; survivorship analysis.

Basic Science Course consists of lectures, demonstrations, written paper, EMQs,

MCQ examination and small group vivas.
Topics include pathogenesis of infection; implant choice and fixation; fractures;
biomechanics; nerve injury; spines; bone and soft tissue tumours; radiology;
orthotics/prosthetics.

For further information telephone: 0115 823 1115 or

E-mail: oas-admin@nottingham.ac.uk
www.nottingham.ac.uk/medicine/study/training/frcs

NOTTINGHAM HAND SURGERY

REVISION COURSE
Queens Medical Centre, Nottingham
8-10 September 2016
Course includes lectures, clinical demonstrations
and small group vivas
Topics covered include anatomy review; flexor tendon repair; nerve entrapment;
trigger finger and De Quervains disease; metacarpal fractures; amputations;
Dupuytrens disease; crush injuries; trapeziectomy.

Long established course (in its 17th year) with nationwide Faculty
For further information telephone: 0115 823 1115 or
E-mail: oas-admin@nottingham.ac.uk
www.nottingham.ac.uk/medicine/study/training/frcs
42.123
research-article2015
BAJ0010.1302/2048-0105.42.123456

WORLD NEWS

Global View
BELFAST, UK
BRUSSELS, BELGIUM
Aspirin a safe thromboprophylac-
Arthroscopic approach seems to
tic agent versus other agents in the
have a role in the treatment of
prevention of early thromboembolic
ongoing synovitis following TAR.2
events and mortality.1

NEW YORK, NY
Medial UKA improves lateral joint space
congruence and width which may be
helpful in reducing osteoarthritis pro-
gression in the lateral compartment.6

VANCOUVER, CANADA BRISTOL, UK

Pseudotumour formation following Cadaveric models of unicortical fixa-
metal-on-poly arthroplasty is a rare tion shows an 8 hole unicortical plate
cause of delayed instability in hip for metacarpal fractures can tolerate
8 arthroplasty.7 early mobilisation.8

DALLAS, TX
Flexible nails for paediatric femoral
shaft fractures versus spica immobilisa-
tion provide comparable clinical and
radiographic outcomes but likely ear-
lier mobilisation.10
TAMPA, FL
Gamma 3 versus InterTAN nail tested in a
biomechanical cadaveric model of intertro-
chanteric hip fracture, with lower rotational
forces seen in the InterTAN group.11

References
1. Bone Joint J 2016;98-B:341-8.
2. Foot Ankle Int 2016;37:142-9. Toulouse, FRANCE
3. J Bone Joint Surg [Am] 2016;98:199-210. Peripheral nerve sheath tumours in patients
4. Clin Orthop Relat Res 2016;474:1269-79. with NF-1 are not associated with poor
5. J Foot Ankle Surg 2016;55:90-3. prognosis, unless recurrent or metastatic.12
6. Knee 2016 (Epub ahead of print).
7. Bone Joint J 2016;98-B:187-93.
8. J Hand Surg Eur Vol 2016;41:367-72.
ZURICH, SWITZERLAND
9. J Child Orthop 2016;10:1-14.
10. J Bone Joint Surg [Am] 2016;98:267-75. Axial headless intramedullary compres-
sion screws for the treatment of proxi-
11. J Orthop Trauma 2016;30:164-9.
mal and middle phalanges fractures
12. Eur J Cancer 2016;56:77-84. offers good early mobilisation with no
13. Eur Spine J 2016;25:1056-63. major complications.16
14. Pak J Med Sci 2016;32:44-8.
15. Bone Joint J 2016;98-B:194-200.
16. J Hand Surg Eur Vol 2016;(Epub ahead of print) PMID: 27056277.
17. Bone Joint J 2016;98-B:334-40.

Bone & Joint360 | volume 5 | issue 3 | June 2016

 A quick glance at recent orthopaedic developments around the world

Solna, SWEDEN
Sacral Ewings sarcoma is associated with sig- SEOUL, SOUTH KOREA
nificantly better 5-year survival rates than pel- Posterior antiglide plating of distal fibula
vic Ewings sarcoma.3 BEIJING, CHINA should be performed with short plates and
positioning to be posterolateral rather than
Arthroscopic fixation of isolated greater
truly posterior to prevent peroneal tendi-
tuberosity fractures requires increased
nopathy.5
operating time with only subtle differ-
ences in functional outcomes.4

Beirut, Lebanon
Detailed review of the EOS biplanar radiograph
system including pitfalls and uses.9

NIIGATA, JAPAN
9
Corticosteroid periarticular injection
following TKA can provide significant
reduction in cumulative 24 hour pain
scores.15

AHVAZ, IRAN
Uncemented hip hemiarthroplasty has signifi-
ASSIUT, EGYPT cantly higher complication rates and higher
pain levels with poorer functional outcomes
Anterior versus posterior approach
than their cemented counterparts.14
comparable for tuberculous spondy-
lodiscitis, but posterior may have the
edge in terms of deformity correction.13

AUCKLAND, NEW ZEALAND

Factors predictive of early peripros-
thetic joint infection are found to be
male gender, previous surgery, liga-
ment reconstruction and use of anti-
biotic cement.17

Bone & Joint360 | volume 5 | issue 3 | June 2016

research-article2016
specialty summaries
Roundup360
Hip & Pelvis
X-ref For other Roundups in this
issue that cross-reference with Hip
& Pelvis see: Knee Roundups 3, 5;
Wrist & Hand Roundup 5; Spine
Roundup5, Trauma Roundups 1,
2, 5, 7, 8; Childrens Orthopaedic
Roundup 6; Research Roundups 1,
2, 4, 5, 6.
Hip arthroplasty more
complicated in the mentally
unwell X-ref
Surgeons in North Carolina
(USA) have undertaken an interest-
ing retrospective database study,
designed to compare medical and
10 surgical complication rates between
two cohorts undergoing total hip
arthroplasty, some with and some
without mental health diagnoses.
The study aims to answer the ques-
tion, do mental health diagnoses
have an effect on complication
rates?1 The outcomes were com-
pared between a control group of
591 000 patients and 87 000, all
with psychiatric disease (depres-
sion, schizophrenia or bipolar disor-
der). Patients were identified from
the Medicare database with linkage
performed between ICD-10 codes,
allowing patients undergoing total
hip arthroplasty to be linked to
their mental health diagnoses (if
indeed they had one). Outcomes
were assessed at two years, but in
essence only codeable complica-
tions recorded as a post-operative
complication or requiring a further
healthcare episode were captured.
In the psychiatric disorder group,
the authors report that at 90 days
there were increased rates of 13 of
the 14 listed medical complications,
Bone & Joint360 | volume 5 | issue 3 | june 2016
and at two years there were
increased rates in five out of six
surgical complications, including
infection, dislocation, periprosthetic
fracture and revision. Their literature
review attempts to understand
these phenomena in terms of pos-
sible biochemical changes seen sys-
temically in patients with psychiatric
diagnoses and makes for stimulat-
ing reading although it is (for the
most part) conjecture. The authors
overall conclusion - that these
data should prompt arthroplasty
surgeons to undertake appropriate
counselling pre-operatively in such
patients - is worthy of note and is a
new finding.
A small piece in the
hemiarthroplasty
puzzle X-ref
Debate is still ongoing regard-
ing the relative risks and benefits of
stem cementation when undertak-
ing arthroplasty procedures for
neck of femur fractures. On the
one hand there are concerns over
the systemic and cardiovascular
effects of cement in this physi-
ologically relatively weak patient
cohort. Conversely, however, the
poor bone quality of many hip
fracture patients has potential
negative implications for the use
of uncemented implants (whether
hydroxyapatite-coated or not),
which rely on bony biological
processes to achieve satisfactory
long-term fixation. An interesting
randomised study from Stockholm
(Sweden) is worthy of inclusion in
this months 360 roundup.2 Initially
conceived as two separate studies
looking at hemiarthroplasty and
total hip arthroplasty (THA) respec-
tively, the two studies were pooled
midway through the project due
to low recruitment numbers. Not
exactly gold standard methodol-
ogy, however, this is more than
illustrative of real world research in
a difficult-to-study patient cohort.
In a therefore slightly complex
study design, all patients were
randomised to receive either a
cemented Exeter or uncemented
Bimetric stem; those aged between
65 and 79 years received a THA with
cemented polyethylene socket,
those aged 80 years and over, a
monopolar hemiarthroplasty. This
made the results perhaps more
generalisable to day-to-day clinical
practice. Among the 67 patients
receiving cemented stems, there
were no intra-operative fractures,
compared with nine from the group
of 74 receiving an uncemented
implant. Additionally, there were
no differences in mortality rates
between the two groups. Con-
versely, however, a substantial
number (though not all) of the
scoring assessment tools used
demonstrated significantly better
symptomatic and functional out-
comes with cemented prostheses.
Although the numbers are relatively
small, this study clearly provides
food for thought for all surgeons
treating intracapsular fractures,
suggesting substantial benefits
to the use of a cemented stem,
no increase in associated mortal-
ity rates and fewer intra-operative
complications. Detractors would
argue that this study may be under-
powered for mortality as a primary
endpoint, however, it certainly
constitutes an important piece in an
increasingly clear jigsaw.
A second look at cement in
trauma X-ref
Following on from the Swedish
paper, this study from Ahvaz (Iran)
again looks at the relative risks and
benefits of stem cementation, this
time in 51 patients over the age of
65 years, all of whom underwent
hemiarthroplasty (not THAR) for a
fractured neck of femur.3 While this
study is not randomised (indeed it
is not explained how patients were
allocated to receiving cemented or
uncemented stems), its findings
correlate with those of the group
from Stockholm. Of the 22 patients
receiving a cemented stem (all
received a bipolar hemiarthroplasty),
21% sustained an intra- or post-
operative complication. This rate was
significantly higher in the 29 who
were treated with an uncemented
prosthesis (31%), who also had
higher pain levels post-operatively
than those receiving uncemented
implants. HSS scores at four and 24
weeks were better in the cemented
group (although there are no data
on pre-operative symptomatic and
functional levels). Although far less
robust than the data from the Swed-
ish RCT, this again clearly provides
food for thought for all surgeons still
considering the use of uncemented
stems in the hip fracture context.
A fresh look at resurfacing?
It is easy to confuse the concerns
surrounding metal-on-metal
arthroplasty and the concept of hip
resurfacing. The complication profile
is different, and although the two
often go hand in hand, given the tri-
bological restrictions on larger bear-
ing surfaces it is important perhaps
to remember that resurfacing as a
concept does not necessarily require
a metal-on-metal bearing, and that
difficulties with many resurfacings
are due to the tribology of the bear-
ing surface and not necessarily the
concept itself. At a time when hip
resurfacing has largely fallen from
favour due to concerns over adverse
reactions to metal debris, it is inter-
esting to read this series describing
the seven- to ten-year results of a
metal-on-polyethylene (MoP) hip
resurfacing arthroplasty system.
Running the risk of high wear rates
due to adhesive wear, large sliding
distances and restrictions on the
thickness of the polyethylene, hard-
on-soft resurfacing was largely
abandoned in the 1990s due to the
high wear rates associated with the
larger head size. However, things
have moved on in surface tech-
nologies and hence surgeons from
Washington (USA) have reported
their results of a prospective series
of 190 patients (all of whom were
self-selecting) who underwent hip
resurfacing rather than total hip
arthroplasty.4 The series reports hip
resurfacing using highly cross-linked
polyethylene, with the rationale that
the perceived improvement in wear
properties of the highly cross-linked
polyethylene may allow for the
potential benefits of hip resurfacing
without the drawback of a metal-
on-metal bearing surface. Although
some previous authors and surgeons
have expressed serious concerns
over the possibility for delamina-
tion and catastrophic failure within
the weight-bearing portion of the
acetabular liner when manufactured
from polyethylene, this particular
series certainly makes a reasonable
case for such a system. Survivor-
ship at between seven and ten
years was 97%, and perhaps more
importantly there were substantial
improvements in patient satisfaction
scores following the procedure. A
subgroup of 51 patients also under-
went metal artefact reduction CT
scanning post-implantation as part
of osteolysis surveillance, and CT
visible osteolysis rates were found to
be only in the region of 2%. While
further evaluation and longer-term
follow-up are clearly required for
wider interest to develop in the use
of such a system, these early results
are certainly promising, suggest-
ing that with a few design tweaks,
resurfacing as a concept may not be
consigned to the scrapheap just yet.
Tranexamic acid in hip
arthroplasty surgery X-ref
Many readers of 360 will use
tranexamic acid (TXA) as a matter
of routine for patients undergoing
THA. Thus far, the most definitive
paper in support of this approach
to cross the editorial desks here at
360 is from the Araba Univer-
sity Hospital (Vitoria-Gasteiz,
Spain). Giving blood transfusions
to patients because of blood loss
sustained during a THA is not without
risk, being associated with transmis-
sion of infections and immunological
reactions, among others. In addition,
blood is an expensive and limited
resource. Tranexamic acid has risen to
the fore in common practice and is an
antifibrinolytic that has been shown
to reduce blood loss in many types of
surgery, including THA. Debate, how-
ever, continues as to the best treat-
ment regimen. The authors of this
study5 conducted a randomised, dou-
ble-blind, parallel group, placebo-
controlled trial in two hospitals. All
patients with ASA I-III, aged 18 years
or older and with no known allergy
to TXA were invited to participate.
However, there were a number of
exclusions including severe vascular
ischaemia, history of venous throm-
bosis and pulmonary embolism (PE).
Patients were randomised to one
of three interventions: single dose
of TXA, double dose group and a
placebo control group. The trigger to
transfuse was set at Hb 8.5 g/dl under
normovolaemic conditions, and at 9
g/dl in cases of moderate cardiac or
respiratory disease or symptoms of
acute anaemia. Although rather small
in eventual analysis, with 35 patients
from the single dose group, 36
from the double dose group and 37
from the placebo group, there were
some important findings. The study
confirms that TXA does reduce bleed-
ing, up to the second day following
surgery. However, there was no
difference between the intervention
groups in terms of estimated blood
loss. There was, on the other hand, a
difference in blood transfusion rates
(22.9% single dose vs 11.1% in the
double dose group and 37.8% in the
control group).
In summary, we
should all seri-
ously consider
using TXA in
patients undergo-
ing a THA. At
present there is
still not sufficient
evidence to
conclude whether
one pre-operative
dose and one
post-operative dose is any better than
a single pre-operative dose, and only
weak evidence to support a single
dose regime.
Reducing complications in
anterior hips
The overwhelming success of
total hip arthroplasty is one of the
medical miracles of the 20th century.
However, despite the great benefits
that can be achieved, surgeons
continue to innovate in attempts
to improve what is one of the most
successful medical treatments. Use
of the direct anterior approach to
the hip (DAA) is gaining popularity,
mainly due to perceived benefits of
earlier post-operative recovery and
the lower dislocation rate associated
with a technique that is muscle spar-
ing. The steep learning curve and
reported complications in the hands
of an inexperienced surgeon have
discouraged experienced surgeons
from trying something new. The
common complications associated
Bone & Joint360 | volume 5 | issue 3 | june 2016
with the DAA include femoral shaft
fracture, component misalignment,
anterior dislocation and wound com-
plications, with some series reporting
an incidence as high as 9% for major
complications and a 6.5% early
re-operation rate. Using what the
authors from Juntendo University
(Tokyo, Japan) rather hopefully
term countermeasures6 may, how-
ever, reduce these complications and
help keep the unwary out of trouble.
The measures evaluated in this study
include: exclusion criteria for DAA; no
positioning table; use of fluoroscopy;
and experienced assistant having
performed over 100 procedures.
The authors also
excluded the proce-
dure for surgeons
new to the DAA
in patients with a
previous history
of osteotomy, or
femoral abnormal-
ity (Perthes, or
developmental
dysplasia) and soft-
tissue contractures.
The modified tech- 11
nique described utilised fluoroscopy
to aid in the osteotomy level of the
neck, reaming of the acetabulum and
position of the components during
both trial and implant insertion. The
authors applied this technique to
three surgeons starting to undertake
DAA, and reported the results of the
first 40 procedures performed by
each using their countermeasures.
As perhaps would be expected, there
was a fairly long operating time
of 117+/- 27 minutes, and over one
minute of fluoroscopy was used.
Amazingly, however, the authors
report no intra-operative complica-
tions and no re-operations. There
was one late anterior dislocation
which was treated by a closed reduc-
tion and had no further dislocation.
Having compared their early results
with those in the published literature,
the authors concluded that they had
demonstrated a lower complica-
tion rate by employing these four
measures.
 Having your cake and
eating it? The outcomes of
ERAS X-ref
In the era of bundled payment
in the majority of Europe and the
United States, the focus of healthcare
systems is moving from a quality
agenda to a value agenda. One of
the best methods for cost contain-
ment which has become more and
more popular in hospitals world-
wide is the enhanced recovery
programme. These pathways aim
to decrease hospital length of stay
without compromising patient
outcome. Most focus on peri-
operative anaesthetic optimisation,
physiotherapy and planned stays.
Although minimally invasive surgery
was lauded as a potential benefit,
multiple studies have shown that
this does not affect the length of
stay. In this study conducted at the
Royal Infirmary of Edinburgh
(UK), the authors implemented
pre-operative physiotherapy and
occupational therapy, provided
patient literature, and a periarticu-
lar local anaesthetic injection was
12 utilised in order to reduce length
of stay.7 Unusually, the authors
report not only their outcomes in
terms of resource use, but also their
outcomes in terms of functional
scores, 18 months post-operatively.
The study team report the effect of
Knee
X-ref For other Roundups in this
issue that cross-reference with
Knee see: Wrist & Hand Roundup 5,
Trauma Roundup 5, Research Round-
ups 1, 3, 4, 5, 6, 7.
Patient-specific
instrumentation no good
in UKA
As with all joint arthroplasties,
there is good evidence to support the
idea that correct positioning of the
unicompartmental knee arthroplasty
(UKA) implant is vital to ensure
both good function and implant
Bone & Joint360 | volume 5 | issue 3 | june 2016
their programme on a serial cohort
of 1161 patients, all undergoing total
hip arthroplasty with and without
an enhanced recovery programme.
The study reports the outcomes of
611 treated without the enhanced
recovery programme and 550 treated
with the programme. The study
team undertook multivariate analysis
to adjust for confounders and were
able to report that implementing this
programme resulted in a decreased
hospital stay of 1.5 days. Mortality
and dislocation rates were similar
between groups, while the Harris
Hip Score and SF-36 score improved.
Utilising an enhanced recovery
programme is clearly beneficial after
total hip arthroplasty for both the
patient and the hospital system, and
without compromising longer-term
outcomes.
Hip dislocation due to silent
trunnion corrosion
It is always tempting when
things dont quite work out, and
the patient suffers a complication,
to find a reason or excuse as to why
this might have happened. We can
admit to being slightly cynical here
at 360 on encountering this report
on silent trunnion corrosion being
responsible for late hip disloca-
tion. However, in what is a short
paper describing ten cases of hips
revised in Vancouver (Canada),
survivorship. Despite the potential
innovations of computer-assisted
surgery and robotics there is little
evidence to support their use, and
there are ongoing concerns regard-
ing cost and the additional surgical
times. Patient-specific instrumenta-
tion (PSI) is now commonplace and
available in many institutions. An
MRI-based imaging protocol is used
to print 3D bespoke cutting blocks to
guide the frontal and sagittal cuts on
the tibia and the distal femoral cut.
These authors from Aix-Marseille
the authors make a fairly compel-
ling argument that pseudotumour
formation can be seen in metal-on-
polyethylene hips, and that this can
present as a late dislocation.8 The
authors present a case series of ten
MoP THAs with delayed dislocation,
and demonstrated that pseudotu-
mour is an infrequent (and often
unsuspected) but important contrib-
utor to delayed instability following
MoP THA. In their series, the patients
presented at around five years fol-
lowing primary hip replacement,
and in all cases there was histo-
logical confirmation of adverse local
tissue metal reaction. The authors
make the valid point that pseudo-
tumour formation, due to its rare
incidence in MoP hips, is often not
on the list of differential diagnoses,
however, malaligned components
can result in increased trunnion
forces and fretting corrosion, just as
they can at an articulating surface.
It is clearly better to establish this
diagnosis prior to revision, as the
rates of complications are high and a
revision of this nature would ideally
be undertaken by a surgical team
experienced in the management of
adverse metal reactions.
References
1. Klement MR, Bala A, Blizzard DJ, et al.
Should we think twice about psychiatric disease
University, Marseille (France)
designed a randomised controlled
study with 60 patients divided into
two groups using either the PSI tech-
nique or the conventional technique,
and outcomes were assessed using
gait analysis and component posi-
tions.1 There were no reported sta-
tistical differences between the two
groups in terms of gait analysis at one
year, nor in component alignment or
functional scores at three months and
one year after surgery. There have
been some commentators (including
in total hip arthroplasty? J Arthroplasty 2016;[Epub
ahead of print] PMID: 27067760.
2. Inngul C, Blomfeldt R, Ponzer S, Enocson
A. Cemented versus uncemented arthroplasty in
patients with a displaced fracture of the femoral
neck: a randomised controlled trial. Bone Joint J
2015;97-B:1475-80.
3. Khorami M, Arti H, Aghdam AA. Cemented
versus uncemented hemiarthroplasty in patients
with displaced femoral neck fractures. Pak J Med Sci
2016;32:44-48.
4. Pritchett JW. Hip resurfacing using highly cross-
linked polyethylene: prospective study results at 8.5
years. J Arthroplasty 2016; [Epub ahead of print] PMID:
27067469..
5. Barrachina B, Lopez-Picado A, Remon M,
et al. Tranexamic acid compared with placebo
for reducing total blood loss in hip replacement
surgery: a randomized clinical trial. Anesth Analg
2016;122:986-95.
6. Homma Y, Baba T, Kobayashi H, et al. Safety
in early experience with a direct anterior approach
using fluoroscopic guidance with manual leg con-
trol for primary total hip arthroplasty: a consecu-
tive one hundred and twenty case series. Int Orthop
2016. PMID:26993647. [Epub ahead of print]
7. Maempel JF, Clement ND, Ballantyne JA,
Dunstan E. Enhanced recovery programmes after
total hip arthroplasty can result in reduced length
of hospital stay without compromising functional
outcome. Bone Joint J 2016;98-B:475-82.
8.Lash NJ, Whitehouse MR, Greidanus
NV, et al. Delayed dislocation following metal-
on-polyethylene arthroplasty of the hip due to
silent trunnion corrosion. Bone Joint J 2016;98-B:
187-93.
a letter to the Editor2) suggesting
that, given the lack of difference in
outcomes between the two templat-
ing approaches, PSI would benefit
a relatively inexperienced surgeon.
However, here at 360 we would
interpret the data differently. Surely
we should be careful of advocating
PSI as a replacement for experience?
The PSI technique is not infallible and
to make the most of PSI, the surgeon
surely needs a good understanding
not only of the technique and how
the instrumentation works, but of the
system itself. Bespoke instrumenta-
tion and cutting blocks remain a
viable option, however, the benefits
are far from proven.
Epidemiology: competing
risks X-ref
Among the lies, damn lies and
statistics found smattered across
research in orthopaedics, we tend
to recognise common patterns in sta-
tistical analysis and assume these to
be correct. This leads to the standard
and oft-used statistical tests monop-
olising the reporting of the majority
of studies. However, statistics itself is
of course its own scientific discipline,
and things do tend to move on. The
venerable Kaplan-Meier curve has
been used to report everything from
the age of the universe (looking
at stars going supernova) to the
chances of a hip or knee replacement
becoming infected. Although the
Kaplan-Meier method is excellent
for reporting cohorts with variable
follow-up and a binary outcome, it
is somewhat limited when it comes
to reporting patients outcomes and
there is the possibility of failure for
other reasons a so-called compet-
ing risk. Epidemiologists have been
working with statisticians to produce
competing risk models for reporting
the likelihood of various population-
based risk models, and revision
arthroplasty is no exception. This
much more accomplished approach
has been applied to revision of tibial
implant types, with death accounted
for as being a competing risk by the
clever chaps at the Mayo Clinic,
Minnesota (USA). The authors
report the outcomes of 22 864
primary TKAs performed at the Mayo
Clinic and followed up for a mean of
7.8 years (0.1 to 26.3 years),3 and they
were able to compare risk estimates
using the two methods. The authors
established that due to the size of the
competing risk of death (four times
more likely than revision), there was
an overestimate of revision by 3%
at five years, 14% at ten years, 32%
at 15 years, and 57% at 20 years.
This study confirms what would be
expected, namely that if a competing
risk model is not used then the
Kaplan-Meier method may over-
estimate implant failure in arthro-
plasty, and this should be taken into
consideration for other studies in the
orthopaedic literature.
Catching up with the
Europeans? Rehabilitation
in the US under the
spotlight X-ref
Traditionally, healthcare pro-
viders in the US have lauded the
rehabilitation facility as a suitable
alternative to care in an acute hos-
pital environment. The step down
to a rehabilitation environment
certainly has a significant attraction,
and for years insurance companies
and healthcare providers have been
attracted to the concept
of faster recovery and
reduced total cost.
There is increasing
evidence that accel-
erated discharge
pathways and
discharge
directly home
may have some
significant advan-
tages, removing
the requirement for
a rehabilitation facility.
The outcomes of over
14000 large joint arthroplas-
ties were used as the basis of
this three-year retrospective study
conducted in Cleveland (USA).
The authors used a fairly complex
Bayesian hierarchical regression
model to account for the complexi-
ties of the data and attempted to
unpick the effects of surgeon and
hospital factors on discharge loca-
tion.4 The authors established that
a rapid recovery protocol increased
the chances of being d
ischarged
home, with a 45% increase in likeli-
hood if one were in place. This can
clearly result in cost savings to the
provider, as well as a better environ-
ment for the patient.
How do unicompartmental
knees do in revision? X-ref
One of the fundamental differ-
ences between unicompartmental
knee arthroplasty (UKA) and total
knee arthroplasty (TKA) (at least if
you listen to the proponents) is the
ease of revision. It has even been
said by prominent surgeons that a
revised UKA is akin to a primary total
knee rather than a revision opera-
tion, both in complexity of surgery
and longevity of the implant. There
is now some evidence to suggest
that at least some of this statement
isnt quite correct. The complexity
of revision of a unicompartmental to
a total knee can be quite high, often
requiring stems and wedges on the
tibial side at least. An arthroplasty
group in Haukeland University
Hospital, Bergen (Norway) have
set their minds to the second part
of the question
regarding how
well they do.5
From a patients
perspective, is
a revision UKA
similar to a
revised TKA in
terms of longev-
ity? The authors
demonstrated a
similar outcome
when UKAs were
revised to TKAs,
compared with
when TKAs were
revised TKAs.
Overall survivor-
ships were similar between the
two groups, though the risk of re-
revision was much higher in the TKA
to TKA group. The group report on a
huge number of revised prostheses
from the Norwegian Arthroplasty
Register, reporting the EuroQol-5D,
KOOS score and the longevity of 768
failed primary TKAs and 578 failed
UKAs. This is a somewhat confus-
ingly reported study, and the overall
message should be the primary
outcome measure patients with a
revision knee, whether the primary
was a TKA or a UKA, have broadly
similar outcomes in terms of survival
and functional scores. There are
some subtle differences if one starts
to look at the detail of the data, with
Bone & Joint360 | volume 5 | issue 3 | june 2016
deep infection roughly twice as likely
in the TKA group (probably due to
the added complexity of the surgery
and operative time) and re-revision
is more common in the TKA group
in the over 70-year-olds. It certainly
appears that in Norway at least, the
outcomes of a total knee revision are
similar to a unicompartmental knee
revision.
The complication of
revision X-ref
While it is widely accepted that
revision arthroplasty is a risky busi-
ness and that the risk of adverse
events is much higher than in primary
joint replacement, there have been
few studies quantifying the risks,
specifically in comparison with
primary joint replacement. As part of
the American College of Surgeons
quality improvement programme, a
two-year audit of patients undergo-
ing hip and knee arthroplasty was
undertaken. This report from Rush
University Medical Center,
Chicago (USA) aims to compare the
rates of complications and adverse
events between primary and revision
joint replacements.6 With the effect 13
of adverse events on reimbursement
systems becoming increasingly preva-
lent, the authors aimed to determine
the adverse events that are more likely
in revision arthroplasty. The dataset
included over 48 000 knee replace-
ments and 70 000 hip replacements,
with around 10% of procedures being
revision surgery. The authors dem-
onstrated that patients undergoing
revision procedures had higher rates
of systemic sepsis (relative risk (RR)
3.5), deep infection (RR 4), and organ/
space infection (RR 7), but that DVT
and PE rates were similar between
primary and revision arthroplasty. The
relative risks of complications were
broadly similar between hip and knee
subgroups. A clear understanding
of adverse event rates is essential in
providing a clear benchmark against
which to measure performance and
set reimbursement rates. In these days
of public accountability and bench-
marking, this kind of paper is essential
to set the expected standard.
 Stemmed knee arthroplasties
in the obese?
Patients with an increased body
mass index are at greater risk of
complications following total knee
arthroplasty (TKA), specifically early
failure and worse clinical outcomes.
Although there is plenty of research
surrounding the relative benefits or
otherwise of surgery for this difficult
group of patients, it is clear that not
only do these patients benefit greatly
from arthroplasty, but also that the
obesity problem isnt going away
anytime soon. While some studies
report successful TKAs in patients
with increased BMI, other studies
suggest patients with an increased
BMI are at an elevated risk for a vari-
ety of complications including infec-
tion, early failure, lower knee scores
and decreased function. What we
have almost singularly failed to do is
to establish if there are any modifica-
tions in operative technique that
could be made to improve outcomes
in this group of patients. A research
team in Sainte-Marguerite Hos-
pital, Marseille (France) have set
14 out to establish if additional tibial
fixation during primary arthroplasty
should be used in patients with
increased BMI,7 with the rationale
that this might improve load distribu-
tion and thereby prevent early failure
and improve clinical outcomes. They
undertook a randomised trial of 120
patients, all with a BMI >30 and
randomised them based on a BMI
stratification to either a stemmed or
standard cemented tibial compo-
nent. Follow-up was only to two
years post-surgery, however, during
the follow-up period, patients with
a stemmed tibial component had
better outcomes than those with
the standard implant. However, the
difference was small and not clini-
cally important, and therefore the
authors do not advocate stemmed
tibial components given the difficulty
Bone & Joint360 | volume 5 | issue 3 | june 2016
if the patient needs a revision. We
would encourage the authors of
this study to perform a longer-term
evaluation on this group, however.
We are hardly surprised that there
are no clinically significant differ-
ences in terms of clinical outcomes
here at 360. Where we think there is
most likely to be a difference is in the
rates of later loosening due to the
increased mechanical stresses on the
tibial base plate. If there is a differ-
ence here, it wont become apparent
until five or ten years of follow-up.
An effect of medial UKA on
the lateral side?
Medial unicompartmental knee
arthroplasty (UKA) is an excellent
surgical option for the right patient.
In patients with isolated medial
compartment osteoarthritis and
functioning ligaments, the results
are excellent. Studies show a greater
than 90% survival rate at ten years
with good clinical outcomes, how-
ever, critics question the progression
of lateral osteoarthritis, given that
it remains the leading indication
for revision. This is the first study
from Weill Cornell Medicine,
New York (USA) to evaluate the
effect of medial UKA on the lateral
compartment.8 The authors report
the results of 174 UKAs at six weeks
of follow-up and compare the results
with 41 healthy knees, utilised with
a novel software-based method to
measure joint space congruence fol-
lowing UKA. The results of this study
are really quite surprising, with
medial UKA improving congruence
and joint space width in the lateral
compartment. It is not unreasonable
to conclude that this in itself may
reduce the rate of lateral compart-
ment osteoarthritis progression.
Can corticosteroid injections
address pain after TKA?
While total knee arthroplasty
(TKA) is, for the most part, con-
sidered to be among the most
successful of operations in ortho- early post-operative period follow-
paedic surgery, it can on occasion ing TKA.
leave patients with intractable
pain. Around 5% of patients suf- References
fer anterior knee pain which can 1. Ollivier M, Parratte S, Lunebourg A, Viehweger
be severe, and management of E, Argenson JN. The John Insall Award. No functional
these patients in recent times has
benefit after unicompartmental knee arthroplasty
involved a focus on multimodal
performed with patient-specific instrumentation: a
pain management and specifically
randomized trial. Clin Orthop Relat Res 2016;474:60-68.
the use of periarticular injections.
2. Kartik Logishetty, Gareth G. Jones, Justin
Researchers in Nekoyama Miyao
P. Cobb. Letter to the Editor: The John Insall Award.
Hospital, Niigata (Japan) have
No functional benefit after unicompartmental knee
noted that the use of periarticular
arthroplasty performed with patient specific instru-
injections to control pain after TKA
mentation: a randomized trial. Clin Orthop Relat Res
has gained wide acceptance, but
2016;474:272273.
that the use of corticosteroid injec-
3. Maradit Kremers H, Kremers WK, Sierra
tions remains somewhat controver-
RJ, Lewallen DG, Berry DJ. Competing risk of
sial, to say the least.9 The balance
death when comparing tibial implant types in
of the profound anti-inflammatory
total knee arthroplasty. J Bone Joint Surg [Am]
effects and the benefit it may
2016;98-A:591-596.
have on synovitis must inevitably
4. London DA, Vilensky S, ORourke C, et al.
be weighed against the marked
Discharge disposition after joint replacement and
immunomodulatory effects and
the potential for cost savings: effect of hospital pol-
increased risk of deep infection.
icies and surgeons. J Arthroplasty 2016;31:743-748.
The authors created their own
5. Leta TH, Lygre SH, Skredderstuen A, et al.
double-blinded, randomised con-
Outcomes of unicompartmental knee arthroplasty
trolled trial which was designed to
after aseptic revision to total knee arthroplasty:
establish the safety and efficacy of
a comparative study of 768 TKAs and 578 UKAs
corticosteroid injection in control-
revised to TKAs from the Norwegian Arthroplasty
ling pain after a TKA. The study
team successfully recruited 77
Register (1994 to 2011). J Bone Joint Surg [Am]
2016;98-A:431-440.
patients who were randomised to
6. Bohl DD, Samuel AM, Basques BA, et al.
injection with or without corticos-
How much do adverse event rates differ between
teroid. Outcomes were assessed
primary and revision total joint arthroplasty?
as pain at rest during the first 24
J Arthroplasty 2016;31:596-602.
hours, with secondary outcomes of
7.Parratte S, Ollivier M, Lunebourg
complication rates including surgi-
A, Verdier N, Argenson JN. Do stemmed
cal site infection. While there was
tibial components in total knee arthroplasty
no difference in the rate of com-
improve outcomes in patients with obesity? Clin
plications, there was a significant
Orthop Relat Res 2016 [Epub ahead of print].
improvement in the perceived pain
PMID:26992719.
scores over a 24-hour period. The
8. Khamaisy S, Zuiderbaan HA, van der List JP,
corticosteroid group experienced
Nam D, Pearle AD. Medial unicompartmental knee
a significantly lower cumulative
arthroplasty improves congruence and restores joint
pain score (139 vs 264). While
space width of the lateral compartment. Knee 2016;
future studies are still needed to
PMID: 26994481. [Epub ahead of print]
confirm the safety of corticosteroid
in periarticular injections, in the 9. Tsukada S, Wakui M, Hoshino A. The impact
longer term it is clear from the data of including corticosteroid in a periarticular injec-
presented here that a periarticu- tion for pain control after total knee arthroplasty:
lar injection with corticosteroid a double-blind randomised controlled trial. Bone
significantly decreases pain in the Joint J 2016;98-B:194-200.5
 Foot & Ankle
X-ref For other Roundups in this
issue that cross-reference with Foot
& Ankle see: Trauma Roundup 3;
Research Roundup 6.
Preservation of the failing
total ankle a pipe dream?
In terms of adult reconstruction,
total ankle arthroplasty (TAA) is an
established but relatively young
technology in comparison with
implants available for the hip and
knee. TAA outcomes have been part
of the National Joint Registry since
2010, but the early data capture is
likely to be woefully incomplete. Pre-
viously reported independent series
suggest that ten-year survivals of up
to 90% are certainly possible from
published series.1 TAAs are subject to
the same failure mechanisms as seen
in the hip and knee prostheses, but
at an accelerated rate. Osteolysis and
cyst formation is evident in around
one in five TAAs at five years. The
significance of this in terms of the
natural history of cyst expansion and
subsequent progression to sympto-
matic loosening of the implant is as
yet unknown. Similarly, there is no
current consensus as to the indica-
tions for operative management of
such defects around TAAs. The team
from Duke University, Durham
(USA) have been addressing early
osteolysis with a different approach,
undertaking grafting of the defect
prior to revising components as
necessary. They present their data
from a series of 726 patients over 15
years, 33 of whom required revision
with grafting to a cystic defect.2 The
cohort included both fixed- and
mobile-bearing implants, and revi-
sion was undertaken for patients
with radiographic progression of
cysts over 1 cm, symptomatic cysts,
or varus deformity resulting from
component subsidence. It is worth
noting that these revision procedures
were often combined with revision
to long-stemmed TAA components,
and grafting was performed with
allograft bone chips augmented with
BMPs and other biologically active
agents. The success rate, defined as
retention of the implants, was stated
to be 98% at two years, dropping
to 60% at four years. This paper
is an important starting point for
the development of revision ankle
arthroplasty in the presence of bone
loss. Although sadly lacking any
PROM data at follow-up, this series
does provide a guide as to what can
be reasonably expected from such
revision procedures, and sets a bar
by which to measure future attempts
at salvage. The use of structural
grafting with biological potential, as
well as the presence of a well-fixed
prosthesis is the key take-home mes-
sage, and underlines the principles
to successful TAA salvage. The
argument for implant retention is
bolstered by a reported amputation
rate of up to 19% following failed
salvage arthrodesis performed in the
context of failed arthroplasty.3
Arthroscopy following TAA?
Sticking with the topic of
improving outcomes in TAA, the
topic of arthroscopic debride-
ment of the painful TAA is dealt
with in this paper from Brussels
(Belgium). Although only a very
small cohort of 12 patients, the
authors describe an arthroscopic
approach to tackle ongoing pain fol-
lowing ankle arthroplasty.4 Arguing
that perhaps this is due to an ongo-
ing synovitis, these surgeons under-
took arthroscopic debridement and
present their results here. Painful
synovitis is a common problem after
ankle arthroplasty, and although
a broad range of rates are quoted
in the literature (between 20% and
60%), it is clear that this is a signifi-
cant problem and can be difficult to
treat, so much so that some designs
of TAA have been adapted to include
extensions to incorporate the sides
of the talus and hence reduce gutter
pain. There is a lack of evidence to
support this adaptation. The results
presented in this paper suggest a
modest but significant improve-
ment in the American Orthopaedic
Foot & Ankle Society scores in this
post-arthroscopic cohort (improv-
ing from a mean of 64.6 to 73.5),
with the majority of patients still
exhibiting residual symptoms at a
persistent, but much lower level.
Patients who developed a painful
ankylosis across the joint benefited
less from debridement, with the
improvement in their PROMs less
pronounced. The authors rightly
emphasise the need to rule out
malalignment as the driver for
impingement prior to embark-
ing upon a simple arthroscopic
debridement, but this paper serves
to underline the difficulty involved
in treating this patient group,
although in selected cases a simple
arthroscopic debridement clearly
has some utility.
Posterior plating of the distal
fibula: should we worry about
secondary peroneal tendon
attrition? X-ref
The treatment of peroneal
tendon injuries has now become
commonplace, with techniques
including repair, excision and teno-
desis as appropriate to the degree of
injury, and despite some difficulties
on occasion reaching the diagnosis,
treatments are usually very effective.
Plating the posterior aspect of the
distal fibula is a widely utilised, use-
ful technique allowing the surgeon
to address the deforming forces
with a buttress plate. Despite some
randomised controlled trials showing
equivocal outcomes in Weber B frac-
tures, there remains some concern
regarding peroneal tendon attrition
following placement of metalwork
adjacent to the functional muscu-
lotendinous unit. Previous studies
would suggest that the incidence
of peroneal tendinopathy after
posterior fixation may be seen in up
to 40% of patients in some series.
This observational study from Seoul
(South Korea) sets out to ascertain
Bone & Joint360 | volume 5 | issue 3 | june 2016
the incidence of peroneal tendinopa-
thy after posterior antiglide plating of
the distal fibula.5 The authors report
their experience in 70 patients,
all of whom underwent posterior
antiglide plating of the distal fibula.
The incidence of peroneal tendon
complications was 4.3% based upon
the findings of a direct inspection of
the peroneal tendons at removal of
the implanted metalwork. On the
face of things a reassuring statistic,
however, careful inspection of the
patient cohort data reveals that
nearly 60% of the patients under-
went hardware removal for lateral
fibula pain, deemed not to be due to
peroneal tendon irritation, making
us slightly suspicious of definitions.
The devil here, of course, is in the
details; establishing which structure
is the source of pain post-ankle plat-
ing is not an exact science, a fact the
authors acknowledge. They go on to
recommend the use of shorter plates
which do not traverse the peroneal
groove or indeed extend to the tip
15
of the posterior fibula, and describe
their chosen position for the plate to
be posterolateral rather than truly
posterior. These all seem like sensible
measures to avoid symptomatic
hardware which requires removal.
This technique is a valuable one for
salvage fixation and when the poster-
olateral approach is required to plate
the posterior malleolus. Avoiding
secondary morbidity from the plate,
however, is an important factor
when planning fracture fixation.
Augmenting Achilles tendon
repairs leads to long-term
strength deficits X-ref
It is rare to see long-term follow-
ups of previously reported ran-
domised controlled trials, however,
many studies stop short of appropri-
ate follow-up to establish long-term
outcomes. In an interesting study
from Oulu (Finland), the authors
report the 14-year follow-up of a
randomised controlled trial evaluat-
ing augmented versus simple repair
 in Achilles tendon rupture.6 The
research team report their study of
60 patients, all presenting with an
acute Achilles tendon rupture man-
aged over a three-year period. At 14
years of follow-up, 55 patients were
available for review. All patients were
managed with a similar splinting
protocol as their rehabilitation, with
the only difference being that 28
patients received a simple end-to-
end suture repair while 27 patients
received a fascial flap-augmented
repair. The research team reported
myriad outcomes including the Lep-
pilahti Achilles tendon score, isoki-
netic plantar flexion strength (peak
torque and the work-displacement
deficit at 10 intervals over the ankle
range of motion), tendon elonga-
tion, and the RAND 36-item health
survey. The bottom line is that the
end-to-end repair group performed
better at final follow-up. There were
no differences in re-rupture rates and
the augmented group had poorer
calf muscle deficit that persisted right
through to final follow-up.
One screw a screw too few
16 Achieving a stable fixation during
arthrodesis is the key to reducing
complications including metal-
work fatigue and nonunion. The
compression screw has long been
the most reliable fixation in subtalar
arthrodesis, although there are a
variety of screw con-
figurations around,
all of which have their
potential advantages
in either surgical
access, achieving
compression or
stability. Research-
ers in Kalamazoo
(USA) undertook a
biomechanical study
using a surrogate
bone model of the
subtalar joint.7 They
tested three potential constructs a
single posterior screw, two minimally
divergent posterior screws, and a
highly divergent screw construct.
The stability of the constructs was
Bone & Joint360 | volume 5 | issue 3 | june 2016
tested using a servo-hydrolic testing
apparatus. This was then correlated
to a fresh cadaveric study using five
fresh frozen cadavers. As perhaps
could be predicted, the two diver-
gent screws offered significantly
higher torsional stability over either
of the other constructs. While this in
itself is not surprising, it is important
to add a slight note of caution: diver-
gent screws by their nature do not
increase the compression with the
addition of the second screw and, as
such, care should be taken in place-
ment of the initial screw specifically
to ensure that as much compression
as possible is achieved prior to place-
ment of the second screw, to ensure
effective fusion.
Osteochondral defects more
common than previously
thought X-ref
The relatively poor outcomes in
ankle fractures are puzzling. Up to a
third of patients experiencing a sim-
ple ankle fracture will never recover
to their pre-injury status, experienc-
ing long-term restrictions in function.
While there are a number of theories
as to why this might be, there is a
distinct lack of evidence to support
one potential cause over another.
Researchers in Amsterdam (The
Netherlands) have set out specifi-
cally to establish what the impact is
in terms of long-term function.8 Their
study concerns 100
ankles, all requiring
fixation following
fracture of a range of
Weber subclassifica-
tions. Each patient
underwent a CT scan
following fixation,
and the presence and
type of osteochondral
defect (OCD) was
diagnosed from this
scan. Clinical out-
comes were assessed
at a year following surgery using
the Foot and Ankle Outcome Score,
and the results stratified by OCD
presence and type. In this series, 10%
(n = 10) of ankles had sustained an
osteochondral defect. The lesions
were all isolated talar injuries and
were an average of 4 mm in diameter.
Although one might have expected
those patients with osteochondral
injuries to have a poorer outcome,
this was not in fact the case in this
study. How much weight can be
given to this finding really depends
on the interpretation of any perceived
variation in outcomes between ankle
fracture types and osteochondral
defect types. With a low event rate, if
there is a broad spread of pathologies
and functional impairments between
outcomes then it stands to reason
that there may be an element of type
II error here.
Measuring range of motion in
the foot and ankle
Taking a slightly different
approach to that seen in a hand
paper in this months 360, research-
ers in Stanmore (UK) set out to
establish if their standardised meas-
urement for range of motion used in
the TARVA (Total Ankle Replacement
Versus Arthrodesis) study9,10 really
is a standardised measurement. The
protocol utilised a digital goniom-
eter, and the composite range of
motion in the hindfoot was meas-
ured by measuring the tibial:floor
angle. Two observers conducted
measurements on 46 ankles from
two groups: controls, and patients
with ankle arthritis treated in a
variety of ways. The measurement
method was validated with both
intra- and inter-class correlations.
The authors established that the
median difference was just 1.5
within observer, and the intra- and
inter-class correlation coefficients
were excellent at 0.95 and 0.94 in
the two groups. The accuracy of the
measurements was equally impres-
sive in the ankle arthritis group.
These authors have clearly shown
that the use of a digital goniom-
eter and their method provides an
accurate and reliable measurement
of ankle range of motion. However,
the measurement is not necessarily
precise. To estimate the precision
dynamic range of motion, radio-
graphs would be required.
Transfibular approach the
future of ankle arthroplasty?
As surgeons continue to elusively
seek the everlasting (or at least ten-
year lasting) ankle arthroplasty, more
innovative approaches to solving the
various biomechanical problems that
limit longevity and therefore success
have led to some unusual designs of
ankle replacement. The transfibular
total ankle arthroplasty is a similar
innovative approach. Osteotomising
the fibula allows access to the lateral
portion of the ankle joint. This in itself
obviously causes some morbidity,
however, there is a not unreasonable
argument that the direct approach
to the joint allows for more accurate
positioning of the centre of rotation,
potentially smaller bone cuts, and
avoids the risks of traction injury to
the dorsal neurovascular bundles.
Despite these theoretical advantages,
and the commercial availability of
implants and instrumentation for
performing the procedure, there
are no reports of complication rates
to support the assertion that this
may be a safer option. A surgical
team in Baltimore (USA) have
produced an early report of their
own experience with 20 total ankle
arthroplasties, aimed at assessing
the safety of such an approach with
regard to intra-operative complica-
tions.11 As would be expected with
an early safety report, follow-up
was only 18 months, and the article
focuses on safety rather than clinical
outcomes. The authors saw no cases
of fibular nonunion, although there
were four re-operations. Two of these
were arthroplasty-related (one for
anterior impingement and one for
deep infection), and, in addition,
the fibular plates were removed in
two cases. We would tend to agree
with the authors here this early
series supports the use of such an
approach and shows the complica-
tion rates to be in line with the widely
accepted anterior approach to ankle
arthroplasty.
References
1.Zaidi R, Cro S, Gurusamy K, et al. The
outcome of total ankle replacement: a sys-
tematic review and meta-analysis. Bone Joint J
2013;95-B:1500-1507.
2. Gross CE, Huh J, Green C, et al. Outcomes of
bone grafting of bone cysts after total ankle arthro-
plasty. Foot Ankle Int 2016;37:157-164.
3. Jeng CL, Campbell JT, Tang EY, Cerrato RA,
Myerson MS. Tibiotalocalcaneal arthrodesis with
bulk femoral head allograft for salvage of large
defects in the ankle. Foot Ankle Int 2013;34:1256-1266.
Wrist & Hand
X-ref For other Roundups in this
issue that cross-reference with Wrist
& Hand see: Trauma Roundup 6;
Research Roundup 6.
The elderly wrist fracture
to treat or not to treat?
It has been known ever since
Abraham Colles that older people
with wrist fractures usually do
unexpectedly and remarkably well.
We suspect that there is a tempta-
tion to fix these surgically unless
the fragments are well reduced and
stable; surgeons not wishing to be
ageist, and with a paucity of data
to support differing treatments by
age, there may be a temptation
to over-intervene in the elderly. A
team from Wenzhou Medical
University, Wenzhou (China)
has reviewed the available litera-
ture, and produced a worthwhile
analysis including two RCTs and four
retrospective studies.1 Their review
reports on the expected outcomes of
surgical and non-surgical treatment
in patients over 60 years of age, with
an isolated distal radial fracture. The
study team report that, in composite
outcome analysis in patients over
60 years, although surgery gave
better grip strength and improved
radiology, this was at the expense of
a higher complication rate with no
evidence of better clinical outcome
measured with a goniometer, pain
scales and functional scores. So in
these days of risk aversion and cost
4.Devos Bevernage B, Deleu PA, Birch I,
et al. Arthroscopic debridement after total ankle
arthroplasty. Foot Ankle Int 2016;37:142-149.
5. Ahn J, Kim S, Lee JS, Woo K, Sung KS.
Incidence of peroneal tendinopathy after applica-
tion of a posterior antiglide plate for repair of supi-
nation external rotation lateral malleolar fractures.
J Foot Ankle Surg 2016;55:90-93.
6. Heikkinen J, Lantto I, Flinkkil T, et al.
Augmented compared with nonaugmented sur-
gical repair after total achilles rupture: results of
a prospective randomized trial with thirteen or
pressure, one might consider the
evidence and relieve some elderly
patients of the imposition of an
operation.
How reliable is wrist
arthroplasty?
We are familiar with the excellent
and durable results for many designs
of hip and knee replacement, yet
the metal-on-metal saga reminds us
that implant surgery can be at best
unreliable, if not catastrophic. When
even elbow and ankle replacements
are starting to get their share of good
long-term follow-up series, it does
beg the question: why does wrist
arthroplasty not have such a good
pedigree? The orthopaedic literature
is riddled with fairly encouraging
small series of short-term results,
however, some designs have been
withdrawn. With a niche operation
with currently limited indications
and little evidence to support its
outcomes, it is tricky to formulate an
opinion on the likely success of such
a procedure particularly so when
many reports are written by early
adopters or designing surgeons,
which introduces a certain bias
into the proceedings. A group from
Thomas Jefferson University
Hospital, Philadelphia (USA) is
to be applauded for their candour in
reporting the rather miserable results
from their large series of 105 total
and partial wrist replacements.2 With
a mean follow-up of just 35 +/- 28
more years of follow-up. J Bone Joint Surg [Am]
2016;98-A:85-92.
7.Jastifer JR, Alrafeek S, Howard P,
Gustafson PA, Coughlin MJ. Biomechanical
evaluation of strength and stiffness of subtalar
joint arthrodesis screw constructs. Foot Ankle Int
2016;37:419-426.
8.Nosewicz TL, Beerekamp MS, De Muinck
Keizer RO, et al. Prospective computed tomo-
graphic analysis of osteochondral lesions of the ankle
joint associated with ankle fractures. Foot Ankle Int
2016: 1071100716644470. [Epub ahead of print]
months, the surgical team reported
51% of patients suffered a complica-
tion and 39% required a revision
procedure. Stiffness and component
failure were the most common rea-
sons. Hand surgeons would be wise
to make their patients aware that wrist
arthroplasty, although an appealing
concept, remains experimental.
Antibiotics in simple hand
trauma
From time to time a study is
published which really should alter
practice, and here at 360 we would
recommend a change in practice
based on this paper. Antibiotics are
expensive and there is the matter
of resistance, which may one day
become an apocalyptic public health
issue, so we all have a responsibility
for stewardship of antibiotic use. In
this important work from Oxford
and London (UK), a meta-analysis
was undertaken of antibiotic use
in simple hand wounds requiring
surgical treatment.3 Following a fairly
extensive review of the literature,
the study team was able to include
13 studies reporting the outcomes
of 2578 patients. The authors quite
sensibly excluded open fractures,
crush injuries and bites from their
meta-analysis. The majority of studies
were of good quality evidence with
five RCTs reported, allowing for some
meta-analysis to be performed. The
headline result is that there were no
differences in infection rates between
Bone & Joint360 | volume 5 | issue 3 | june 2016
9.Thornton J, Sabah S, Segaren N, et al.
Validated method for measuring functional range
of motion in patients with ankle arthritis. Foot Ankle
Int 2016: 1071100716645391. [Epub ahead of print]
10.No authors listed. Total ankle replacement
versus arthrodesis: randomised clinical trial. http://
www.anklearthritis.co.uk/ (date last accessed 11
May 2016).
11. Tan EW, Maccario C, Talusan PG, Schon
LC. Early complications and secondary procedures
in transfibular total ankle replacement. Foot Ankle
Int 2016: 1071100716644817. [Epub ahead of print]
those managed with and without pro-
phylactic antibiotics (risk ratio 0.89,
range 0.65-1.23). In this large and well
conducted meta-analysis, there was
no evidence that the routine use of
prophylactic antibiotics reduces the
infection rate in simple hand wounds.
There is a clear message: these injuries
should not receive prophylaxis.
BMP complicates scaphoid
nonunion surgery
Nonunion is one of the last 17
unsolved problems in surgery
even those with major practices in
nonunion and trauma have difficulty
goading some fractures into union.
This, combined with the blossom-
ing basic science to support our
understanding of matrix biology and
bone healing, has resulted in a range
of biologics, the first of which was
of course the recombinant human
protein (rhBMP). Initially widely
adopted in trauma nonunion and
the spine, reports of complications,
high costs and even suggestions
of cancer and local compressive
symptoms from prolific bone forma-
tion have resulted in a steady erosion
of its regular use. That said, there is
no doubt that rhBMP does have a
profound effect on the formation of
callus. We were intrigued to read this
brief report from OrthoCarolina
Hand Center, Charlotte (USA),
describing the authors experi-
ence in just six cases of recalcitrant
nonunion of the scaphoid;4 to our
 knowledge this is the only such
paper. The authors report six cases
performed over a three-year period,
all revision fixations for previous
open reduction and internal fixation.
Of those receiving surgery, there
was persistent nonunion in two, and
CT-proven healing in four patients.
However, there were significant
associated complications. Hetero-
topic ossification was seen in four
cases, one requiring revision surgery.
All in all, only a single patient united
without complications. While the
concept remains attractive for BMP,
the nature of application with an
uncontrolled bolus and sustained
release (the only options with a
single growth factor from amongst a
cascade of factors) clearly results in
high levels of complications. For the
moment, BMP would be difficult to
recommend in scaphoid nonunion.
Visual estimation of joint
positions inconsistent X-ref
The venerable goniometer has
somewhat fallen out of fashion
lately. It is a rare occurrence to
see a surgeon or therapist care-
18 fully measuring out ranges of joint
motion in the clinic, something that
was commonplace a few years ago.
However, these readings are still
being recorded in patient records,
as they are essential documentation
for the reasons behind surgery, the
documentation of recovery and can,
in certain circumstances (such as
elbow stiffness), guide treatment.
The question posed by researchers
at the Mayo Clinic in Jacksonville
(USA) is, how accurate is visual esti-
mation of joint position in the hand
and wrist?5 The research team under-
took a series of evaluations with 40
observers 20 hand surgeons and
20 therapists. The observers were
estimating the position of the wrist
metacarpophalangeal (MCP) and
proximal interphalangeal (PIP) joints
with a volunteer, who was placed
in some pre-fabricated, low-profile
orthoses to ensure accuracy of
positioning. In addition, control
measurements using radiographs,
Bone & Joint360 | volume 5 | issue 3 | june 2016
digital photographs and a goniome-
ter were estimated . Perhaps as might
be expected, the visual assessments
were inconsistent and never really
within the 5 of
the measurements
obtained on control
radiographs. How-
ever, perhaps more
surprisingly, the use
of the goniometer
did not consistently
result in accurate
assessment of joint
position (which isnt
that surprising as
the goniometer can-
not be positioned
over the centre of
rotation and is by
definition dictated by the soft-tissue
envelope). However, it was more
accurate than visual assessment.
Accurately determining the range
of motion seen in any joint is always
going to be difficult, however, given
the results presented here it seems
more likely that while the goniome-
ter does suffer from systematic error,
is the most consistent and reliable.
Perhaps use of the goniometer
should make a resurgence in ortho-
paedic practice?
Endoscopic carpal tunnel
release and fellowship
training
The thorny topic of endoscopic
carpal tunnel release and surgical
preference has been examined from
a different perspective by surgeons
at University of North Carolina
School of Medicine, Chapel Hill
(USA) who asked the question,
are surgical preferences dictated
by fellowship training?6 The study
team identified surgeons who had
undertaken fellowship training in
hand surgery using the American
Board of Orthopaedic Surgery Part
II database, and then went on to
cross-reference this with cases from
the American Board of Orthopaedic
Surgery database. They attempted
to establish from this which surgical
treatment patterns were based on
surgeon training by subdividing the
patient group into those undergo-
ing open carpal tunnel release, and
those having an endoscopic pro-
cedure. Although
there are clearly
some flaws with
this methodology,
there are also some
clear-cut associa-
tions. Around 12%
of carpal tunnel
releases were
performed endo-
scopically, and,
overall, patients
were 4.5 times as
likely to have an
endoscopic carpal
tunnel release if
their treating surgeon had been
fellowship-trained. These data are
very much open to interpretation
on one hand it is heartening to see
that surgeons are only undertaking
the more complex procedure if they
have had appropriate training, while
on the other it is clear that fellowship
training does bias treatment options.
Given the equivalent complication
rates (although nerve injury was
much higher in the endoscopic
group), it does not seem unreason-
able to use either approach.
One cortex a cortex too
few? X-ref
Biomechanically unicortical fixa- of axial headless intramedullary
tion has some significant disadvan-
tages, including a fulcrum rather
than a balance beam principle. How-
ever, there are some disadvantages
to protruding screw heads, par-
ticularly on flexor tendon surfaces.
There is a bit of a trade-off, however,
between compromise on fixation for
soft-tissues and the disadvantages of
a slower mobilisation protocol used
by some surgeons when unicorti-
cal fixation is used. In an interesting
cadaveric model, a research team at
Frenchay Hospital, Bristol (UK)
ask whether unicortical fixation pro-
vides enough biomechanical stability
to allow for early mobilisation.7 Their
study involved fixation of metacarpal
fractures with either an eight-hole
unicortical plate or a four-hole
bicortical plate construct. The bones
were loaded using a bending load,
and tested to single-cycle failure,
rather than fatigue failure. As would
be expected with this construct, the
mean load to failure was increased in
the eight unicortical screws (414N vs
296N). While we would agree with
the authors here at 360 that this does
suggest early mobilisation is likely to
be possible with this construct, with
no ill effects, it does illustrate for us
the disparity that can creep in with
choice of biomechanical testing. A
four-point load model will tend to
work better with plate constructs
that distribute the load across a
larger working distance. The results
may have been different if a torque,
or even cycles to failure model, were
chosen.
Headless screws in metacarpal
fractures? X-ref
The difficulties of proud screw
heads and tips is given a slightly
different approach to the multiple
unicortical approach from Bristol,
with surgeons at the University
Hospital of Zurich (Switzer-
land) turning their attention
to the outcomes of 31 displaced
fractures of the proximal and mid-
dle phalanges of the digits.8 They
developed a rather neat system
compression screws. Although only
really suitable for extra-articular
displaced or unstable fracture pat-
terns, the concept in itself is clearly
quite neat. The authors report that
of the 31 fractures in 26 patients
treated with this method over a
12-month period, there were no
major complications, and patients
were able to undertake early mobi-
lisation with no reported issues
with prominent metalwork. This
neat technique is clearly one that
should be in the armamentarium
of surgeons treating fractures of
the fingers, however, one wonders
what would occur if the metal-
work became infected (given how
difficult these screws would be to
remove), and if indeed they are
needed at all- the functional results
of neighbour strapping are clearly
quite reasonable and a comparative
study is needed here.
References
1.Chen Y, Chen X, Li Z, et al. Safety and effi-
cacy of operative versus nonsurgical management
of distal radius fractures in elderly patients: a
systematic review and meta-analysis. J Hand Surg
Am 2016;41:404-413.
2.Gaspar MP, Lou J, Kane PM, et al.
Complications following partial and total wrist
arthroplasty: a single-center retrospective review.
J Hand Surg Am 2016;41:47-53.
3. Murphy GRF, Gardiner MD, Glass GE, etal.
Meta-analysis of antibiotics for simple hand inju-
ries requiring surgery. Br J Surg 2016;103:487-492.
4.Brannan PS, Gaston RG, Loeffler BJ,
Lewis DR. Complications with the use of BMP-2
in scaphoid nonunion surgery. J Hand Surg Am
2016;41:602-608.
5. McVeigh KH, Murray PM, Heckman MG, 7.Dickson JK, Bhat W, Gujral S, et al.
Rawal B, Peterson JJ. Accuracy and validity of
goniometer and visual assessments of angular
joint positions of the hand and wrist. J Hand
Surg Am 2016;PMID: 26810826. [Epub ahead of
print]
6.Smetana BS, Zhou X, Hurwitz S,
Kamath GV, Patterson JM. Effects of hand
fellowship training on rates of endoscopic and
open carpal tunnel release. J Surg Hand Am
2016;PMID: 26832310. [Epub ahead of print]
Unicortical fixation of metacarpal fractures: is it
strong enough? J Hand Surg Eur Vol 2016;41:367-372.
8. Giesen T, Gazzola R, Poggetti A, Giovanoli
P, Calcagni M. Intramedullary headless screw
fixation for fractures of the proximal and mid-
dle phalanges in the digits of the hand: a review
of 31 consecutive fractures. J Hand Surg Eur Vol
2016;PMID: 27056277. [Epub ahead of print]

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 Shoulder & Elbow
Mental Health a better
determinant of outcome than
tear size in rotator cuff tears
It is well known that the degree
of pain can influence patients men-
tal health state it doesnt require
a rocket scientist to understand
the link between chronic pain and
depression. However there are more
subtle nuances to the link between
mental health and outcomes. Per-
haps one of the most eye-opening
studies we have read in recent times
aims to explore the link between
mental health, functional outcomes
and rotator cuff tear morphology.
The research team based at the
University of Utah (USA) report
their study linking the SF-36 mental
health score and rotator cuff score
to a range of outcome measures1
(simple shoulder test (SST), Ameri-
can Shoulder and Elbow Surgeons
(ASES) Score and a VAS score for
shoulder pain). The study cohort
consisted of 169 patients all with a
diagnosis of full thickness rotator
cuff scores. The patients rotator
cuff morphology was assessed
using MRI scanning to establish the
number of tendons involved, the
tear surface area and retraction.
The analysis was undertaken using
multivariable regression models
and adjustment was made for
almost every conceivable variable.
Of all the potential predictive vari-
ables screened, the mental health
component of the SF-36 was by far
the strongest predictor of the VAS
shoulder pain score, VAS shoulder
function score, SST score and the
ASES score. The tear morphology
and severity had a much poorer
correlation with any of the outcome
measures; however appeared
to correlate best with shoulder
functional scores. Once a multi-
variable model was introduced, the
association between SF-36 mental
health score was marked with all
three outcome scores. This study is
definitely food for thought. Whilst
the tear size and morphology had
some bearing on the shoulder func-
tional scores, the patients mental
health status dominated outcome
measures on multivariable analysis.
This clearly is likely to play an influ-
ential role in patient-reported pain
and function.
How best to assess the GT
fracture X-ref
The handed-down wisdom from
the greats of orthopaedic surgery is
that 5 mm of displacement around
the shoulder is the threshold for a
displaced fracture or part. Despite would have thought to expose the
the time that has passed since Neers
original classification, nobody has
yet bettered his original definitions
and they are still in widespread use
across the world today. Although the
utility and simplicity of this approach
is clear in the age of cross-sectional
imaging and multiple radiographic
views, it is less than clear if the 5
mm rule still applies for the greater
tuberosity. A study team from
Boston (USA) and Amsterdam
(The Netherlands) report their
study which aims to establish what
the diagnostic strength of assessing
fracture displacement of the greater
tuberosity is on plain films and cross-
sectional imaging.2 The authors
designed a survey-based study and
although invitations were sent to 791
orthopaedic surgeons, they were
only able to include the responses of
180 who replied in their article. The
respondents were all given identi-
cal information about 22 fractures
and randomised to one of radio-
graph alone, radiograph and cross
sectional CT or radiograph, cross
sectional CT and volume-rendered
CT. Study participants were asked
not only to assess the displacement
but also to recommend operative or
non-operative treatment, and the
level of confidence with which they
did so for each case. There were no
differences in inter-observer error for
displacement, or any discernible dis-
sention as to which patients should
be treated operatively. However
there were significant differences in
the reported confidence with which
the treatment decisions were made.
The group with volume-rendered
images as well as radiographs
reported much greater confidence
levels in their treatment decisions. It
certainly appears from this research
that the addition of a CT of any
variety did not change treatment
decisions; however they offered the
surgeon greater confidence in mak-
ing that decision not a reason one
of patients, variable indications for
patient to ionising radiation!
Arthroscopic treatment
of greater tuberosity
fractures? X-ref
There is little that a shoulder
surgeon will not consider putting a
scope into. Having reported papers
concerning everything from sub-
scapular decompressions to sterno-
clavicular joint scopes and coracoid
transfers performed arthroscopically,
it was only a matter of time before
we expected to see arthroscopic fixa-
tion of humeral fractures described.
This paper from Beijing (China)
describes just that although only in
isolated greater tuberosity fractures
with displacements of less than
2cm. The authors describe their own
cohort of 79 patients treated over a
six -year period.3 Their patients were
treated in a heterogenous manner
and the authors readily accept that
the series itself is not really compa-
rable as those patients with greater
displacements or larger fragment
sizes were treated in general with an
open approach. The arthroscopic
group received a double row-type
repair where the open group under-
went an ORIF. There were very few of
the initial 53 open and 26 arthro-
scopic patients available for review,
just 17 and 15 retrospectively. Clinical
outcomes were assessed using a
clinician administered ROM, VAS
score, and American Shoulder and
Elbow Surgeons (ASES) score, along
Bone & Joint360 | volume 5 | issue 3 | june 2016
with regular radiographic review to
a mean of 36 months follow-up. The
arthroscopic group had longer surgi-
cal times (95 mins vs 61 mins) and
there were however some subtle dif-
ferences in the functional outcomes
with a greater range of motion and
better ASES score in the arthroscopic
group, although these differences are
not likely to have reached the MCID.
We found this study rather disap-
pointing, in so far as it promised
to compare the two approaches,
however with a very small number
surgery and some lack of clarity in
the manuscript we were left thinking
there were no real arguments to be
made for the arthroscopic approach.
Nothing spoils surgical results
like a non-operative group!
It is not uncommon for surgeons
to undertake a resection of the corner
of the scapula for patients complain-
ing of snapping scapula. This chronic
and slightly controversial diagnosis
is rather subjective in its presenta- 21
tion and treatment options. Like
many small print procedures there
is little in the way of comparative
studies and although there are plenty
of case series describing various
approaches, is far from clear if the
benefit reported is related at all to
the surgery, or simply the natural
course of the condition. Shoulder
surgeons in Helsinki (Finland)
report a comparative series of 24
patients, 15 treated operatively with
a snapping scapula.4 Those patients
undergoing the surgical approach
were treated with a resection of the
superomedial portion of the scapula
and a combined levator scapulae
release. There are few such cases,
and the authors reported patients
treated at their centre over a 20-year
period. Follow-up was to over 20
years following presentation in both
groups. Whilst there are some clear
limitations to such a small cohort
with retrospective design and limited
questionnaire based follow-up, we
 cant help thinking that for such a
rare condition, perhaps this is the
best evidence there is likely to be.
There were no differences in pain
scores between the two groups, how-
ever crepitus was variably present
across both of the groups and there
did not seem to be an advantage
from surgical release in terms of the
presence or absence of crepitus. We
would wholeheartedly agree with the
authors here although their paper
could be used to support opera-
tive treatment of these patients, the
inclusion of a similarly performing
non-operative group certainly leads
one to think that whatever treatments
are offered, the patients all tend to
recover given time.
Proximal humeral plates still
have the edge X-ref
Whilst much of the world is
somewhat at sixes and sevens in the
light of the PROFFER trial, suggest-
ing that for many proximal humeral
fractures the outcomes of opera-
tive and non-operative treatment
were equivocal, investigators in
Sao Paulo (Brazil) have not been
22 deterred by the suggestion that
operative intervention may not have
as much role as previously thought,
and published
their randomised
study.5 The study
team randomised
patients with a
two- or three-
part proximal
humeral fracture
to either locking
plate or locking
nail fixation. Their study recruited
72 patients, all randomised to one
intervention or another, and the out-
comes were reported using the Con-
stant score at 12 months, in addition
to a secondary outcome of the DASH
score. In terms of clinical outcomes
there were few differences between
the groups, with no significant dif-
ferences in either clinical outcome
score at final or any of the interval
Bone & Joint360 | volume 5 | issue 3 | june 2016
follow-up visits. Radiographic out-
comes were similarly unchanged
between the two groups; however
there were some significant differ-
ences in favour of the plate group
with regards to reoperation and
complication rates. For the moment
it seems that although the functional
outcomes are similar, the proximal
humeral plates of the PHILOS type
approach have a significant edge
over the nails in terms of complica-
tions and reoperation rates.
Humeral fractures and
longevity X-ref
The proximal humerus is one of
the most common sites for fragility
fractures, and like the neck of femur
fracture, is common amongst the
elderly and frail. There is little known
about the impact of a proximal
humeral fracture on quality and
length of life, and our expectations
here at 360 were high when we
stumbled across this paper from
Herley (Denmark) which reports
the outcomes of arthroplasty for
proximal humeral fractures.6 This
registry-based study reports mortal-
ity as its primary outcome measure
and is based on the results of 5853
primary shoulder arthroplasties
performed over
a six-year period.
The authors
essentially under-
took a rather
simple study
comparing mor-
tality between
groups for
diagnoses at the
arbitrary end points of 30 days, 90
days and a year. Perhaps unsurpris-
ingly, those patients with a fracture
had a six-fold risk of mortality when
compared with the general popula-
tion and those shoulder arthroplas-
ties being performed for arthritis
during the first 30 days. While none
of the information presented here is
new and we cant help wondering
if more could have been made of a
large cohort of patients such as these
- it does underline the difficult nature
of these injuries, and that it isnt just
hip fractures that carry a significant
mortality burden.
The glenosphere and clinical
outcomes
Despite the dramatic rise in
popularity over the past few years in
the use of the reverse shoulder and
impressive clinical results seemingly
able to salvage a functional shoulder
from some of the most bleak of situ-
ations, the reverse shoulder suffers
from many of the same limitations
that the total shoulder does on the
glenoid side with regards to bone
stock and longevity; however the
biomechanics are of course signifi-
cantly different. It is the impact of
these different biomechanics and
specifically the glenosphere diameter
that is the focus of an important
clinical outcomes paper from New
York (USA).7 The authors report a
prospective case-controlled series of
297 primary reverse shoulder arthro-
plasties. The procedures were under-
taken using either a 38 mm or 42 mm
glenosphere, and clinical outcomes
were measured using the American
Shoulder and Elbow Surgeons (ASES)
scores and clinical assessment of
range of motion. As perhaps could
be expected from the small number
of preceding biomechnical studies,
those patients with the larger 42
mm glenosphere had significantly
improved forward elevation and
active external rotation. The authors
do not however report a clear pat-
tern in clinical outcomes with the
male shoulders performing better
with the 38 mm glenosphere and the
female shoulders performing better
with the 42 mm implant. There were
no differences in the intra-operative
complication rates. It is perhaps
not surprising that there is little
association between clinical score
and implant size; however the clini-
cal improvement in range of motion
associated with a larger glenosphere
is potentially a very important obser-
vation. There are few implant design
features in any arthroplasty that
have been demonstrated to improve
clinical outcomes. We remained
potentially slightly concerned about
the impact on the biomechanics of
the glenoid fixation. A larger gleno-
spehere will result in more torque
forces dissipated across the glenoid
fixation, and any impact in longevity
will of course not be apparent in a
two year follow-up series.
References
1.Wylie JD, Suter T, Potter MQ, Granger
EK, Tashjian RZ. Mental health has a stronger
association with patient-reported shoulder pain
and function than tear size in patients with full-
thickness rotator cuff tears. J Bone Joint Surg [Am]
2016;98:251-6.
2. Janssen SJ, Hermanussen HH, Guitton TG,
et al. greater tuberosity fractures: does fracture
assessment and treatment recommendation vary
based on imaging modality? Clin Orthop Relat Res
2016;474:1257-65.
3. Liao W, Zhang H, Li Z, Li J. Is arthroscopic
technique superior to open reduction internal
fixation in the treatment of isolated displaced
greater tuberosity fractures? Clin Orthop Relat Res
2016;474:1269-79.
4. Vastamki M, Vastamki H. Open surgical
treatment for snapping scapula provides durable
pain relief, but so does nonsurgical treatment. Clin
Orthop Relat Res 2016;474:799-805.
5.Gracitelli ME, Malavolta EA, Assuno
JH, et al. Locking intramedullary nails com-
pared with locking plates for two- and three-part
proximal humeral surgical neck fractures: a ran-
domized controlled trial. J Shoulder Elbow Surg
2016;25:695-703.
6. Amundsen A, Rasmussen JV, Olsen BS,
Brorson S. Mortality after shoulder arthro-
plasty: 30-day, 90-day, and 1-year mortal-
ity after shoulder replacement-5853 primary
operations reported to the Danish Shoulder
Arthroplasty Registry. J Shoulder Elbow Surg
2016;25:756-62.
7.Mollon B, Mahure SA, Roche CP,
Zuckerman JD. Impact of glenosphere size
on clinical outcomes after reverse total shoul-
der arthroplasty: an analysis of 297 shoulders.
J Shoulder Elbow Surg 2016;25:763-71.
 30th Edinburgh International Trauma Symposium
and Trauma Instructional Course
Edinburgh International Trauma Symposium 17th 19th August 2016
The Symposium is aimed at established orthopaedic surgeons with a trauma practice. A faculty of international and
national experts will cover advances and controversies in the management of regional orthopaedic injuries, as well as the
diverse challenges presented by multiple trauma, mass casualties and fragility fractures. Fee 750 (three days)
Edinburgh Instructional Trauma Course 15th -19th August 2016
This popular course provides a complete overview of orthopaedic trauma from head to foot, encompassing paediatric and
adult injuries, fragility fractures in the elderly, spinal injuries, and the complications of trauma. The level of the course is
aimed at the orthopaedic Fellowship examination and is also suitable for established surgeons wishing for a general
update, new trainees requiring an overview of the subject, and senior nurses and physiotherapists. Fees 800 (five days)
INVITED INTERNATIONAL FACULTY INCLUDE
Professor Heather Vallier (Cleveland, Ohio), Professor Mike McKee (Tornto)
and Professor David Ring (Boston).
Venue: Sheraton Hotel, Edinburgh, Scotland.
About Edinburgh: Edinburgh is Scotlands capital city, a World Heritage Site and has a proud history of medical
education and research. It is a vibrant city famous for its hospitals, International Festival and Fringe Festival.

Format
AT THE EDINBURGH SHERATON HOTEL:
Short, focused lectures Debates Ample time for case-based discussion
Break-out sessions for more in-depth expert analysis Dry-bone skills labs
AT THE UNIVERSITY OF EDINBURGH MEDICAL SCHOOL ANATOMY DEPARTMENT:
Cadaveric sessions focusing on surgical approaches and fracture fixation.
Further information and a detailed programme are available on our website: www.trauma.co.uk
or by email: symposium@trauma.co.uk.

SPONSORED BY

The Orthopaedic www.trauma.co.uk

Trauma Society symposium@trauma.co.uk.
 Spine
X-ref For other Roundups in this
issue that cross-reference with
Spine see: Childrens Orthopaedics
Roundup 5
Stress reduction as effective
as CBT in lower back pain
Effective non-operative manage-
ment of chronic lower back pain can
be a difficult trick to pull off, and a
randomised trial comparing different
modalities is an even more difficult
task. We were delighted to read this
randomised controlled trial in JAMA,
which reports the outcomes of a
large study comparing usual care,
mindfulness stress reduction and
cognitive behavioural therapy (CBT)
as interventions for managing chronic
lower back pain. The research team in
Washington State (USA) recruited
342 adults, all with a clear history of
chronic lower back pain.1 Participants
were randomised to either stand-
ard care, CBT or mindfulness stress
reduction (a yoga-based therapy).
The groups were evenly sized, and
24 outcomes were assessed at regular
intervals until final follow-up. The
research team chose a co-primary
outcome of clinically meaningful
improvement in the back pain bother-
some index and the Roland Disability
Questionnaire (RDQ). The addition
of CBT and mindfulness therapy
improved the percentage of patients
achieving a clinically meaningful
improvement on the RDQ outcomes
(60.5% and 57.7%, respectively) over
standard care (44%). There were
no differences seen between the
mindfulness group and CBT group at
any follow-up interval in this study.
This is an interesting study in that
it validates the use of mindfulness
stress reduction in the management
of lower back pain, and finds it to be
as effective as the best talking therapy
(CBT). Mindfulness-based relaxation
and stress reduction is a simple and
easy way to provide a technique that
appears to be as effective as CBT. A
useful addition to the few options to
treat chronic back pain.
Bone & Joint360 | volume 5 | issue 3 | june 2016
Coccygectomy: a success in
coccydynia
Coccydynia is quite literally a really important paper, as it outlines
pain in the bum for many patients.
Sometimes post-traumatic, and
sometimes spontaneous, patients
are famously problematic to treat,
and teasing out the often functional
overlay and somatisation that many
patients exhibit can be difficult. Not
unreasonably, surgeons are naturally
cautious about coccyx excision. A
brave group of spinal surgeons in
Charlotte (USA) have, however,
undertaken a large number of
coccygectomies, and report their
experience of just short of 100 cases
performed over a five-year period.2
All patients in their observational
series had chronic pain, associ-
ated with pain on palpation and
radiological abnormality. All patients
underwent a coccygectomy follow-
ing failure of conservative treat-
ment methods.
Outcomes were
measured with
the Oswestry
Disability Index
(ODI), a visual
analogue scale
and quality of life
score which was
estimated with
the SF-36 score.
Outcomes were
assessed at two
years following
treatment, with
success defined as an improvement
of 20 points on the ODI, which
represents a clinically significant
change. Using the authors criteria of
success, 69 patients had a successful
outcome, and, of the remaining 25
patients, six had poorer or equivalent
scores to the pre-operative condi-
tion, while the remainder failed to
improve significantly. Patients who
went on to have an unsuccessful
outcome presented with poorer pre-
operative ODI scores and VAS scores.
Perhaps least surprisingly, they had a
higher incidence of psychiatric prob-
lems and heavy opioid use. This is a
authors results suggest that both
that coccygectomy can be a very
successful operation where selected
problems are concerned and may
well be significantly underutilised,
perhaps due to unfounded fears
of complications and poor clinical
outcomes.
Tuberculosis better treated
posteriorly
Authors from Assiut (Egypt)
studied the influence that the
surgical approach might have on
outcomes when treating patients
with tuberculosis spondylosis of the
spine.3 Their report describes the
outcomes of 42 patients. Twenty
of the patients were treated with
anterior debridement, decompres-
sion and instrumentation, while
22 patients were treated with
posterolateral decompression and
instrumenta-
tion. Arguments
can be made for
either an anterior
approach (poten-
tially better
access to the disc,
and any paraver-
tebral collection)
or a posterior
approach (easier
correction of
the common
kyphotic deform-
ity). Outcomes
were assessed at an average of 15
months, and on the face of it the
anterior surgical approach appeared
simpler, with shorter operative times
and lower recorded blood loss. How-
ever, the posterolateral approach
allowed for significantly better cor-
rection of kyphosis, and the results
mirror this with less post-operative
deformity and some improvement
in back pain, giving better results
at final follow-up. There were no
differences between the two groups
in the effectiveness of surgery (fusion
rates and functional outcomes) or
incidence of nerve root injury. The
anterolateral and posterolateral
approaches are sufficient for treat-
ment of infection, however, despite
the small size of this series for a com-
parative study, we would tend to
agree that the reported advantages
of superior correction of deformity
and lower incidence of prolonged
back pain would give the posterior
approach the edge.
Cervical disc arthroplasty:
a safe alternative to fusion
Cervical disc arthroplasty has a
mixed history. With reports of diffi-
cult to treat infections, abraded wear
debris making its way into the spinal
canal, and high rates of re-operation
associated with the early spinal disc
replacements, the debated benefits
of a lower incidence of adjacent
segment disease seemed to pale into
insignificance, and for a time many
surgeons lost interest in the concept.
As tribology has improved and the
implant companies have renewed
their interest in spinal arthroplasty,
there is a new enthusiasm for disc
arthroplasty, particularly in the
cervical spine. A review team in
Guangzhou (China) have taken
the initiative in cervical disc arthro-
plasty and set out to establish what,
if anything, has changed in the litera-
ture since the initial poor reports.4
Their extensive search of the indexed
literature identified 12 RCTs report-
ing the outcomes of 3234 patients,
randomised to eight different models
of disc arthroplasty. The study team
chose to use re-operation as their
primary outcome measure. An unfor-
tunate observation is that nine of the
studies included in this meta-analysis
received industry funding, so one
has to take the results with a slight
pinch of salt. The headline result
of this study was that the overall
re-operation rates (6% versus 12%
relative risk (RR) 0.54) were lower in
the arthroplasty group, as was the
re-operation rate at the index level
(RR 0.5) and at the adjacent levels
(RR 0.54). The results are clearly in
favour of the disc arthroplasty, if re-
operation is taken as the end point.
The authors (as in all meta-analyses)
recommend additional high-quality
studies. However, we would inject a
note of caution here; the end point
of re-operation is not as hard an
end point as it first appears. If the
treating surgeons are hesitant about
treatment of adjacent levels due to
the difficulties of achieving a fusion
with a disc in situ, or are concerned
about the difficulties associated
with achieving fusion in an already
replaced disc, then the outcome is
meaningless.
Lumbar spine disease and hip
biomechanics X-ref
The lumbar spine, pelvis and
hips have a complex and dynamic
relationship during gait. Any change
in lumbar spinal mechanics will
have an effect on pelvic motion, and
hip and lower limb function. The
counter is, of course, also true. This
is an incredibly complicated area
to unpick and the decision-making
surrounding implant position in the
hip in the presence of a significant
spinal deformity is a difficult one. The
orthopaedic group at the Hospital
for Special Surgery, New York
(USA) have turned their atten-
tion to one facet of this problem:
the effect that sitting may have on
hip biomechanics.5 In the sitting
position, the pelvic tilt (which is
directly determined by the centre
of gravity and the lumbar spine)
in turn determines the acetabular
rim position and thereby the risk of
anterior impingement (which can
lead to posterior dislocation after hip
arthroplasty). The authors designed
a study to compare the changes in
pelvic tilt between a group with and
without lumbar spine disease, all
having total hip arthroplasty. With a
reasonable sample of 325 patients all
undergoing radiographs using the
EOS system, the authors excluded
83 patients with spinal anomalies,
further surgery or scoliosis. Of the
remainder, patients were categorised
as having radiographic arthrosis or
not, and a range of radiographic
parameters were measured in both
standing and sitting positions. When
interpreting their results, the authors
controlled for age, sex and BMI, and
did see some changes between the
two groups. Those patients with
degenerative lumbar spine disease
had a more marked pelvic tilt (mean
of 5 more posterior pelvic tilt) and
less lordosis (by a mean of 7) in the
standing position although when
sitting, the results were slightly
different, with patients managing
to achieve just 4 off the standard-
ised pelvic tilt. However, in order
to do so, 10 less spine flexion was
used and consequently 10 more
femoroacetabular flexion. This is an
interesting paper in that it highlights
the difficulties of assessing a compos-
ite range of motion associated with
spinal and hip pathology. In those
patients with lumbar spine disease,
this paper would suggest there is
functionally less acetabular antever-
sion to allow the patient to sit. It may
be prudent to take this into account
when positioning components.
Does marrow oedema relate
to back pain?
A research team in Fukushima
(Japan), in collaboration with
investigators in Gothenburg
(Sweden), identified an impor-
tant positive finding on a simple
cross-sectional study.6 The cause of
back pain in degenerative scoliosis is
often far from clear. The study team
undertook a study of 120 patients,
all with degenerative scoliosis who
had previously undergone both CT
and MRI scanning. The aim of the
study was to establish if changes on
the MRI scan correlated to clini-
cal low back pain. The presence of
bone marrow oedema was strongly
associated with the report of low
back pain. Patients reporting subjec-
tive low back pain were significantly
more likely to have bone marrow
oedema present on their MRI scan
(96.9% n = 62/64) compared with
those who did not report low back
pain (37.5% n =21/56), and this was
seen more commonly on the convex
than the concave side of the scoliosis.
There was a moderate correlation
between oedema score and pain
severity. Perhaps more subjectively,
there was a strong correlation
between the laterality and site of
the oedema and the reported pain.
Although just an associative finding,
there is clearly some further work
to be done here. A post-surgical
follow-up study with repeated pain
scores and oedema scores would
very rapidly establish if there is a
treatment effect for correction and
fusion. Tantalisingly, should this be
the case then marrow oedema would
be a tempting candidate to predict
those patients who may benefit from
surgical intervention for other causes
of low back pain.
Minor scoliosis curves not so
minor?
Little is known about any disease
where there is no presentation to
medical services. In orthopaedics, we
struggle particularly in determining
whether the natural history of minor
untreated conditions will give rise to
more serious conditions later in life.
This is where birth cohort studies
are of great use allowing epide-
miological study of the apparently
well, along with those presenting
with symptoms. Investigators using
a birth cohort based in Oxford
(UK) have conducted an extremely
valuable study of smaller curves in
adolescent idiopathic scoliosis.7 Their
study utilised the Avon Longitudi-
nal Study of Parents and Children
(ALSPAC), a birth cohort of over
14000 patients. The current report
concerns a subset of 5299 patients
with a DEXA scoliosis measure, and
another cohort of 4038 participants
who had undertaken a structured
pain questionnaire. The full data
were only available for 3184 partici-
pants, nonetheless this is by far the
largest cohort study with imaging
on scoliosis. The study revealed the
incidence of spinal curves to be 6.3%
(n = 202/3184), with 3.9% having a
curve greater than 10. There was a
Bone & Joint360 | volume 5 | issue 3 | june 2016
marked association between spinal
curves and the reporting of back
pain (odds ratio 1.42). Aside from
the pain issue, this translated into
significantly more days off school
and avoidance of activities that might
provoke back pain. While sub-
clinical scoliosis is clearly not a major
functional problem, it does remain a
potential cause for intermittent back
pain and reduced participation in
social and developmental activities.
Despite the authors call to screen
patients for scoliosis, given the
lack of suitable treatment for these
minor curves, clearly the risks would
outweigh the benefits. Here at 360
we think it would be prudent to keep
scoliosis in mind as a potential cause
of back pain in the apparently clini-
cally normal child.
References
1.Cherkin DC, Sherman KJ, Balderson BH,
etal. Effect of mindfulness-based stress reduction
vs cognitive behavioral therapy or usual care on
back pain and functional limitations in adults with
chronic low back pain: a randomized clinical trial.
JAMA 2016;315:1240-1249.
2. Hanley EN, Ode G, Jackson Iii BJ, Seymour 25
R. Coccygectomy for patients with chronic coc-
cydynia: a prospective, observational study of 98
patients. Bone Joint J 2016;98-B:526-533.
3. Hassan K, Elmorshidy E. Anterior versus pos-
terior approach in surgical treatment of tubercu-
lous spondylodiscitis of thoracic and lumbar spine.
Eur Spine J 2016;25:1056-1063.
4.Zhong ZM, Zhu SY, Zhuang JS, Wu Q,
Chen JT. Reoperation after cervical disc arthro-
plasty versus anterior cervical discectomy and
fusion: a meta-analysis. Clin Orthop Relat Res
2016;474:1307-1316.
5.Esposito CI, Miller TT, Kim HJ, et al. Does
degenerative lumbar spine disease influence femo-
roacetabular flexion in patients undergoing total
hip arthroplasty? Clin Orthop Relat Res 2016; (Epub
ahead of print) PMID:27020429.
6.Nakamae T, Yamada K, Shimbo T,
etal. Bone marrow edema and low back pain
in elderly degenerative lumbar scoliosis: a
cross-sectional study. Spine (Phila Pa 1976)
2016;41:885-892.
7.Clark EM, Tobias JH, Fairbank J. The impact of
small spinal curves in adolescents who have not pre-
sented to secondary care: a population-based cohort
study. Spine (Phila Pa 1976) 2016;41:E611-E617.
 Trauma
X-ref For other Roundups in this
issue that cross-reference with
Trauma see: Hip Roundups 2, 3; Foot
& Ankle Roundups 3, 4, 6; Wrist &
Hand Roundups 7, 8; Shoulder &
Elbow Roundups 2, 3, 5, 6; Oncology
Roundup 6; Childrens Orthopaedics
Roundups 1, 4, 6.
Percutaneous plating in hip
fracture? X-ref
Despite the complexity of the
patients, variation in injury patterns
and broad array of surgical tech-
niques and implants available to treat
fractures of the femoral neck, we
have been essentially unable to dem-
onstrate that one approach is supe-
rior to another for the majority of
hip fractures. Even the thresholds for
which patients should have a total
hip arthroplasty are rather shades
of grey, if one looks too carefully at
the literature. A review team from
Southwest Hospital, Chongqing
(China) have undertaken their own
meta-analysis of the literature, com-
26 paring intramedullary nail versus per-
cutaneous compression plate (PCCP)
fixation for intertrochanteric hip frac-
tures, presumably hoping that with a
minimally invasive approach to plate
fixation, the pendulum might swing
decisively in the favour of the plate.1
The review teams methodology was
fairly standard, relying on the tools
provided by the Cochrane Collabora-
tion. Following a thorough literature
review, there were six trials of varying
design that were suitable for inclu-
sion in this meta-analysis, report-
ing the outcomes of 908 fractures
treated with either intervention. A
pooled analysis was undertaken for
all 908 patients, with 412 receiving
intramedullary fixation versus 496
being treated with PCCP. Reading the
paper and authors commentary on
the results, one gets the impression
that they were hoping to find in
favour of PCCP. However, although
PCCP resulted in slightly lower blood
transfusion rates, shorter length of
stay, and a reduced likelihood of
Bone & Joint360 | volume 5 | issue 3 | june 2016
implant-related complications in the
studies reviewed, there were no dif-
ferences found in the main outcome
measures. There was no advantage
of one approach over another for
the duration of surgery, systemic
complications, mortality rates,
likelihood of re-operation, Harris hip
score or rate of recovery of walking
ability. In recent times, intramedul-
lary nail fixation has perhaps gained
popularity in the management of
proximal femoral fractures, and the
data presented here do not sup-
port one treatment modality over
another. Even when percutaneous
approaches are utilised for the plate
insertion, there does not appear to
be any advantage of one method
over another.
Hip fracture under the
spotlight X-ref
The management of patients
with displaced fractures of the
femoral neck has been the subject of
much controversy, and probably will
be for some time to come. With an
ageing population, best manage-
ment of this problem is becoming
not just a clinical priority, but also
an economic one. With increasing
numbers of procedures being per-
formed, the pressures on healthcare
services continue to rise. However,
the aim remains simple: to restore
the patient as closely as possible
to their pre-morbid condition. The
stakes are high, with many frail and
elderly patients unable to adequately
withstand a secondary procedure.
Adding to the mix the increasing
evidence that time to theatre has
a direct impact on morbidity and
mortality, surgery must be an urgent
priority, with the most effective
techniques employed readily avail-
able in every orthopaedic depart-
ment. The authors of this important
review from Lund (Sweden) have
done a sterling job of collating all
the relevant papers on the manage-
ment of displaced hip fractures,
to produce guidelines based on
the best evidence in the current
orthopaedic literature.2 We would
thoroughly recommend this paper to
all 360 readers involved in the man-
agement of this frail patient group.
The specific emphasis of the review
is to attempt to establish which
implants and surgical techniques
were advantageous in displaced
intracapsular neck of femur fractures,
in addition to reviewing the evidence
informing management of patients
with severe cognitive impairment.
Within the usual limitations of study
design, such as the inability to pool
results for direct comparisons and
heterogeneity of the data presented,
the authors were able to come to
some valid conclusions. The current
literature does support younger
patients (< 65 years) being treated
with internal fixation as opposed to
arthroplasty when used in conjunc-
tion with robust follow-up and
an understanding from both the
patient and the surgeon that a THA
may be required at a later date.
Those patients with a functional or
cognitive impairment with additional
comorbidities are likely to benefit
most from a cemented, modular,
unipolar hemiarthroplasty and there
is strong evidence to support the use
of the direct lateral approach rather
than the posterior approach for
hemiarthroplasty. Seven randomised
trials report results in the active
older patient (> 65 years) who were
living independently prior to their
fall. The evidence base from four of
these suggested a better quality of
life after THA, while three showed no
functional difference. In one study
there was a rate of revision of 2.5%
in the THA group, compared with
20% in the hemiarthroplasty group,
with acetabular erosion remaining
the concern in an otherwise active
patient. The authors report that the
risks of dislocation were not clear,
pointing to a recent meta-analysis
that did not find any difference in
dislocation rate between THA and
hemiarthroplasty. The authors
concluded from their review that
in this patient group, THA is the
management of choice, however,
the quality of data supporting
this conclusion is not necessarily
generalisable to many orthopaedic
departments. Is it acceptable to delay
a patient with a hip fracture until a
hip surgeon is available to perform
a total hip arthroplasty? Would it be
better to instead perform a modular
hemiarthroplasty, thus avoiding
any unnecessary delay? We are
seeing increasing numbers of THAs
performed for hip fractures, and this
is likely to continue. We need the
best possible evidence upon which
to base our decisions, which could
have considerable repercussions not
only for the patient but also for those
who are responsible for planning
the future healthcare needs of our
patient population. Here at 360 we
are very much hoping that the multi-
national, randomised study based in
Ontario, Canada, comparing hemiar-
throplasty with THA in displaced hip
fractures will provide us with some
concrete answers.
Managing the soft-tissue
envelope in closed, high-
energy complex foot and
ankle fractures: a novel
technique X-ref
As every surgeon managing bony
trauma will attest, the higher the
energy, the more difficult the fracture
mostly because of the associated
soft-tissue injury. The state of the
soft-tissue envelope is both a rate-
limiting step to the timing of inter-
ventions, and a key factor in recovery
when attempting to manage high-
energy extremity injuries. This is par-
ticularly relevant in the foot where
the available soft-tissue coverage
is both thin and highly specialised.
Avoiding full thickness necrosis and
wound breakdown while reducing
and holding fractures are the goals
in surgical planning. This paper from
the Royal Centre for Defence
Medicine, Birmingham (UK) out-
lines a novel technique to speed the
recovery of the soft-tissue envelope
in which severe swelling and blister-
ing occurs.3 Negative pressure dress-
ings have been a revolution in the
management of soft-tissue trauma in
open and closed wounds. Taking the
next natural step from the closed
wound dressing, surgeons describe
an approach to reduce wound
dehiscence by evacuating tissue fluid
as it collects between the dermal and
epidermal layers.
This is achieved
by making
multiple small
fenestrations over
the traumatised
skin and then
applying a sealed
negative pressure
wound therapy
system to evacu-
ate the resultant
oedematous fluid.
This technique
has the potential to be beneficial
in salvaging traumatised special-
ist tissues such as the sole of the
foot. Salvage here is imperative, as
free tissue transfer often leads to a
poor result due to the shear forces
on the graft and its insensibility
in a weight-bearing region of the
foot. It may also facilitate earlier
reduction and internal fixation of
underlying fractures, which is itself
beneficial to the soft-tissue envelope
by reducing the deformity, internal
bleeding from raw surfaces and
the resultant inflammation within
the foot. We look forward to a well
conducted clinical study to support
this approach.
Changing practice one PRCT
at a time X-ref
The healthcare costs associated
with running a large, randomised
controlled trial run into the millions.
With large numbers of randomised
controlled trials answering questions
as diverse as splintage for Achilles
tendons, or type of hip arthroplasty,
one does wonder: does the outcome
make any difference? Or are these
trials just a big waste of time? We
were really interested to read a sec-
ondary analysis as a result of DRAFFT,
a health technology appraisal study.
A large multicentre randomised con-
trolled trial designed to evaluate the
health economic differences between
K-wires and volar locking plates
in reducible closed distal radius
fractures, the study came down in
favour of the K-wire fixation, as there
were no real differences between
the groups in terms of outcomes.
However, there
were lower
implant costs
and resource
utilisation in the
K-wire group. In
a very interest-
ing secondary
analysis, the
group in Oxford
(UK) set out to
establish if there
were any measur-
able changes in
orthopaedic practice as a direct result
of this well publicised trial.4 The
answer is, emphatically, yes there
were. The use of K-wires rose from
12% of fractures in the UK prior to the
study, to 48% following publication.
It certainly appears that these studies
are able to drive change. What has,
perhaps, been particularly notable
about the DRAFFT study is the high
level of post-publication exposure it
has had, and the engagement of the
orthopaedic community.
Non-invasive Hb
monitoring X-ref
Accurate and effective measure-
ment of patients haemoglobin
(Hb) is an essential aspect of patient
monitoring both pre-, intra- and
post-operatively. The innovation of
the HemoCue (ngelholm, Sweden) found any differences in efficacy
has allowed for bedside testing and
improved intra-operative patient
care. We were intrigued to see this
report from the Mayo Clinic, Roch-
ester (USA) investigating the utility
of a novel, non-invasive haemoglo-
bin monitor.5 The investigators have
undertaken a comparative evaluation
of non-invasive and invasive Hb mon-
itoring in the intensive care setting.
Their prospective analysis compares
reliability, cost and patient prefer-
ences between the two systems. The
authors undertook analysis on 100
consecutive patients undergoing day
one post-operative blood tests. Hae-
moglobin measurements from both
the traditional invasive blood draw-
ing approach, and the non-invasive
measurement, were compared with
two samples within 30 minutes of
each other. There were no significant
differences between means on paired
testing and concordance testing.
However, there were savings in
terms of cost ($26 vs $2 per patient)
and a strong patient preference
for the non-invasive approach. The
non-invasive approach appears to
win hands down for isolated Hb
measurements. The authors have
comprehensively demonstrated this
to be more efficient, less expensive,
and preferred by patients when
compared with serum haemoglobin
measurements.
Distal radius again? X-ref
How much research resource
needs to be expended to establish
the same outcome before clini-
cians will change their practice? If
the paper by Costa et al4 is to be
believed, then practice in the UK at
least has dramatically changed as
a result of the DRAFFT study. This
randomised controlled trial (this
time in the older patient popula-
tion) reported from the Karolinska
Institute, Stockholm (Sweden)
takes a slight variation on the theme
and compares external fixation (ex-
fix) with or without K-wires to volar
plates (either with or without ex-fix
augmentation) in the distal radius.6
None of the reported studies have
worthy of a mention. Although the
between treatment modalities in the
distal radius, and therefore favoured
the K-wires on cost-effectiveness
grounds. In this particular study, 140
patients presenting with a dorsally
displaced distal radius fracture were
randomised to fixation with a volar
locking plate (n = 70) or external
Bone & Joint360 | volume 5 | issue 3 | june 2016
fixation with the optional addition
of K-wires (n = 70). Outcomes were
assessed regularly, and at 12 months
of final follow-up using the EQ-5D,
PRWE and DASH scores. Secondary
outcome measures including range
of motion and grip strength were
also reported. While there were
significant differences in radiographic
outcomes between the two groups,
with the volar plate group achieving
a better reduction and maintaining
this difference in secondary out-
comes, this did not translate into dif-
ferences in functional scores, range
of motion or changes in any patient-
reported outcome score. The authors
concluded that both techniques are
equally suitable treatment options
after low-energy trauma in a popula-
tion aged 50 to 74 years. This study
underlines for us the importance of
co-ordination in the design and con-
duct of randomised controlled trials,
both nationally and internationally.
The outcome of this study could
realistically have been predicted
reliably from the many similar studies
that have come before. However,
there are many questions surround- 27
ing the management of distal radial
fractures that could very usefully
have been studied by the study
team. As national networks are start-
ing to emerge in trauma research, we
wonder here at 360 if it will be long
before there is some international co-
ordination of research questions.
Rotational control in sliding
hip screws X-ref
The biomechanical stability of
constructs surrounding the proximal
femur continues to dominate the
basic science literature. Although
many studies are not worth com-
menting upon, this cadaveric study
from Tampa (USA) is certainly
jury is still somewhat undecided
about the relative benefits of nails
versus plates in the stabilisation
of pertrochanteric fractures of the
proximal femur, there are some
clear patterns emerging in the
literature. What is still far from
clear, however, is how the different
 designs of the devices affect their
biomechanical properties. In a
well designed cadaveric study, the
venerable Gamma 3 nail was tested
against the much newer InterTAN
nail in a study designed to establish
if the two screw designs had an
effect on rotational stability.7 The
tests were conducted in 11 pairs of
hemipelvises, with the intention of
establishing the effects of stability
on a biaxial walking simulation in
patients with an unstable intertro-
chanteric fracture. In an impressive
show of cadaveric modeling, the
cadavers were subjected to three
months of testing, and then testing
to failure. In what is a tour de force of
biomechanical testing, the authors
clearly conclude that the femoral
head rotation is significantly lower
in the InterTAN group, as indeed is
the maximal femoral head col-
lapse. On all of the measures, the
more modern dual screw design
provided better biomechanical
stability. Despite the relatively clear
conclusions, it is important to note
that Tampa is one of the originating
28 centres for the InterTAN device, and
this will doubtless have influenced
Bone & Joint360 | volume 5 | issue 3 | june 2016
the interpretation at least of these
results.
Salvage of femoral neck
fixation how well does it
actually work? X-ref
As the incidence and prevalence
of hip fractures continues to rise in
the setting of an ageing and increas-
ingly healthy older population, it
is perhaps to be expected that the
need for salvage after failed fixation,
nonunion or implant fracture is also
likely to increase. For most patients,
the universal solution to difficult
proximal femoral fracture complica-
tions is a total hip arthroplasty, and
we all tend to be reassuring with our
patients as to the likely outcome.
Here at 360 HQ, we were delighted
to read a systematic review from
London (UK) aimed at quantify-
ing just how well patients do with
total hip arthroplasty for trauma
following failed internal fixation.8
The review team performed sys-
tematic review and meta-analysis
with the preferred reporting items
for systematic reviews and meta-
analysis (PRISMA) guidelines, using
the PubMed, EMBASE and Cochrane
library databases. They were able to
report composite outcome measures
for complication rates (deep infec-
tion, peri-prosthetic fracture) and
functional assessments with the
EQ-5D as compared with the total
hip population. Perhaps reassur-
ingly, the functional outcomes were
not significantly different to those
patients undergoing primary THR
for hip fracture, however, there were
significantly more complications
in the revision group. This under-
lines to us the importance of these
procedures being performed by
experienced revision hip surgeons,
with the necessary skills and experi-
ence to achieve an excellent result
in what are very complex and frail
patients.
References
1.Shen J, Hu C, Yu S, Huang K, Xie Z. A meta-
analysis of percutenous compression plate versus
intramedullary nail for treatment of intertrochan-
teric HIP fractures. Int J Surg 2016; 29:151-158.
2.Rogmark C, Leonardsson O. Hip arthro-
plasty for the treatment of displaced fractures of
the femoral neck in elderly patients. Bone Joint J
2016;98-B:291-297.
3. Poon H, Le Cocq H, Mountain AJ, Sargeant
ID. Dermal fenestration with negative pressure
wound therapy: a technique for managing soft tis-
sue injuries associated with high-energy complex
foot fractures. J Foot Ankle Surg 2016;55:161-165.
4.Costa ML, Jameson SS, Reed MR. Do large
pragmatic randomised trials change clinical prac-
tice? Assessing the impact of the Distal Radius
Acute Fracture Fixation Trial (DRAFFT). Bone Joint J
2016;98-B:410-413.
5. Martin JR, Camp CL, Stitz A, et al. Noninvasive
hemoglobin monitoring: a rapid, reliable, and cost-
effective method following total joint replacement.
J Bone Joint Surg [Am] 2016;98-A:349-355.
6.Mellstrand Navarro C, Ahrengart L,
Trnqvist H, Ponzer S. Volar locking plate or
external fixation with optional addition of K-wires
for dorsally displaced distal radius fractures: a
randomized controlled study. J Orthop Trauma
2016;30:217-224.
7.Santoni BG, Nayak AN, Cooper SA, etal.
Comparison of femoral head rotation ands
varus collapse between a single lag screw and
integrated dual screw intertrochanteric hip
fracture fixation device using a cadaveric hemi-
pelvis biomechanical model. J Orthop Trauma
2016;30:164-169.
8. Mahmoud SS, Pearse EO, Smith TO, Hing
CB. Outcomes of total hip arthroplasty, as a sal-
vage procedure, following failed internal fixation
of intracapsular fractures of the femoral neck: a
systematic review and meta-analysis. Bone Joint J
2016;98-B:452-460.8.
 Oncology
Nerve sheath tumours not as
bad as we thought?
Even by the standards of
orthopaedic oncology, nerve sheath
tumours are rare, usually arising as
the result of radiotherapy or neurofi-
bromatosis type 1 (NF1). They remain
a bit of an enigma. Reaching the
diagnosis and decision on optimal
management can be tricky, and there
remains some significant uncertainty
as to whether neurofibromatosis-
related nerve sheath tumours vary
in prognosis away from the sporadic
forms. Oncologists at the IUCT-
Oncopole, Toulouse (France)
conducted a large study of 353
patients (37% with NF1 and 59% with
sporadic tumours), presenting over
a 23-year period with histologically
proven malignant peripheral nerve
sheath tumours (MPNST).1 Review
included a multivariate analysis,
and demonstrated the perhaps not
surprising poor prognostic factors
which included high grade, deep
location, locally advanced stage
at diagnosis, and macroscopically
incomplete resection. Interestingly,
those patients with NF1 did not
experience a negative prognostic
effect, except for those suffering
recurrence or metastasis. In this
setting, where NF1-related MPNST
patients were treated with palliative
chemotherapy, survival was poorer
than in patients with sporadic forms.
This study queries the conventional
belief that NF1 is a poor prognostic
indicator for patients with MPNST. It
is one of the largest studies of what
is a poorly understood diagnosis,
mostly due to its rarity. While this
study does have its shortcomings,
we would urge readers to re-evaluate
their preconceptions in patients with
neurofibromatosis and malignant
nerve sheath tumours.
Ewings sarcoma in the pelvis
Tumours seen in the pelvis
generally suffer from later diagnosis
and poorer prognosis than their
appendicular skeleton cousins.
The combination of inaccessibility,
proximity to vital structures and
delayed diagnosis can make the
outlook rather bleak for patients
presenting with primary tumours
of the pelvis, and especially so with
Ewings sarcoma. In an interesting
paper from the Scandinavian group
at the Karolinska University
Hospital, Solna (Sweden), the
authors sought to tease out any
differences between sacral and
non-sacral tumours.2 The study team
were able to report on the outcomes
of 117 patients with Ewings sarcoma
of the pelvic ring; 88 had tumours
in the innominate bones and 29 in
the sacrum. As would perhaps be
expected in a mixed bag of presenta-
tions such as this, treatment was
with a combination of radiotherapy
and surgery. Radiotherapy was the
sole local treatment for 40% of the
innominate bone tumours, in con-
trast to 79% of the sacral tumours.
The five-year disease-free survival
rate in the sacral tumour group was
significantly better than in those
with innominate bone tumours
(66% vs 40%). This paper has two
interesting messages: disease-free
survival among patients with Ewings
sarcoma was improved in tumours
localised to the sacrum compared
with the innominate bones; and local
radiation therapy alone appears to
result in acceptable local tumour
control, and may be the treatment of
choice for sacral tumours. This study
should, however, be taken in con-
text; the absence of documentation
of systemic therapy is a major limita-
tion, and is of utmost importance
in Ewings sarcoma. Should there
be any unreported differences here,
then the findings of this study are
completely invalidated. The authors
hypothesise that the difference in
behaviour between sacral tumours
and non-sacral tumours may be due
to a different biologic microenviron-
ment, possibly the close proximity
to the presacral venous plexus,
although this does seem to be an
assertion without evidence.
Bone grafting in polyostotic
fibrous dysplasia
Polyostotic fibrous dysplasia
(PFD) is a genetic disease (GNAS
mutation) that results in the replace-
ment of normal marrow cells with
immature osteoprogenitor cells,
producing fibro-osseous tissue in
place of normal marrow. One of the
widely accepted treatments for PFD
is bone grafting following excision of
the fibrous tissue. Researchers at the
National Institutes of Health,
Bethesda (USA) have attempted
to shed some light on the role of
grafting in the treatment of this
tricky condition. Their clinical paper
reports the outcomes of 23 subjects
undergoing 52 bone-grafting pro-
cedures and reported to an average
follow-up of 20 years.3 The investiga-
tors attempted to establish if graft
material (autograft vs allograft) and
type (structural vs non-structural) of
grafting had any influence on out-
comes. The authors were unable to
show any advantage in their series of
graft types or materials. The authors
conclude that bone grafting, includ-
ing both allograft and autograft, is of
limited value in ablating the lesions
of fibrous dysplasia.
Radiation and non-Hodgkins
lymphoma
Non-Hodgkins lymphoma (NHL)
of bone is traditionally treated with
chemotherapy and radiation therapy,
but the role of radiotherapy in
disease management, and particu-
larly in terms of patient functional
outcomes and survival after treat-
ment, has not been extensively
studied. These authors from Rush
University, Chicago (USA) have
investigated the survival advantage
of radiotherapy in a large cohort of
70 patients, all with NHL of bone and
assessed at a minimum follow-up of
six months for associated complica-
tions of radiotherapy.4 All patients
included in this retrospective analysis
Bone & Joint360 | volume 5 | issue 3 | june 2016
had biopsy-proven NHL of bone.
One group of patients were treated
with systemic therapy alone (n =
46 patients), and the other with
combined modality therapy (n =
24 patients). In all cases, rituximab
was the sole chemotherapy agent
utilised. There were no differences in
Kaplan-Meier survivorship in patients
treated with and without radiation at
five years. Patients who were treated
with radiation were more likely to
experience problems with fracture
healing, and were at a higher risk
for fracture in the post-treatment
period. While the results of this study
are fairly clear-cut with regard to the
disadvantages of radiation therapy,
there are certainly also some difficul-
ties with the power of this study. A
post hoc analysis suggested that this
study was only powered to establish
a 30% difference in survival. The jury
is still out on any survival benefit
of radiation therapy, however, the
downsides in terms of orthopaedic
complications are quite clear.
29
A new approach for desmoid
tumours?
Magnetic resonance-guided,
high-intensity focused ultrasound
(MRgFUS) is a relatively new non-
invasive therapeutic modality that
may be useful to treat extremity
tumours, especially in situations in
which standard treatments would
be associated with unacceptable
morbidity or are ineffective, as is
the case with desmoid fibromatosis.
Researchers at Stanford (USA) are
amongst the first investigators to
report the use of MRgFUS in a clinical
setting,5 and here at 360 we are quite
excited about the potential applica-
tions of this technology in the future.
This small experimental and clinical
study reports the outcomes of nine
patients with extremity desmoid
tumours in a cadaver study, demon-
strating the ability of the technique
to ablate a predetermined target vol-
ume in the cadaveric tissue. The nine
patients who underwent treatment
 all had refractory tumours that had
either failed to respond to traditional
treatment or had tumour-related
symptoms. There were five patients
available for interval scan follow-up
and, of these, tumour regression
was seen in four. This study provides
early evidence that MRgFUS may be
useful as a novel treatment modality
for desmoid tumours, and is certainly
worth further investigation in this as
well as other types of tumours.
Meta-analysis not quite
right? X-ref
There is an age-old adage -
rubbish in, rubbish out - that can
be applied to most things in life, but
30 particularly to medical statistics.
Noting the findings of a number of
recently published meta-analyses, all
of which concluded that pathologic
fracture is a negative prognostic
factor in osteosarcoma, an author
from Vanderbilt University,
Nashville (USA) has questioned
this conclusion are meta-analyses
always correct?6 Arguing (elo-
quently) that the methodology of
meta-analysis is to use composite
outcome measures, the author
emphasises that meta-analysis
can generate false conclusions if
Bone & Joint360 | volume 5 | issue 3 | june 2016
important confounding variables
were not accounted for in the
index studies, thereby compromis-
ing internal validity. In his study, a
multivariable survival analysis of a
retrospective cohort of 131 patients
(21 patients who suffered pathologic
fracture, and 110 patients who did
not), with conventional, high-grade
osteosarcoma of the extremity long
bones treated with neoadjuvant
chemotherapy and surgical resec-
tion, was performed. Pathologic
fracture did not significantly affect
patient outcome or disease-free
survival after controlling for con-
founding factors not accounted
for in prior meta-analyses, such as
tumour size, chemotherapy response
and proximal tumour location. The
author makes the point that uniform-
ity of reporting and the sharing of
individual study data would allow
for adjusted meta-analysis to be per-
formed, enabling greater accuracy in
meta-analysis outcomes reporting.
The counterargument, of course, is
that use of multivariable outcomes in
studies with limited events (this case
has just 21) is in itself invalid, because
although an adjusted analysis is likely
to describe the small data set well,
it perhaps may not be applicable to
larger data sets. We wouldnt discard
the meta-analyses results just yet,
however, there is enough here to get
us thinking.
Grafting in giant cell tumours
The treatment of the giant cell
tumour consumes perhaps more
words in orthopaedic literature than
any other diagnosis in orthopaedic
oncology. The pages of this journal
are full of discussion surrounding
bone grafting or polymethylmeth-
acrylate (PMMA) support, with a
range of studies on the topic. A small
study from New Jersey Medi-
cal School, New Jersey (USA),
however, has something to add
on the topic. Although describing
the outcomes of just 43 patients,
the series reports one of the most
homogeneous patient groups
reported in the literature. All of the
patients had a similar lesion treated
in the epiphysis of a long bone.7 All
patients underwent intralesional
curettage and then treatment with
either PMMA alone or graft (with
Non-Hodgkins lymphoma of bone? Clinical results
or without PMMA supplementa-
tion). Outcomes were assessed to a
mean of 59 months with measures
of joint degeneration and functional
outcome scores. Though a small
study, this well conducted, careful
trial demonstrated clearly that when
compared with PMMA alone, the use
of peri-articular bone graft constructs
reduce post-operative complica-
tions (fractures and arthritis), and
apparently without increasing the
likelihood of tumour recurrence. The
hypothesis suggested is that thermal
damage from PMMA is decreased
because bone graft increases the
distance between the exothermic
reaction of PMMA and the articular
cartilage. The authors also hypoth-
esise that the PMMA modulus
mismatch between cortical bone and
cancellous bone results in it acting as
a rigid surface, concentrating pres-
sure on the already thin cartilage and
subchondral plate tissue. This may
result in cartilage damage, fracture,
and arthrosis.
References
1.Valentin T, Le Cesne A, Ray-Coquard I,
et al. Management and prognosis of malignant
peripheral nerve sheath tumors: The experience of
the French Sarcoma Group (GSF-GETO). Eur J Cancer
2016;56:77-84.
2.Hesla AC, Tsagozis P, Jebsen N, et al.
Improved prognosis for patients with Ewing sar-
coma in the sacrum compared with the innominate
bones: the Scandinavian Sarcoma Group experi-
ence. J Bone Joint Surg [Am] 2016;98-A:199-210.
3. Leet AI, Boyce AM, Ibrahim KA, et al. Bone-
grafting in polyostotic fibrous dysplasia. J Bone
Joint Surg [Am] 2016;98-A:211-219.
4.Ibrahim I, Haughom BD, Fillingham Y,
Gitelis S. Is radiation necessary for treatment of
with contemporary therapy. Clin Orthop Relat Res
2016;474:719-730.
5. Avedian RS, Bitton R, Gold G, Butts-Pauly
K, Ghanouni P. Is MR-guided high-intensity
focused ultrasound a feasible treatment modal-
ity for desmoid tumors? Clin Orthop Relat Res
2016;474:697-704.
6.Cates JM. Pathologic fracture a poor prognos-
tic factor in osteosarcoma: misleading conclusions
from meta-analyses? Eur J Surg Oncol 2016; PMID:
26895688. [Epub ahead of print].
7. Benevenia J, Rivero SM, Moore J, et al.
Supplemental bone grafting in giant cell tumor of
the extremity reduces nononcologic complications.
Clin Orthop Relat Res 2016; PMID: 26932739. [Epub
ahead of print].
 Childrens orthopaedics
Washers in the medial
epicondyle X-ref
Adding a metal washer to screw
fixation of medial epicondylar
fractures increases the likelihood of
implant removal following surgical
stabilisation. This is perhaps all that
needs to be said about this simple
paper from Pennsylvania State
College of Medicine (USA).1
What the authors dont manage in
methodology and robust analysis,
they make up for in the simple and
useful message in their paper. Their
retrospective review reports the
outcomes of 16 patients (17 elbows),
all adolescents with displaced medial
epicondylar fracture dislocations
who were managed surgically
between 2008 and 2014. In 12 frac-
tures, a screw and washer were used,
and in five, a screw alone. Follow-up
was reported to 11.5 months, and
during the follow-up period all frac-
tures healed themselves. In fractures
treated with a screw alone, there
was no associated fragmentation
or penetration of the epicondylar
fragment and, as such, there were no
patients who requested metalwork
removal. However, in the washer
group, seven of 12 patients treated
with a screw and washer requested
removal of metalwork. Washers are
often used in this situation because
of the perceived risk of epicondylar
fragmentation; however in this small
series with short-term follow-up,
this fear does not appear to increase
the risk of implant removal. This is a
very simple paper which conveys a
practical message of interest to any
surgeon involved in the manage-
ment of this injury.
Modified Dunn osteotomy
acceptable for unstable SUFE
Unstable slipped upper femoral
epiphysis (SUFE) is a problematic
condition to treat. Although stable
or minimally displaced SUFE are
associated with excellent outcomes
from pinning in situ, the manage-
ment of unstable acute SUFE is much
more controversial. Contemporary
thought has swung towards open
reduction and pinning, often using a
modified Dunn procedure. There are
few large series reported of surgical
dislocation. We were pleased to
see this single-surgeon series from
Nationwide Childrens Hospital,
Ohio (USA) reporting the outcomes
of 31 hips with unstable SUFE.2 The
modification of the hip dislocation
described here includes the addition
of an extended retinacular flap. The
patients were all operated on within
24 hours of presentation (mean
13.9hrs), although there was no
information reported on the timing
of symptoms. The authors report that
at over two years of follow-up, just
6% of patients developed avascular
necrosis at around four months,
and three patients (10%) developed
mild heterotopic ossification requir-
ing no treatment. There was no
evidence in this series of nonunion,
delayed union, or post-operative hip
subluxation/dislocation. Radiological
anatomy was effectively normalised
with restoration of and slip angle
with minimal change in greater
trochanteric height and femoral neck
length. Given the effective restora-
tion of normal hip biomechanics, this
series underlines the importance of
normal hip geometry.
Does vitamin D deficiency
influence time to physeal
closure?
Sometimes an incidental finding
leads to a surprising hypothesis or
insight into a disease. Noting that
there was an unexpected preva-
lence of female patients in a cohort
presenting with SUFE when the
condition typically has a significant
male predominance, the paediatric
team at Southampton General
Hospital (UK) set out to try and
establish what the causation might
be.3 Between June 2007 and July
2012, 23 of 27 (85.2%) patients pre-
senting with SUFE in their unit were
assessed as vitamin D deficient,
with serum 25-(OH)D < 52 nmol/L.
Unusually, the majority (n = 17/27)
were female, with a mean age of 11.5
years. Although slightly limited by
its methodology, the paper is very
much of interest given the unusual
association. What is not quite clear,
despite a high level of vitamin D
deficiency being observed in SUFE
patients in a northern European
unit, is whether the delayed physeal
closure that is known to be associ-
ated with vitamin D deficiency is the
cause here. Although the causation
is far from clear, the association of
low vitamin D, SUFE and female
sex is a novel one which is worthy
of note. Sadly, the paper does not
include BMI data, which would be
helpful in interpreting the results as
vitamin D is a fat soluble vitamin.
Combined with the lack of con-
sensus surrounding what actually
constitutes a low vitamin D status
for the UK population as a whole,
this leaves us with some difficulties
in drawing any firm conclusions
from what remains an interesting
observation.
Flexible nailing in childrens
femoral fractures X-ref
The flexible nail has a relatively
small window of clinical applicabil-
ity in childrens femoral fractures.
Too flexible for older childrens
fractures, and lacking in the length
stability required to adequately
stabilise comminuted fractures
(even with the use of the end caps),
the debate continues as to which
children they are indicated in, and if
indeed they are better than a simple
hip spica. The paediatric trauma
surgeons at the Texas Scottish
Rite Hospital for Children,
Dallas (USA) have provided the
first large comparative series of
patients managed with either spica
immobilisation or flexible femoral
nailing.4 Their carefully reported
series includes the outcomes of a
retrospective cohort study of 262
patients aged between four and five
Bone & Joint360 | volume 5 | issue 3 | june 2016
years, of whom 104 were treated
with intramedullary nail (IMN) and
158 with an immediate spica cast
immobilisation. The patients were
followed up for a mean of 32 weeks,
and outcomes were reported both
radiographically and clinically.
Radiographically, at final follow-
up there were no relevant mean
differences in coronal angulation
(< 15), sagittal angulation (< 20)
or shortening (<20 mm) between
the two groups. However, those
in the intramedullary nail cohort
often required a second operation
for metalwork removal, and of
course a longer follow-up period
was reported. It is important to
bear in mind that this study is not
a randomised study, and with a
surgeons discretion method for
selection of treatment, the cohorts
are not matched. Those treated with
IMN tended to be slightly older,
heavier (mean 21.5 vs 18.0 kg) and
more likely to have a higher-energy
mechanism of injury. Children 31
aged four to five years with an
isolated femoral fracture have
similar clinical and radiographic
outcomes with immediate spica
cast immobilisation as they do with
flexible intramedullary nail, based
on the data presented here. While
these data can be used to legitimise
whichever treatment modality the
surgeon is planning, it is important
to remember that these are very
different treatments. There are no
cost-effectiveness data presented,
and although the surgery has the
drawbacks associated with the
potential for complications and
longer follow-up periods, the bene-
fits of earlier mobilisation and fuller
engagement in social and other
activities are likely in the eyes of
many to outweigh the downsides.
EOS biplanar radiographs
X-ref
Assessment of the paediatric
spine is problematic. The complex
deformities that are associated with
 scoliosis do not lend themselves very
well to simple 2D imaging. Although
clearly written with the intention of
promoting the EOS biplanar system,
this report from University of
Saint Joseph, Beirut (Lebanon)
does provide a relatively balanced
review of the EOS technology, its
advantages, major uses and pitfalls.5
For those considering including EOS
in their practice, this article is well
worth a read, making the argument
that for correction and evaluation
of scoliosis in the paediatric spine,
the 3D reconstructions are achieved
at a fraction of the dose of plain
film radiation, let alone a CT scan.
The review, however, highlights the
need to have a skilled operator of the
workstation as 3D reconstructions
are not produced automatically and
can be tricky to achieve.
Osteonecrosis after paediatric
femoral neck fractures X-ref
The femoral neck fracture in chil-
dren is a rare and significant prob-
lem. In adults, osteonecrosis from
displaced femoral neck fractures can
be difficult enough to treat, however,
32 in children the prospect of lifelong
disability and difficulties associated
with successful reconstruction are of
great concern. Surgeons at Harvard
Medical School, Massachusetts
(USA) have set out to review the
potential risk factors for osteonecro-
sis, in an attempt to identify what
is most likely to lead to the condi-
tion.6 They were able to assemble a
cohort of 70 fractures treated over
a ten-year period and undertook a
comprehensive, multivariable logistic
regression analysis to identify factors
Bone & Joint360 | volume 5 | issue 3 | june 2016
associated with osteonecrosis. They
were able to evaluate the effect of
patient factors (age, sex), injury fac-
tors (mechanism, time to treatment,
fracture location and displacement)
and treatment factors (time to sur-
gery, fixation method,
capsular decompres-
sion and post-operative
alignment) as poten-
tially causally linked
to the development of
osteonecrosis. Their
cohort had an event rate
of around 30%, which
is in line with previous
literature. The significant
risk factors uncovered
by the authors for the
development of oste-
onecrosis are fracture
displacement, fracture
location and time to treatment (<
24h). Interestingly, capsular decom-
pression does not make a difference
to eventual outcome. This paper
represents probably the most reliable
data on this topic with a cohort of 70
patients, all with reasonable follow-
up. Although to a certain extent
the die is cast at the time of injury,
clearly providing timely surgery
will improve the likelihood of head
survival.
Calcaneal scoring for SUFE?
To pin or not to pin? There has
been much recent work on prophy-
lactic pinning of the contralateral
hip in unilateral slipped upper
femoral epiphysis (SUFE). The current
literature suggests that if only one
option is available, it is safer and
cheaper to pin the contralateral hip
prophylactically. However, there
have been several recent studies
suggesting that the modified Oxford
Hip Score may be an effective way
of screening for an impending SUFE
and, as such, could potentially be
used to aid decision-
making surrounding
prophylactic pinning.
These authors from Yale
School of Medicine,
New Haven (USA)
propose a different
approach, instead using
ossification of the calca-
neal apophysis to guide
the decision-making
surrounding pinning.7
They reason that the
calcaneal scoring system
provides a bone age
that relates directly to
peak height velocity, and that this
may be used in place of the Oxford
score for an easier to apply approach
which is comparable, but less
complex, than the modified Oxford
method to aid in the prediction of a
contralateral slip. The authors report
a purely imaging-based study where
they examined 279 matching hip
and feet radiographs of 94 children.
They were able to establish that
there was a reasonable correlation
between the modified Oxford score
and the calcaneal scoring system. The
weighted risk of contralateral slipped
capital femoral epiphysis (SCFE)
referenced from the literature on the
Oxford score was therefore 94% for
calcaneal stage 0, 86.5% for stage 1,
90.3% for stage 2, 55.8% for stage 3,
6.1% for stage 4, and 0% for stage 5.
This paper is certainly of substantial
interest regarding an easier method
for quantifying the risk of SUFE,
however, we do have some concerns
about the conclusions that have been
drawn, here at 360. This study does
not actually evaluate the value of cal-
caneal scoring as a predictor of SUFE;
it evaluates the ability of the calcaneal
score to predict modified Oxford Hip
Scores a completely different thing.
References
1.Pace GI, Hennrikus WL. Fixation of dis-
placed medial epicondyle fractures in adolescents.
J Pediatr Orthop 2016. [Epub ahead of print] PMID:
26974528.
2.Persinger F, Davis RL 2nd, Samora WP,
Klingele KE. Treatment of unstable slipped
capital epiphysis via the modified Dunn procedure.
J Pediatr Orthop 2016. [Epub ahead of print] PMID:
26866640.
3.Judd J, Welch R, Clarke A, Reading IC,
Clarke NMP. Vitamin D deficiency in slipped upper
femoral epiphysis: time to physeal fusion. J Pediatr
Orthop 2016;36:247-52.
4.Ramo BA, Martus JE, Tareen N, et al.
Intramedullary nailing compared with spica casts for
isolated femoral fractures in four and five-year-old
children. J Bone Joint Surg [Am] 2016;98-A:267-75.
5. Melhem E, Assi A, El Rachkidi R, Ghanem I.
EOS() biplanar X-ray imaging: concept, develop-
ments, benefits, and limitations. J Child Orthop
2016;10:1-14.
6.Spence D, DiMauro JP, Miller PE, et al.
Osteonecrosis after femoral neck fractures in
children and adolescents: analysis of risk factors.
J Pediatr Orthop 2016;36:111-116.
7.Nicholson AD, Huez CM, Sanders JO, Liu
RW, Cooperman DR. Calcaneal scoring as an
adjunct to modified Oxford hip scores: prediction
of contralateral slipped capital femoral epiphysis.
J Pediatr Orthop 2016;36:132-138.
 Research
X-ref For other Roundups in this
issue that cross-reference with
Research see: Hip Roundups 1, 5, 7;
Knee Roundups 2, 3, 4; Wrist & Hand
Roundup 5; Trauma Roundup 4, 5.
Seronegative infections of the
hip and knee X-ref
Early diagnosis of peripros-
thetic joint infection (PJI) can have
significant implications for its
successful treatment. However, in
some patients it can be difficult to
arrive at a definitive diagnosis, and
biochemical markers of inflammation
including erythrocyte sedimenta-
tion rate (ESR) and the C-reactive
protein (CRP) are routinely used
as a diagnostic aide. There is some
evidence to suggest that a normal
CRP and ESR are sensitive enough to
definitively rule out a PJI, although
others have suggested that this will
lead to a significant number of false
negatives. The authors of this study
from the Mayo Clinic, Rochester
(USA) aimed to report on and iden-
tify the outcomes for patients treated
for PJI, all with negative serology
(ESR and CRP within normal limits).1
The authors used their institutional
database to identify the patients
and pathogens most commonly
implicated. Their institutional regis-
try contained 952 PJIs and, of those,
38 (4%) had a CRP and ESR within
normal limits and formed the basis
for this study (17 THAs and 21 TKAs).
In the majority of cases two positive
samples for tissue culture were
identified. In this cohort (perhaps
unsurprisingly) the outcomes follow-
ing two-stage revision were similar
to published success rates. Across
their whole cohort the authors
calculated a sensitivity of ESR and
CRP of 81% and 93%, respectively.
However, when the CRP and ESR
were combined with pre-operative
joint aspiration, the sensitivity rose
to 99.7%, including patients with
a negative serology. Although the
incidence of seronegative joint
infections was low, this large study
highlights the importance of exercis-
ing extreme caution when excluding
a definitive diagnosis of a PJI on just
the ESR and CRP. A significant num-
ber of suspected patients will have
a PJI despite normal inflammatory
markers. It is therefore important to
consider normal inflammatory mark-
ers in the light of a patients clinical
condition, and have a low threshold
to perform a joint aspiration. If there
is any doubt regarding patients
with equivocal results, they should
be discussed in a multidisciplinary
team setting among clinicians with
an interest in treating PJIs including
senior microbiologists, infectious
diseases consultants and patholo-
gists. A missed or delayed diagnosis
can have significant ramifications for
the successful treatment of this chal-
lenging condition.
The lateral cutaneous nerve
of the thigh X-ref
There is no such thing as a free
lunch. Economists have been using
this phrase for years, indicating that
there is always a trade-off for every-
thing. Surgical approaches to total
hip arthroplasty are no different.
The posterior approach historically
has a higher rate of dislocation,
and the direct lateral approach has
higher abductor weakness. While
the direct anterior approach has
been widely marketed and lauded
as a muscle-sparing approach,
one of the key risks of this approach
is damage to the lateral femoral
cutaneous nerve (LFCN). It must
be emphasised to patients that one
third of individuals may be affected
by numbness after surgery, and that
there is the potential for femoral
nerve damage affecting the quadri-
ceps. This anatomic study from the
University of Zurich (Switzer-
land) nicely highlights the course
of the LFCN and reminds us that
there are no free lunches when per-
forming total hip arthroplasty.2 The
study team used a decent sample
size of 28 cadaveric hemipelvises,
and the course and branches of the
LFCN from the inguinal ligament
through the thigh and onwards
were established. The course of the
nerve and its eventual branching
pattern were noted and the relation-
ship between the anterior superior
iliac spine and the surgical plane of
the anterior approach also identi-
fied. The authors describe three
unique branching patterns, seen
in roughly a third of patients. The
sartorius pattern sees an anterior-
dominant bundle running under
the cover of the lateral border of the
sartorius, the posterior type sees a
dominant posterior branch, and the
fan type has early multiple small
branches which make the nerve
branches difficult to identify. Given
the proximal branching in around
half of specimens, and the anatomic
patterns seen, the authors conclude
that it is impossible to approach the
hip joint anteriorly without injury to
the nerve in around half of patients.
Minimising complications
with pre-operative
haemoglobin X-ref
There are any number of studies
demonstrating that pre-operative
anaemia leads to post-operative
transfusion, and that post-operative
transfusion is associated with
complications. This may in part be
due to transfusion triggers or an
associative confounder (are patients
at risk of complications more likely
to be anaemic?). However, it is puz-
zling that there arent any studies
considering this question: if the pre-
operative haemoglobin level could
be corrected, would that reduce
the complication rates in large joint
arthroplasty? The arthroplasty group
in Edinburgh (UK) have published
their own study which takes a fresh
look at the difficult-to-unpick topic of
haemoglobin, transfusion, com-
plications and arthroplasty.3 Their
study used data from 2284 patients
undergoing total knee arthroplasty
to explore any association between
Bone & Joint360 | volume 5 | issue 3 | june 2016
pre-operative haemoglobin and
transfusion. The authors established
using a receiver operating character-
istic (ROC) analysis that thresholds
of 13.75 g/dl for males and 12.75 g/
dl for females were associated with a
sixfold increased risk of transfusion.
The authors note that complica-
tion rates associated with anaemia
include cardiac arrhythmia, deep
infection, mortality and increased
length of hospital stay. Although the
authors boldly assert that their data
can justify pre-operative optimisa-
tion of the haemoglobin prior to
joint replacement, we do have a
fundamental difficulty here at 360
with changing practice on papers
like this that assert association, not
causation it is far from clear if
patients with pre-operative low Hb
are at risk of complications because
of their Hb, or if in fact patients with
comorbidities are at risk of complica-
tions and incidentally are also likely
to have a low Hb.
Thromboprophylaxis and 33
aspirin X-ref
The spectre of thromboprophy-
laxis continues to raise its ugly head.
A thorny medico-legal issue with
questionable national guidance
based on dubious drug company-
sponsored studies, it is easy to see
why surgeons feel aggrieved about
the widespread unselected use of
low molecular weight heparin as a
thromboprophylactic agent, with its
inherent disadvantages. There are
a number of different approaches
to this problem, and we were
delighted to read this report from
Belfast (UK) concerning the use of
aspirin thromboprophylaxis in 11 459
patients.4 The study team under-
took an analysis of the pulmonary
embolism risks and 90-day mortality
risk, both all-cause and pulmonary
embolism related. Within the limits
of the data presented, the authors
were able to establish that pulmonary
embolism was responsible for just
18% of deaths. Further to this, the
 authors undertook a stratified analysis
of those patients receiving aspirin and
other forms of thromboprophylaxis.
What they can be certain of is that
there is no increased risk of death
or thromboembolic events when
aspirin is used in conjunction with
individualised risk assessments. The
use of aspirin appears to be safe as a
thromboprophylaxis agent in primary
arthroplasty, and is not associated
with an increased incidence of DVT in
a select group of low-risk patients.
Preventing infection in total
knee arthroplasty X-ref
Though periprosthetic joint
infection after total knee arthroplasty
remains a rare complication, it is
associated with huge morbidity and
spiraling healthcare costs. As pro-
phylactic and therapeutic antibiotics
become less and less effective, pre-
vention (as they say) is always going
to be better than cure. Sadly, despite
the large health economic costs
associated with periprosthetic infec-
tion and some of the prophylactic
measures taken, there
are still significant
34 numbers of patients
who suffer this most
costly and disabling of
complications. We were
delighted here at 360 to
read this analysis from
authors at North Shore
Hospital (Auckland,
New Zealand) of risks
factors for infection
and their likely
efficacy.5 The paper
concerns the out-
comes of 64 566 joint arthroplasties
from across New Zealand with out-
comes assessed for early peripros-
thetic joint infection at six and 12
months of follow-up. The authors
attempted to establish links between
infections and common, easily defin-
able patient, surgeon and surgical
risks. Outcomes were assessed using
multivariate logistic regression analy-
sis and adjustment was therefore
Bone & Joint360 | volume 5 | issue 3 | june 2016
made for potential confounders.
The authors established that there
was an association between male
gender (OR 1.85), previous surgery
(OR 2.45), ligament reconstruction
(OR 1.85) and antibiotic cement (OR
1.93).
Analgesics in
osteoarthritis X-ref
Analgesics are the mainstay of
treatment for osteoarthritis, with
patients from all orthopaedic sub-
disciplines requiring analgesics as
part of their treatment regime. It was
with some interest then that we read
this paper from The Lancet by a meta-
analysis team based at the Univer-
sity of Bern (Switzerland). Using
the most up-to-date network meta-
analysis techniques they set out to
establish what, if anything, were
the differences between the various
analgesic regimes for osteoarthritis.6
The authors identified 74 randomised
trials of at least 100 patients, each
describing the outcomes of 58 556
patients, all reporting physical
function and pain
outcomes follow-
ing different anal-
gesic regimens
for osteoarthritis.
The random effects
models used allowed
for multiple comparisons,
and random effects were
applied at a trial level. The
interventions compared were
diclofenac 150 mg/day, etoricoxib
30 mg/day, 60 mg/day, and 90
mg/day, and rofecoxib 25 mg/day
and 50 mg/day, with comparison
groups of paracetamol or placebo.
Network meta-analysis allowed for
more complex node comparisons,
giving a more comprehensive result.
The authors identified 23 nodes that
were suitable to form part of the
network based on the seven different
drugs and dosage combinations.
The meta-analysis comprehen-
sively established that there was
no real role for paracetamol, with
no discernible improvement over
placebo in a comprehensive analysis.
However, there was more substantial
evidence for the use of NSAIDs, with
diclofenac 150 mg/day providing
the most robust analgesia of all the
agents studied.
Vitamin D ineffective in
the treatment of knee
osteoarthritis X-ref
There has been a trend to
recommend a range of vitamins
and nutritional supplementation
to reduce the burden of osteoar-
thritis, and particularly to improve
symptoms and long-term sequelae.
However, despite this widespread
adoption and often recommenda-
tion from the medical fraternity,
there is in practice little evidence to
support its use. Researchers from
Tasmania (Australia) recently
conducted their own randomised
controlled trial publishing evalua-
tions of the outcomes of vitamin D
as a treatment for knee osteoarthritis
in a study of over 400 patients.7
Participants were randomised to
either vitamin D supplementation
or a placebo for a two-year period,
and outcomes assessed with clinical
scores (WOMAC) and an MRI-derived
measure of tibial cartilage volume.
The follow-up was 82% complete
and the authors were therefore
able to report the outcomes of 340
patients at two years. There were no
differences in any of the reported
outcome measures and thus, given
the large size and careful methodol-
ogy, it can be fairly conclusively
surmised that vitamin D has no real
benefits in knee osteoarthritis.
Body mass in brief
In this big paper which recently
garnered press coverage and was
published in The Lancet, research-
ers in London (UK) reported on
the global trends in body mass in
200 countries across the world.8
While not an orthopaedic paper as
such, it is worth a mention in brief
with some obvious direct relevance
2016 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.53.360448
to orthopaedics. Amazingly, there
are now more obese people on the
planet than underweight people.
Clearly the demand for surgical
treatment of osteoarthritis is likely to
become more challenging in future.
References
1.McArthur BA, Abdel MP, Taunton MJ,
Osmon DR, Hanssen AD. Seronegative infec-
tions in hip and knee arthroplasty: periprosthetic
infections with normal erythrocyte sedimenta-
tion rate and C-reactive protein level. Bone Joint J
2015;97-B:939-944.
2. Rudin D, Manestar M, Ullrich O, Erhardt J,
Grob K. The anatomical course of the lateral femo-
ral cutaneous nerve with special attention to the
anterior approach to the hip joint. J Bone Joint Surg
[Am] 2016;98-A:561-567.
3. Maempel JF, Wickramasinghe NR,
Clement ND, Brenkel IJ, Walmsley PJ. The
pre-operative levels of haemoglobin in the blood
can be used to predict the risk of allogenic blood
transfusion after total knee arthroplasty. Bone Joint
J 2016;98-B:490-497.
4. Ogonda L, Hill J, Doran E, et al. Aspirin for
thromboprophylaxis after primary lower limb
arthroplasty: early thromboembolic events and
90 day mortality in 11 459 patients. Bone Joint J
2016;98-B:341-348.
5. Tayton ER, Frampton C, Hooper GJ, Young
SW. The impact of patient and surgical factors
on the rate of infection after primary total knee
arthroplasty: an analysis of 64 566 joints from the
New Zealand Joint Registry. Bone Joint J 2016;98-B:
334-340.
6. da Costa BR, Reichenbach S, Keller N, et al.
Effectiveness of non-steroidal anti-inflammatory
drugs for the treatment of pain in knee and hip osteo-
arthritis: a network meta-analysis. Lancet 2016; PMID:
26997557. [Epub ahead of print]
7. Jin X, Jones G, Cicuttini F, et al. Effect of vita-
min D supplementation on tibial cartilage volume
and knee pain among patients with symptomatic
knee osteoarthritis: a randomized clinical trial.
JAMA 2016;315:1005-1013.
8. Di Cesare M, Bentham J, Stevens GA,
et al. NCD Risk Factor Collaboration (NCD-
RisC). Trends in adult body-mass index in 200
countries from 1975 to 2014: a pooled analysis
of 1698 population-based measurement studies
with 192 million participants. Lancet 2016;387:
1377-1396.
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research-article2016
Cochrane Corner
Cochrane Corner
Correspondence should be sent to A. Das MRCS(Eng),
Trauma & Orthopaedics, Queens Medical Centre, Nottingham
University Hospitals, Derby Road, Nottingham NG7 2UH, UK.
E-mail: avidas17@doctors.org.uk
Anaesthesia for hip fracture surgery in adults
The hip fracture population, fraught with frailty and medical comorbidi-
ties, have a high risk of morbidity and mortality. There have been huge
improvements in the care pathway for these patients to improve out-
comes over the last decade, an important facet within which has been the
anaesthetic package. This updated review is an international collabora-
tion which specifically looks at regional anaesthesia alone versus general
anaesthesia alone for proximal femur fracture repair.1
The review included 31 trials (reporting the outcomes of 3231
patients). Meta analyses of suitable studies within this 31 did not find any
difference in mortality at one month (11 studies of 2152 participants), no
difference in risk of pneumonia (six studies of 761 participants), no differ-
ence in the risk of post-operative myocardial infarction (four studies of
559 participants), no difference in risk of stroke (six studies of 729 partici-
36
pants) and no difference in perioperative acute confusional state (six stud-
ies of 624 participants).
The review did find that when chemical thromboprophylaxis was not
used, the risk of deep vein thrombosis (DVT) was reduced with regional
anaesthesia but there was no difference in DVT risk if prophylaxis was
used.
While there are a large number of trials in this research area, the
authors state that the clinical practice across them is varied and that the
quality of evidence is low, raising uncertainty over the conclusions drawn
from this meta-analyses. There are likely to be situations when patients
have strong indications for a spinal anaesthetic or a general anaesthetic,
but for patients that can have both there seems no firm evidence either
way, and we can continue to base the choice on anaesthetist and patient
preference. It must be noted, however, that this review did not include
trials evaluating the intra- or peri-operative use of blocks alongside gen-
eral anaesthesia.
Rehabilitation following carpal tunnel release
The post-operative management of carpal tunnel decompression surgery
is rather heterogeneous, with varied surgeon preferences in dressings and
splints not to mention the myriad of multi-modal therapies. This updated
review from Australia looked at the trial data for some of these rehabili-
tation interventions.2
The authors found 22 trials comparing interventions against one
another or against a no treatment control or placebo. These studies
found no statistically significant differences between the various therapies
trialled. In short, there are apparent benefits of bulky dressings, splints,
Bone & Joint360 | volume 5 | issue 3 | june 2016
early mobilisation or combinations of hand therapy over any other post-
operative protocol. Perhaps less surprisingly there was limited evidence to
suggest any efficacy with desensitisation, the use of arnica, laser therapy
or electrical stimulation.
This low quality and limited evidence base leaves the surgeon
with only their experiences to inform the prescription of post-operative
management, from the huge array of rehabilitation interventions that
are available to the patient. In common with many complex
interventions, it appears the best evidence is perhaps still expert opin-
ion. What is clear from the assembled evidence, however, is that there
is little excuse for offering expensive and time-consuming therapies
post-operatively.
Aquatic exercise for the treatment of knee and hip
osteoarthritis
With the increasing expectations amongst patients as a whole, and par-
ticularly in the younger population, treatments that can alleviate symp-
toms and delay joint arthroplasty surgery are becoming more and more
important. This updated review from Denmark evaluated the effects of
aquatic exercise for people with hip and/or knee arthritis, compared with
no intervention.3
This review found 13 trials whose participants (n = 1190) were mostly
female, with a mean age of 68 and BMI of 29.4. These participants
received an average of 12 weeks of physical exercise intervention in water.
The authors found a moderate quality evidence that such exercise may
have small, short-term clinically relevant benefits on patient-reported
pain and disability outcome scores, with the caveat that the conclusions
were drawn from a very mixed population of participants with knee and
hip OA.
Given the lack of adverse effects, it seems not unreasonable to offer
hydrotherapy in patients in whom symptoms are difficult to manage in
any other way. This said, clearly this is not a long-term solution, and sur-
geons and patients can be forgiven for being sceptical given the data pre-
sented here.
Interventions for treating stable ankle fractures in
children
This new review from the UK identified found three trials (reporting the
outcomes of 189) evaluating non-surgical management options for the
low-risk fractures we see in children with obviously stable injury
configurations.4
 Two trials compared an air cast stirrup brace with a rigid cast (one trial
removing both at two weeks, the other removing the stirrup at five days
versus walking cast for three weeks). Low-quality evidence favoured the
stirrup group in both trials in function scores at four weeks, with the latter
trial quoting a mean difference of 6% in scores with 5% equating to a
clinically important difference. The authors also quote very low-quality
evidence from both trials suggesting a quicker return to pre-injury activity
in stirrup groups and moderate quality evidence suggesting no difference
in pain. Neither trial reported any unacceptable outcomes. Similar con-
clusions, though supported by only very low-quality evidence, were
drawn from the third trial comparing Tubigrip (Mlnlycke Health Care,
Oldham, UK) and crutches versus walking cast for two weeks.
Surgical versus conservative interventions for
treating anterior cruciate ligament (ACL) injuries
This new review from Oxford, UK looks at this common injury affecting
our young active population, with a view to evaluating whether ligament
reconstruction gives better overall outcomes than non-surgical
treatment.5
The authors found one suitable trial that treated adults (aged between
18 and 35) randomising treatment to either ACL reconstruction and struc-
tured rehabilitation, or structured rehabilitation alone.6 The study found
no difference between the two groups in patient-reported knee scores at
both two and five years. However, there were far fewer treatment failures
in the ACL reconstruction group (graft failure) than in the conservative
group (subsequent ACL reconstruction).5 A total of 51% of patients in the
2016
German Congress of Orthopaedics and Traumatology
conservatively-treated group elected to have ligament reconstruction at
five years for knee instability.5
We must be cautious in drawing conclusions from one study, and the
authors do suggest the overall quality of the evidence was low, with a
high-risk of bias.5 It is important to remember that knee instability can be
associated with meniscal tears, which in themselves carry a high risk of
long-term degenerative sequelae. With further good-quality studies, if the
results are reproduced; the high number of patients failing conservative
management by five years with ongoing instability perhaps advocates
ligament reconstruction in these symptomatic young adults. This is some-
what in contrast to those studies on older patients where the results are
very much equivocal in the older patient population.
References
1. Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults.
Cochrane Database Syst Rev 2016;2:CD000521.
2. Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel
release. Cochrane Database Syst Rev 2016;2:CD004158.
3. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoar-
thritis. Cochrane Database Syst Rev 2016:CD005523.
4. Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane
Database Syst Rev 2016;4:CD010836.
5. Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative inter-
ventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev 2016;4:CD011166.
6.Frobell RB, Roos HP, Roos EM, et al. Treatment for acute anterior cruciate ligament tear: five year
outcome of randomised trial. BMJ 2013;346(7895):f232.
2016 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.53.360445
37
Main Topics:
Joint preservation or joint replacement
Image-guided planning and surgery
Non-operative fracture treatment
Sports medicine in orthopaedics and traumatology
Chronic back pain multimodal therapy
Patient safety and management of complications
Prevention, non-operative treatment and rehabilitation
dkou.org/2016/international
BACK
TO THE
FUTURE
Berlin 25 28 October
tration
Early Bird Regis
16
until 15 August 20
Bone & Joint360 | volume 5 | issue 3 | june 2016
research-article2016

Medico-legal Feature
Peter H. Worlock DM, FRCS
Consultant Orthopaedic Trauma Surgeon, Royal Victoria Infirmary,
Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
Email: peter.worlock@nuth.nhs.uk

Consent: where are we in 2016?

In 2015, the Supreme Court gave their decision
on a case involving the issue of informed con-
sent for an obstetric procedure.1 That judge-
ment (referred to hereafter as Montgomery)
has implications for all doctors practising within
the United Kingdom.
Facts of the case
The claimant was a small, diabetic woman with
a large foetus. The risk of shoulder dystocia was
estimated to be between 9% and 10%, but the
mother was not informed of this because her
38
consultant considered the risk of a grave prob-
lem for the baby to be very small (in the
event of shoulder dystocia occurring, there was
a 0.2% chance of brachial plexus injury and a
0.1% chance of prolonged hypoxia). The option
of planned caesarean section (CS) was not dis-
cussed with the claimant, and induction was
planned for 39 weeks. During delivery, there
was occlusion of the umbilical cord resulting in
a hypoxic brain injury.
Subsequently, the mother claimed that she
should have been warned of the risk of shoulder
dystocia and the potentially catastrophic conse-
quences, and of the alternative of planned CS, in
which case she would have opted for CS. At both
the initial trial and on appeal, the defendants
experts stated that the risk of grave problems
was very small, but also that if such women
were warned, most would opt for CS. Both
courts concluded that to not warn the patient
was accepted as proper by a responsible body of
medical opinion.
The Supreme Court accepted that the con-
sultants decision accorded with a reasonable
body of opinion, but that patients have rights and
are not passive recipients of the care of the medi-
cal profession. A person is entitled to decide
which, if any, of the available forms of treatment
to undergo. The Supreme Court accepted that, if
appropriately warned, the claimant would not
have agreed to undergo the procedure of induc-
tion of labour and thus was entitled to damages.
The Montgomery decision
The judgement from the Supreme Court runs to
37 pages (a total of 117 paragraphs), and para-
graphs 74-93 (inclusive) are instructive reading
for all doctors. The two paragraphs below sum-
marise the key points in the judgement.
The doctor, therefore, has a duty to take rea-
sonable care to ensure that the patient is aware
of any material risks involved in the recom-
mended treatment, and of reasonable alterna-
tive treatments. The test of materiality is whether,
in the circumstances of the particular case, a rea-
sonable person in the patients position would
be likely to attach significance to the risk, or
whether the doctor is (or should be) aware that
the particular patient would be likely to attach
significance to it. The assessment of whether or
not a risk is material cannot be reduced to per-
centages. It is fact-sensitive in relation to indi-
vidual patients. The doctors duty is not fulfilled
by bombarding the patient with technical infor-
mation which they cannot reasonably be
expected to understand, let alone by routinely
demanding a signature on a consent form.
The doctor is, however, entitled to withhold
from the patient information regarding a risk if
he/she reasonably considers that its disclosure
would be seriously detrimental to the patients
health (the so-called therapeutic exception).
Nevertheless, this therapeutic exception is a lim-
ited exception to the principle that the patient
should make the decision on whether to
undergo treatment. The doctor is also excused
from conferring with a patient in circumstances
of necessity, as, for example, where a patient
requires treatment urgently but is unconscious
or otherwise unable to make a decision.
The issue of what should be discussed with
the patient is now a matter of law, not of profes-
sional practice. In pleading a case of lack of con-
sent, it is not a matter of expert medical opinion.
It is for the courts and the law to determine, not
doctors.
The professional position
The decision of the Supreme Court in this case
should not have come as a surprise to anyone. It
is in line with the dissenting judgement of Lord
Scarman in the Sidaway case of 1985,2 with the
case of Pearce v United Bristol Healthcare NHS
Trust in 19993 and with the case of Chester v
Afshar in 2005.4 While it may be thought unrea-
sonable for all doctors to be familiar with these
legal judgements, they should be aware of the
position of the General Medical Council (GMC)
and the Department of Health (DoH).
In 2008, the GMC issued their guidelines in a
booklet entitled Consent: patients and doctors
working together.5 This booklet has been circu-
lated to all doctors registered in the UK. It is
essential reading and very clearly states that
there are four steps in the basic model for
obtaining informed consent:
1. The doctor and patient make an assessment
of the patients condition, taking into
account the patients medical history, views,
experience and knowledge.
2. The doctor uses his/her specialist knowl-
edge/experience/clinical judgement to iden-
tify which investigations/treatments are
likely to benefit the patient.

Bone & Joint360 | volume 5 | issue 3 | june 2016

3. The doctor explains options to the patient,
setting out potential benefits, risks, burdens
and side effects of each option (including
the option of no treatment).
4. The patient weighs up the potential bene-
fits, risks and burdens of the various options.
The patient decides whether to accept any
of the options and, if so, which one.
The GMC further stated that the discussions
with patients should focus on their individual
situation and the risks to them. Doctors should
discuss and find out the patients individual
views about the adverse outcomes that most
concern them. Doctors must tell patients of any
serious adverse outcome (even if the risk is
small) and of any less serious side effects or
complications, if frequent.
With regard to the question of who should
obtain consent, the GMC states that this is the
responsibility of the doctor undertaking an
investigation or providing treatment. If this is
not practical, this doctor may delegate respon-
sibility providing they ensure that:
The person obtaining consent is suitably
trained and qualified.
The person obtaining consent has suffi-
cient knowledge of the proposed inves-
tigation or treatment and understands
the risks involved.
If responsibility for obtaining consent is dele-
gated, the treating doctor is still responsible for
ensuring that the patient has given informed
consent before any investigation or treatment is
undertaken.
The position of the GMC was reinforced by
the DoH in 2009.6 The DoH guidance also
emphasised that the discussion should focus on
the patients individual situation and the risks to
them. Doctors were told to inform the patient of
any material or significant risks or unavoida- consent could now be made on any case from
ble risks (even if small) in the proposed treat-
ment, any alternatives to the proposed treatment
and the risks incurred by doing nothing. The
DoH stated that doctors should provide balanced
information about procedures/risks and check
that patients had understood. A record of the
information given should be made in the notes.
With regard to the issue of who should obtain
consent, the DoH stated that the clinician provid-
ing the treatment or investigation is responsible
for ensuring that the patient has given valid con-
sent before treatment is administered, and that
the consultant overseeing the patients care is
ultimately responsible. Doctors were advised
that inappropriate delegation could mean that
the consent obtained was not valid.
The position of the GMC and DoH on
informed consent has therefore been quite clear
since 2008/09. Indeed, the GMC was so con-
cerned about the Montgomery case that it took
the unusual step of asking the Supreme Court if
it could intervene and present evidence to the
Court. This application was granted and the
GMC gave evidence on their professional posi-
tion. After the judgement, the GMC stated:
Todays judgement is very helpful and it
justifies our decision to intervene in this
case We are pleased that the Court has
endorsed the approach advocated in our
guidance on consent. Good Medical
Practice and Consent: patients and
doctors working together make it clear
that doctors should provide patient centred
care. They must work in partnership with
their patients, listening to their views and
giving them the information they want
and need to make their decisions.
While, in one sense, the Montgomery judgement
simply brings the law into line with the profes-
sional position of the regulator (the GMC) and
the ultimate employer of most doctors in the UK
(the DoH), all doctors need to be aware that the
situation has changed. Although there is no new
legislation, the Supreme Courts interpretation of
the existing law means that (as stated above) the
issue of what should be discussed with the patient
is no longer a matter of professional practice: it is
a matter of law. The judgement means that it will
be possible to look back and raise the issue of lack
of informed consent in cases preceding 2015.
Given the guidance issued by the GMC and DoH
in 2008/09, it seems reasonable to work on the
basis that claims pleading the lack of informed
until the patient recovers capacity.
2008/09 onwards. Perhaps the floodgates are
about to open?
It is interesting to note that the senior barris-
ter for the claimant in the Montgomery case
(James Badenoch QC) was surprised at the earlier
judgements and critical of the ferocity with
which the defendants resisted the claim. He
made the point, It can therefore be said with
certainty that the defendants legal advisers
were, by their approach to this case, personally
responsible for the ultimate reversal of the legal
principle on which they placed such misguided
reliance. Only they can explain how lawyers
experienced in medical law came to espouse and
assiduously to pursue arguments on the facts
and the law which were so devoid of merit.7
What should you do now?
All orthopaedic surgeons taking responsibility for
obtaining investigations and providing treatment
for patients need to think carefully about delegat-
ing responsibility for obtaining informed consent
to their trainees. If you do (and it is reasonable to
do so providing the above criteria have been
met), then you must be prepared to justify train-
ees ability to obtain informed consent and the
specific training they have had in obtaining con-
sent in general and for any specific procedure. If a
claim is advanced in respect of an alleged lack of
informed consent, the Court may reasonably ask
for written documentation that the individual
obtaining consent had the necessary skills and
expertise to do so. The basic model (as above)
from the GMC5 should be used as the template
for the process of obtaining informed consent.
You must have made a formal assessment of
the patients capacity to give informed consent.
Typically, there is lack of capacity for one of the
following reasons:
The patient is unable to comprehend
and retain information material to the
decision. 39
The patient is unable to use and weigh
up this information in the decision-
making process.
The patient is unconscious.
Lack of capacity may be permanent or tempo-
rary. You must record in the notes the details of
why you consider the patient to be lacking in the
capacity to consent and if it is likely to resolve. If
you consider any lack of capacity to be tempo-
rary, you should record fully in the notes why
the investigation or treatment cannot be delayed
As in most cases of alleged clinical negli-
gence, the quality of the medical notes is criti-
cal. You must expect sharp-eyed claimant
solicitors to be scrutinising the notes for written
evidence (or lack of written evidence) that you
have followed the GMC guidance. The author
suggests, therefore, that you:
Make full and comprehensive (legible)
notes on how you reached your diagno-
sis, on your decision-making process,
on your recommended management
plan and on the consent process.
Bone & Joint360 | volume 5 | issue 3 | june 2016
 Document the alternative treatments
(including no treatment) that have been
discussed with the patient (and the
risks/benefits of each).
Make it clear that adequate time was set
aside for a meaningful discussion with
the patient (including multiple meet-
ings if necessary).
Make it clear and document the steps
taken to ensure that the particular con-
cerns and wider circumstances of the
individual patient have been taken into
account.
Try to provide written documentation of
a genuine dialogue between you and
the patient.
Document the potential risks, complica-
tions and adverse outcomes of the
procedure(s) in the individual patient
(amplify, rather than just using
percentages).
Document the risks of possible distress-
ing, painful or dangerous intervening
events.
If exercising the therapeutic exception,
document fully your reasons for doing so.
Record if the patient appears to have
fully understood the advice you have
given them.
40
Where any investigation or treatment is
planned as an elective procedure, then it
should be possible to follow the GMC guide-
lines and document matters fully (although
NHS employers will have to recognise the addi-
tional time this will take in busy out-patient
clinics). The situation may well be different in
an emergency.
Bone & Joint360 | volume 5 | issue 3 | june 2016
The Supreme Court clearly recognised this, and
Montgomery states that you are excused from
conferring with the patient in circumstances of
necessity, as for example where the patient requires
treatment urgently but is unconscious or otherwise
unable to make a decision. You should, therefore
act in the patients best interests to save life and/or
prevent serious harm to their health (and in accord-
ance with any advance directive), and document
fully in the notes what this best interest is and why.
You should consult with colleagues (if time allows)
and discuss what you propose with the patients
family or next of kin (recognising that, except in
children, they cannot legally give consent).
All orthopaedic surgeons treating trauma
will be familiar with this situation in uncon-
scious patients and in elderly patients with
Alzheimers disease. However, the author has
long had concerns about the validity of a signa-
ture on a consent form in patients with severe
limb injuries (albeit conscious and with no sug-
gestion of permanent cognitive impairment). It
difficult to see how a patient in pain from, for
instance, a severe open tibial fracture, after
receiving considerable amounts of opiate anal-
gesia, can be said to give informed consent (as
laid down by the GMC in 2008). In such a situa-
tion, he is prepared to act in the patients best
interest (having followed the procedure out-
lined above), document the situation fully in the
notes and sign a NHS Consent Form 4.
Clearly, at the other end of the trauma spec-
trum are patients with (for instance) isolated wrist
and ankle fractures, who are being assessed in the
fracture clinic. In such a situation, it should be
possible to proceed with the process of obtaining
informed consent exactly as for a planned proce-
dure, using the basic model of the GMC.
2016 The British Editorial Society of Bone & Joint Surgery. DOI: 10.1302/2048-0105.53.360434
Conclusion
Although the law has not changed, the courts
interpretation of it has changed with the
Montgomery ruling; all practising doctors need
to be aware of this. As Sokol stated in the BMJ,8
The law now demands a standard of consent
broadly similar to that required by the profes-
sional guidance of the General Medical Council.
Doctors who follow that guidance will not fall
foul of the law.
References
1.No authors cited. Montgomery v Lanarkshire Health Board,
2015, UKSC 11. https://www.supremecourt.uk/decided-cases/
docs/UKSC_2013_0136_Judgment.pdf (date last accessed 7 April
2016).
2.No authors cited. Sidaway v Board of Governors of the Bethlem
Royal Hospital & Maudsley Hospital, 1985, AC 871. http://www.bailii.
org/uk/cases/UKHL/1985/1.html (date last accessed 7 April 2016).
3.No authors cited. Pearce v United Bristol Healthcare NHS Trust,
1999; PIQR:53. http://swarb.co.uk/pearce-and-pearce-v-united-bris-
tol-healthcare-nhs-trust-ca-20-may-1998/ (date last accessed 7April
2016).
4.No authors cited. Chester v Afshar, 2005, AC 134. http://swarb.
co.uk/chester-v-afshar-hl-14-oct-2004-2/ (date last accessed 7 April
2016).
5.No authors cited. Consent: patients and doctors making deci-
sions together. General Medical Council, 2008. http://www.gmc-uk.
org/guidance/ethical_guidance/consent_guidance_index.asp (date
last accessed 7 April 2016).
6.No authors cited. Reference guide to consent for examination
or treatment (2nd edition). Department of Health, 2009. https://www.
gov.uk/government/uploads/system/uploads/attachment_data/
file/138296/dh_103653__1_.pdf. (date last accessed 7 April 2016).
7. Badenoch J. A doctors duty of disclosure and the decline of The
Bolam Test: A dramatic change in the law on patient consent. Med Leg
J 2016;84:5-17.
8.Sokol DK. Update on the UK law on consent. BMJ 2015;350:h1481.
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13TH WEXHAM PARK INTERNATIONAL
CRUCIATE LIGAMENT MEETING
17TH & 18TH NOVEMBER 2016

The John Lister Postgraduate Centre,

Wexham Park Hospital,
Slough, SL2 4HL, UK

International Speakers
Charlie Brown: Abu Dhabi, UAE
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Course Convenors - Mr Henry Bourke
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A two-day conference with an international
faculty aimed at the practical knee surgeon.
An essential update of all current issues in
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Consultants:
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12 CPD Points Applied For