Ysbyty Gwynedd Hospital NHS Trust

Medial unicompartmental knee replacement (UKR) is a joint-preserving alternative to total knee arthroplasty for patients with isolated medial compartment osteoarthritis. Historically, anterior cruciate ligament (ACL) deficiency has been considered a contraindication to UKR due to concerns over implant failure and instability. However, synchronous ACL reconstruction with UKR has emerged as a potential solution, aiming to restore joint stability while preserving native biomechanics. This review evaluates whether outcomes differ between synchronous ACL reconstruction with UKR and conventional UKR in ACL-intact knees.A systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Sixteen studies were included, comprising 1842 knees, 312 in the intervention group, and 1530 in the comparator group. Eligible studies reported outcomes such as Oxford Knee Score (OKS), Knee Society Score (KSS), implant survival, revision rates, and complications. Meta-analysis was performed using a random-effects model to account for heterogeneity.Both groups demonstrated substantial improvements in patient-reported outcome measures (PROMs), with OKS, Knee injury and Osteoarthritis Outcome Score (KOOS), and KSS scores indicating high postoperative satisfaction. Implant survivorship ranged from 87.5% to 100% in the intervention group and 92-95% in the comparator group. A statistically significant mean OKS difference of 1.6 points favoured the intervention group (p=0.0251), though this fell below the minimal clinically important difference threshold, suggesting functional equivalence.Synchronous ACL reconstruction with UKR offers comparable outcomes to conventional UKR in ACL-intact knees. This approach may be particularly beneficial for younger, active patients with ACL deficiency. Further prospective studies are needed to validate long-term efficacy and refine patient selection.

Abstract Aim Musculoskeletal injuries account for a significant proportion of emergency department (ED) attendances. Some patients will have fractures that require surgical intervention, though may not require immediate admission and await surgery from home. This audit evaluates the initial timeframe of presentation for patients with ambulatory trauma to the ED. Method A retrospective study reviewed patients who presented to ED with ambulatory trauma over a 3-month timeframe. Modalities analysed included triage category allocation, type of clinician seeing, referral to orthopaedics and total time in ED. Results 71 patients had fractures requiring surgical fixation but were discharged awaiting surgery. Most patients self-presented (n = 67) and were seen by an Emergency Nurse Practitioner (ENP) (n = 56). The triage category was insignificant in determining the time to see a clinician (p = 0.042), though did have a correlation with total time spent in department, with the triage category 2 group spending a mean of 6.97 hours in the department, compared to triage category 4 spending an average of 3.87 hours. There was also correlation between the total time in department with the type of clinician seeing the patient. Conclusions Allocating patients to lower triage categories and for review by ENPs could reduce total time in department for patients with ambulatory trauma. Having a member of the orthopaedic team dedicated to ED may also reduce time in the department.

IntroductionGastric outlet obstruction is commonly associated with malignancies and benign conditions such as peptic ulcer disease and Crohn’s disease. This report presents an uncommon instance of gastric endometriosis leading to gastric outlet obstruction, a condition that should be considered in the differential diagnosis.Case descriptionA 37-year-old female presented with persistent postprandial vomiting occurring approximately 30 minutes after meals, along with significant weight loss of 25.4 kg over 2.5 months. Her medical history included a subtotal colectomy with ileo-distal sigmoid anastomosis for slow transit constipation and a total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometriosis. Clinical examination revealed abdominal tenderness and a vague epigastric mass. An abdominal CT scan identified a 5 cm mass arising from the pylorus and duodenal wall, with associated pathological lymph node enhancement. Despite multiple endoscopic biopsies, histological results were non-diagnostic due to the submucosal nature of the lesion; technical limitations prevented the capture of endoscopy images. Due to the severity of symptoms and a strong clinical suspicion of a gastrointestinal stromal tumour (GIST), the patient underwent a Whipple’s resection. Histopathological analysis of the resected specimen unexpectedly confirmed gastric endometriosis.ConclusionThis case highlights the need to consider endometriosis in the differential diagnosis of gastric outlet obstruction, particularly in women with a history of endometriosis or prior gynaecological surgeries. The discrepancy between imaging findings and negative biopsy results underscores the limitations of standard endoscopic biopsy in diagnosing submucosal lesions. Endoscopic ultrasound-guided biopsy or laparoscopic biopsy should be considered when standard biopsies are non-diagnostic. Early recognition of this rare condition can prevent delays in treatment and improve patient outcomes.LEARNING POINTSEndometriosis can cause gastric obstruction and should be considered in the differential diagnosis, especially in women with a history of endometriosis.Endoscopic biopsy may miss the diagnosis due to the submucosal nature of gastric endometriosis.Endoscopic ultrasound-guided fine-needle aspiration or laparoscopic biopsy should be considered before proceeding with major surgery.A trial of medical therapy, such as hormonal suppression, may be an option in some cases before considering surgical intervention.

Intramedullary interlocking nailingis a common surgical procedure for tibial fractures, enabling early patient mobilization. Traditionally, the infrapatellar approach has been used for intramedullary interlocking nailing of tibial fractures, but the suprapatellar approach is gaining attention for its potential benefits. This randomized controlled study aimed to compare the duration of the surgery, intra-operative blood loss, and fluoroscopy time between the suprapatellar and infrapatellar approaches. We included 38 adult patients with tibial shaft fractures, excluding those with non-union, open fractures, revision surgery, or low Glasgow Coma Scale (GCS). Patients were divided equally into two groups using block randomization: Group A (19 patients) underwent the infrapatellar approach, and Group B (19 patients) underwent the suprapatellar approach. Blood loss was measured using the gravimetric method and by changes in pre-operative and post-operative hemoglobin levels. Surgical duration by calculating the time elapsed between the start and end of the procedure and fluoroscopy time was logged from the fluoroscopy machine. In group A, blood loss averaged 154±30.98 mL, slightly more than in group B (150±32.92 mL), though the difference was not statistically significant (p>0.05). Group A also showed a higher difference in hemoglobin levels (2.20±1.13 g/dL) compared to group B (1.15±0.93 g/dL), which was statistically significant (p=0.02). Fluoroscopy time and duration of the surgery were slightly longer in group A compared to group B but not statistically significant (p=0.693). The suprapatellar approach results in less blood loss, potentially promoting faster recovery, reduced need for blood transfusions, and shorter hospital stays. It also entails shorter fluoroscopy time and surgical duration, though not statistically significant, which may reduce radiation exposure for the surgical team.

Proximal humerus fractures are prevalent in older adults, particularly women, primarily due to osteoporosis and increased fall risk. These fractures often result from low-energy falls in elderly patients, while in younger individuals, they are more likely to occur with high-energy trauma, which may involve additional injuries to soft tissue and neurovascular structures. Proper anatomical understanding, including key structures and blood supply, is crucial for effective management and to prevent complications.Several classification systems assist in guiding treatment for proximal humerus fractures, including Codman's, Neer's, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) system, and the Codman-Hertel system, whichhelps predict ischemia risk. Evaluation of proximal humerus fractures begins with Advanced Trauma Life Support (ATLS)protocols, emphasizing a thorough shoulder assessment, particularly focusing on skin integrity in elderly patients. Neurological and vascular examinations are essential due to the common occurrence of nerve injuries, especially involving the axillary nerve. Imaging typically includes multiple standard views, with advanced imaging reserved for complex cases and for assessing associated soft tissue injuries. Treatment options range from conservative management for stable fractures to surgical intervention for more complex cases. Surgical choices include techniques like fixation, nailing, and various arthroplasty options, with some procedures potentially offering advantages for older adults with bone quality or soft tissue challenges. Rehabilitation is a vital component of recovery, with emphasis on early mobility and gradual strengthening to restore function, especially in older patients. Complications following open reduction and internal fixation (ORIF) for proximal humerus fractures can include issues such as non-union, malunion, osteonecrosis, infection, joint stiffness, and fixation failure. In cases where non-union or fixation failure occurs, revision surgery or arthroplasty may be necessary. Joint stiffness may require further intervention if physical therapy is insufficient, while symptomatic osteonecrosis might also need surgical management. Malunion is generally better tolerated in older patients but may require correction in younger individuals. Other surgical options, such as hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA), share similar risks, including infection, fractures, complications at the tuberosity, stiffness, and instability. RSA may be favored when there are tuberosity or rotator cuff issues. Closed reduction with percutaneous pinning carries a high risk of pin migration and malunion, which can result in deformities, pain, and dysfunction. Proper anatomical knowledge is essential to avoid neurovascular injury and to manage common issues such as pin-site infections effectively.

Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective.A Quality Improvement Project was done. The goals to achieve at end of a year were:Daily Trauma Handover in standardised format >90%Ward Handover in standardised format >90%Availability of outcomes of patients in clinic >80%Reduction of paper usage >90% at the end of six monthsAvailability of updated “outliers” information >90% at the weekend ward roundDocumentation from the Trauma Meeting > 90%On-Call documentation in standardised format >90%Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction.We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds.We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use.

Abnormal patella height has been found to be one of the main reasons for abnormal contact between patella and trochlear groove leading to patellar instability in children. Many methods have been described to diagnose patellar instability but most of them are justified only in adults. The reason being incomplete ossification in the paediatric population. These methods have been divided into direct and indirect methods. We analysed the MRI scan of knee of 57 children between 12–14 years of age with no previous diagnosis of patellar instability. Patients with a diagnosis of patellar instability, previous surgery on the knee or trauma and poor MRI scan were excluded from the study. We used Insall -Salvati Index (ISI), Caton-Deschamp Index (CDI) and Patella-Trochlear Index (PTI) and compared the results. We found that 40% of measurements by CDI and 41% by ISI showed patella alta in patients with normal patella height. 10% of patients in PTI readings had value suggestive of abnormal patella height.We concluded that PTI is a more reliable index to be used in children as it uses the length of articular surface and does not rely on bony landmarks. Studies done show PTI is a more reliable and accurate method of measuring patella height.