Clare Carpenter - Academia.edu (original) (raw)

Papers by Clare Carpenter

The Foundation Years, 2009

Acta orthopaedica Belgica, 2008

Acute urinary retention is a common complication after lower limb arthroplasty. The aim of our st... more Acute urinary retention is a common complication after lower limb arthroplasty. The aim of our study was to assess whether the International Prostate Symptom Score (IPSS) and other patient related factors could predict the likelihood of patients developing urinary retention after lower limb arthroplasty. We have also reviewed the literature on this subject. This is a prospective study of 102 male patients undergoing hip or knee arthroplasty. Data collected included age, IPSS, type of operation, type of anaesthesia and development of acute urinary retention in the immediate postoperative period. Thirty-one patients (30.4%) developed acute urinary retention. Of all the parameters studied, age was the only factor that correlated significantly with development of urinary retention. The risk factors for progression of benign prostatic hyperplasia could all be considered as factors for the development of this complication. However, apart from age more than 70 years, it is not practical to...

Journal of Children's Orthopaedics, 2021

Purpose Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the... more Purpose Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH. Methods An 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome. Results In total, 405 (522 hips) cases of DDH were identified, of which 213...

Oral presentations

Background Trainees told us they were not confident when they started their Foundation Year posts... more Background Trainees told us they were not confident when they started their Foundation Year posts within Trauma and Orthopaedics. They did not feel confident in their clinical judgements. Summary of work We developed a patient story simulation session as a part of their departmental induction to give a basic introduction to approaching trauma, teach the basic knowledge to deal with a variety of common Orthopaedic emergencies and improve trainees’ confidence with their own patient management. Simulations addressed relevant competencies for the Trauma and Orthopaedic trainees; clinical skills including cast application, the development of leadership skills with a trauma call simulation and the introduction to the theatre environment and etiquette. We focused on key skills that would translate into their existing Foundation year post. We asked them to self-report confidence levels on a Likert scale pre and post simulation. Summary of results Results were analysed in XLStat 2018, using the Wilcoxon signed-rank test for comparison of 2 non-parametric sets of data. 6 of the 8 SIM sessions ran throughout the afternoon demonstrated a significant improvement in the confidence of the trainees at handling that particular clinical scenario. (Managing trauma calls p=0.014, Open fracture management p=0.014, POP Cast application p=0.016, Use of orthopaedic drills, screwdrivers, plates and screws p=0.017, Reading and presenting radiographs p=0.014 and Preparing for theatre p=0.046) Discussion and conclusions We have demonstrated that the use of a simulation program within the Trauma and Orthopaedic induction results in an increase in confidence amongst the trainees. We are equipping the trainees with the day-to-day skills and confidence necessary to fulfil their role within the Trauma and Orthopaedic team. Improvements in confidence and knowledge have been shown to enable an improvement in patient safety and experience, however this is still being evaluated. We plan on rolling out the use of simulation in induction programs for other departments within Cardiff and Vale Health Boards. We also plan to use simulation sessions more widely to address trainees concerns and learning needs.

Pediatric Emergency Care

Background Isolated avulsion fractures of the greater and lesser trochanter are usually seen in a... more Background Isolated avulsion fractures of the greater and lesser trochanter are usually seen in adolescents prior to the fusion of the apophysis. Greater trochanter fractures in adults have a high incidence of intertrochanteric extension1, 2 and lesser trochanter fractures are regarded as a pathognomonic sign of metastatic disease. These fractures are very rare among children. Methods We report five cases of trochanteric fractures in children of less than two years of age three of which were unrecognized initially in the accident and emergency department. Results Early and complete recovery ensued following immobilization and symptomatic treatment. Surgical intervention was not required. Conclusions There needs to be a high index of suspicion to diagnose these fractures in children and plain radiographs need to be carefully examined when assessing a limping child. Our experience shows when correctly diagnosed these injuries can be treated successfully with supportive treatment and no need for surgical intervention. Level of Evidence IV Case series.

Paediatric Orthopaedics, 2016

Gait analysis provides detailed objective quantitative measurements with regards to locomotion. T... more Gait analysis provides detailed objective quantitative measurements with regards to locomotion. The process of gait analysis involves the evaluation of a combination of data. This includes the visual observation of gait, a standardized clinical examination and instrumented analysis. Biomechanical data including joint movements and forces can be quantified and define the segmental movements of the limbs. This allows an accurate quantification of the deviations away from normal gait parameters and using that data to understand deformity and pathology, plan surgical strategy and objectively measure outcomes subsequent to intervention. Whether gait analysis leads to significant improvement in structural abnormalities, gait, function, quality of life, and cost-effectiveness is still yet to be determined.

The British Journal of Radiology, 2016

10% of all hip fractures are occult on plain radiography, requiring further investigation to asce... more 10% of all hip fractures are occult on plain radiography, requiring further investigation to ascertain the diagnosis. MRI is presently the gold standard investigation, but frequently has disadvantages of time delay resulting in increased hospital stay and mortality. Our aim was to establish whether Multi Detector CT (MDCT) is an appropriate first line investigation of occult femoral neck fractures. From 2013 we elected to use MDCT as the first line investigation in patients believed to have an occult femoral neck fracture with negative plain films. These were reported by consultant musculoskeletal radiologists. We retrospectively analysed the data of consecutive patients presenting to University Hospital of Wales, over 30 months with a clinical suspicion of a hip fracture. 1443 patients were admitted during the study period. 209 (14.5%) had negative plain films requiring further investigation to exclude an occult femoral neck fracture, of which 199 had a CT. 93 patients had no fracture and 20 had isolated greater trochanter fractures. None of these patients progressed to develop an intracapsular femoral neck fracture at 4 month follow up, although one patient sustained an extracapsular fracture following a high energy fall whilst admitted. 26 femoral neck fractures were diagnosed on CT, whilst the remaining 60 patients were diagnosed with other pelvic ring fractures. When interpreted by experienced radiologists MDCT have both sensitivity and specificity of 100%. Advances in knowledge: We recommend the use of MDCT as a safe and appropriate first line investigation for occult femoral neck fractures.

Clinical Journal of Sport Medicine, Feb 1, 2008

... greater trochanter with a full range of pain-free movement and a normal gait pattern. ... The... more ... greater trochanter with a full range of pain-free movement and a normal gait pattern. ... The prognosis for apophysitis is generally good, with appropriate recognition and early treatment ... for injury in adolescent soccer: implementation and validation of an injury surveillance system. ...

Orthopedics, 2008

Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicro... more Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment.

Pediatric Emergency Care, 2011

Elbow injuries make up to 3% to 4% of all emergency department presentations and are often diffic... more Elbow injuries make up to 3% to 4% of all emergency department presentations and are often difficult to diagnose. These injuries are often missed on radiographs because of the large cartilaginous component of the pediatric elbow resulting in malunion. Fractures around the elbow joint are one of the leading causes of litigation claim, and awareness of the pitfalls in diagnosis of these subtle injuries is necessary for a prompt diagnosis. Fracture of the olecranon epiphysis is rare and often being described around puberty and in association with osteogenesis imperfecta. Management using K-wire tension band fixation has been described in the past, which can lead to growth arrest in younger patients.We hereby present a missed rare sleeve-type open olecranon epiphyseal fracture in a young child, highlighting the pitfalls in the diagnosis of these injuries. This article also reviews various options to manage such a rare fracture and also suggests an alternative method of transosseous suture fixation with an excellent result.

Journal of Orthopaedic Surgery and Research, 2013

Background: Osteoporosis is one of the commonest bone diseases in which bone fragility is increas... more Background: Osteoporosis is one of the commonest bone diseases in which bone fragility is increased. Over 300,000 patients present to hospitals in the UK with fragility fractures each year, with medical and social care costsmost of which relate to hip fracture care-at around £2 billion. The number of these fractures rises by 2% a year. The 30 days mortality is 10% and 30% at 1 year. The purpose of this study is to review the current practice according to NICE and BOA guidelines of secondary prevention of osteoporosis and to suggest changes to these guidelines. Methods: Patients over 50 years old admitted as inpatients to our facility with non-neck-of-femur (NOF) fragility fractures in March and September 2008 were studied. Retrospectively (March), looking for risk factors and if treated or not, then prospectively (September), after introducing the new trauma admission sheet. Also cross-sectional study was performed by comparing the services provided for NOF and non-NOF fragility fractures in September. Two-sample t test is used to compare between percentages. Results: Twenty-nine percent of fragility fractures are non-NOF fractures with a mean age of 70 years, while the remaining 71% are NOF fractures with a mean age of 80 years. There is a great difference in the care provided to these patients: non-NOF fragility fractures got less attention for assessment of osteoporosis (25%) and obtained less interest in investigations by medical staff (11%) and, finally, less intentions to treat osteoporosis (35%), compared to NOF fractures in which 35% of cases were assessed, 47% were investigated and 71% were treated for osteoporosis. Twenty-five percent of NOF fracture patients were found to have previous fragility fractures in the preceding years, while only 6% were on osteoporosis treatment before the fracture. Conclusion: Osteoporosis (a new epidemic) is the most common disease of the bone and its incidence is rising rapidly as the population ages. Though treatable, it is often left untreated. We believe that treating patients with non-NOF fragility fractures from osteoporosis before proceeding to NOF fractures would improve their quality of life and reduce the burden on hospital services and funding.

Internet J Orthop Surg, 2007

The authors' report the case of an eleven month old Sudanese girl, who presented to the Accident ... more The authors' report the case of an eleven month old Sudanese girl, who presented to the Accident and Emergency department with a femoral fracture. The fracture was apparently sustained following a minor, unsupervised fall. Subsequent radiographic imaging demonstrated changes which raised the concern of Non Accidental Injury. Only when a more detailed history was taken, and subsequent biochemical results became available was a diagnosis of nutritional rickets and scurvy made. Following appropriate orthopaedic management, and dietary supplementation, the child made a full recovery. We highlight the importance of underlying biochemical abnormalities as a differential diagnosis in fractures presenting as Non Accidental Injury (NAI).

International Orthopaedics, 2014

Legg-Calve-Perthes disease is a paediatric condition encompassing idiopathic osteonecrosis of the... more Legg-Calve-Perthes disease is a paediatric condition encompassing idiopathic osteonecrosis of the femoral head (ONFH). Preventing collapse and the need for subsequent joint replacement remains the major goal of clinical management. This exploratory study utilises a porcine model of surgically induced ONFH. rhBMP-2 with and without zoledronic acid (ZA) was delivered by intra-osseous injection in the phase-transitioning sucrose acetate isobutyrate (SAIB) in an attempt to prevent femoral head collapse. Epiphyseal quotient (EQ) at eight weeks post-surgery was the primary outcome measure. Heterotopic ossification in the joint capsule and bisphosphonate retention in the femoral head were key secondary outcomes. Femoral heads with ONFH and no treatment all collapsed (3/3, EQ < 0.4, P < 0.05 compared to no ONFH). Local delivery of rhBMP-2/SAIB into the femoral head prevented collapse by EQ measurement one of four samples; however, this specimen still showed evidence of significant collapse. In contrast, the combination of local rhBMP-2 and local ZA prevented collapse in two of four samples. Confocal fluorescence microscopy showed locally dosed bisphosphonate entered and was retained in the femoral head. This group also showed strong Calcein signal, indicating new bone formation. Treatment with rhBMP-2 was associated with a limited amount of heterotrophic ossification in the joint capsules in some specimens. Operators reported SAIB to be an efficient way to deliver rhBMP-2 to the femoral head. These data suggest that rhBMP-2 is ineffective for preventing femoral head collapse without the addition of bisphosphonate. Further research will be required to validate the clinical efficacy of a combined local rhBMP-2/bisphosphonate approach.

Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used ... more Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used in the UK in 2004. It corrects deformity by gradual distraction and manipulation. We report the outcomes of a two centre combined experience of the UMEX frame for the treatment of complex congenital foot deformities. Method: The frame was used in the management of 27 complex foot disorders, the majority of which were resistant club feet. All patients had at least 18 month follow up. Results: Good deformity correction was achieved in all cases, with a plantigrade foot immediately post-treatment. However, minor degrees of relapse have been noted when the strict postoperative regimen was not followed. Conclusions: The application of external fixators for the correction of foot deformities can be a complex procedure for the surgeon, and cumbersome for the patient. This frame is simple to apply and manage and allows multi-planar deformity correction in one stage. Our experience and patient outcome data suggest that this technique is a useful surgical option for the Paediatric Orthopaedic surgeon dealing with a relapsed club foot and other complex foot deformities.

The Foundation Years, 2009

Acta orthopaedica Belgica, 2008

Acute urinary retention is a common complication after lower limb arthroplasty. The aim of our st... more Acute urinary retention is a common complication after lower limb arthroplasty. The aim of our study was to assess whether the International Prostate Symptom Score (IPSS) and other patient related factors could predict the likelihood of patients developing urinary retention after lower limb arthroplasty. We have also reviewed the literature on this subject. This is a prospective study of 102 male patients undergoing hip or knee arthroplasty. Data collected included age, IPSS, type of operation, type of anaesthesia and development of acute urinary retention in the immediate postoperative period. Thirty-one patients (30.4%) developed acute urinary retention. Of all the parameters studied, age was the only factor that correlated significantly with development of urinary retention. The risk factors for progression of benign prostatic hyperplasia could all be considered as factors for the development of this complication. However, apart from age more than 70 years, it is not practical to...

Journal of Children's Orthopaedics, 2021

Purpose Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the... more Purpose Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH. Methods An 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome. Results In total, 405 (522 hips) cases of DDH were identified, of which 213...

Oral presentations

Background Trainees told us they were not confident when they started their Foundation Year posts... more Background Trainees told us they were not confident when they started their Foundation Year posts within Trauma and Orthopaedics. They did not feel confident in their clinical judgements. Summary of work We developed a patient story simulation session as a part of their departmental induction to give a basic introduction to approaching trauma, teach the basic knowledge to deal with a variety of common Orthopaedic emergencies and improve trainees’ confidence with their own patient management. Simulations addressed relevant competencies for the Trauma and Orthopaedic trainees; clinical skills including cast application, the development of leadership skills with a trauma call simulation and the introduction to the theatre environment and etiquette. We focused on key skills that would translate into their existing Foundation year post. We asked them to self-report confidence levels on a Likert scale pre and post simulation. Summary of results Results were analysed in XLStat 2018, using the Wilcoxon signed-rank test for comparison of 2 non-parametric sets of data. 6 of the 8 SIM sessions ran throughout the afternoon demonstrated a significant improvement in the confidence of the trainees at handling that particular clinical scenario. (Managing trauma calls p=0.014, Open fracture management p=0.014, POP Cast application p=0.016, Use of orthopaedic drills, screwdrivers, plates and screws p=0.017, Reading and presenting radiographs p=0.014 and Preparing for theatre p=0.046) Discussion and conclusions We have demonstrated that the use of a simulation program within the Trauma and Orthopaedic induction results in an increase in confidence amongst the trainees. We are equipping the trainees with the day-to-day skills and confidence necessary to fulfil their role within the Trauma and Orthopaedic team. Improvements in confidence and knowledge have been shown to enable an improvement in patient safety and experience, however this is still being evaluated. We plan on rolling out the use of simulation in induction programs for other departments within Cardiff and Vale Health Boards. We also plan to use simulation sessions more widely to address trainees concerns and learning needs.

Pediatric Emergency Care

Background Isolated avulsion fractures of the greater and lesser trochanter are usually seen in a... more Background Isolated avulsion fractures of the greater and lesser trochanter are usually seen in adolescents prior to the fusion of the apophysis. Greater trochanter fractures in adults have a high incidence of intertrochanteric extension1, 2 and lesser trochanter fractures are regarded as a pathognomonic sign of metastatic disease. These fractures are very rare among children. Methods We report five cases of trochanteric fractures in children of less than two years of age three of which were unrecognized initially in the accident and emergency department. Results Early and complete recovery ensued following immobilization and symptomatic treatment. Surgical intervention was not required. Conclusions There needs to be a high index of suspicion to diagnose these fractures in children and plain radiographs need to be carefully examined when assessing a limping child. Our experience shows when correctly diagnosed these injuries can be treated successfully with supportive treatment and no need for surgical intervention. Level of Evidence IV Case series.

Paediatric Orthopaedics, 2016

Gait analysis provides detailed objective quantitative measurements with regards to locomotion. T... more Gait analysis provides detailed objective quantitative measurements with regards to locomotion. The process of gait analysis involves the evaluation of a combination of data. This includes the visual observation of gait, a standardized clinical examination and instrumented analysis. Biomechanical data including joint movements and forces can be quantified and define the segmental movements of the limbs. This allows an accurate quantification of the deviations away from normal gait parameters and using that data to understand deformity and pathology, plan surgical strategy and objectively measure outcomes subsequent to intervention. Whether gait analysis leads to significant improvement in structural abnormalities, gait, function, quality of life, and cost-effectiveness is still yet to be determined.

The British Journal of Radiology, 2016

10% of all hip fractures are occult on plain radiography, requiring further investigation to asce... more 10% of all hip fractures are occult on plain radiography, requiring further investigation to ascertain the diagnosis. MRI is presently the gold standard investigation, but frequently has disadvantages of time delay resulting in increased hospital stay and mortality. Our aim was to establish whether Multi Detector CT (MDCT) is an appropriate first line investigation of occult femoral neck fractures. From 2013 we elected to use MDCT as the first line investigation in patients believed to have an occult femoral neck fracture with negative plain films. These were reported by consultant musculoskeletal radiologists. We retrospectively analysed the data of consecutive patients presenting to University Hospital of Wales, over 30 months with a clinical suspicion of a hip fracture. 1443 patients were admitted during the study period. 209 (14.5%) had negative plain films requiring further investigation to exclude an occult femoral neck fracture, of which 199 had a CT. 93 patients had no fracture and 20 had isolated greater trochanter fractures. None of these patients progressed to develop an intracapsular femoral neck fracture at 4 month follow up, although one patient sustained an extracapsular fracture following a high energy fall whilst admitted. 26 femoral neck fractures were diagnosed on CT, whilst the remaining 60 patients were diagnosed with other pelvic ring fractures. When interpreted by experienced radiologists MDCT have both sensitivity and specificity of 100%. Advances in knowledge: We recommend the use of MDCT as a safe and appropriate first line investigation for occult femoral neck fractures.

Clinical Journal of Sport Medicine, Feb 1, 2008

... greater trochanter with a full range of pain-free movement and a normal gait pattern. ... The... more ... greater trochanter with a full range of pain-free movement and a normal gait pattern. ... The prognosis for apophysitis is generally good, with appropriate recognition and early treatment ... for injury in adolescent soccer: implementation and validation of an injury surveillance system. ...

Orthopedics, 2008

Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicro... more Linezolid is the first in a new group of antibiotics called oxazolidinones. As a potent antimicrobial, it has activity against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, penicillin-resistant Streptococcus pneumoniae, and macrolide-resistant streptococci. There are several documented case reports of serotonin toxicity when used with selective serotonin reuptake inhibitors. The symptoms of serotonin syndrome are alteration of mental state, autonomic dysfunction, and neuromuscular disorders. This article presents a case of an interaction of the serotonin reuptake inhibitor venlafaxine and linezolid and the possible diagnostic problems that can occur. A 58-year-old woman presented with signs of systemic infection. Her medical history included bladder resection for transitional cell carcinoma, bilateral total hip arthroplasty (THA), and depression, for which she was on venlafaxine. Serological and imaging investigations revealed MRSA infection of the bilateral THA. The patient was started on vancomycin and rifampicin intravenously. As intravenous access was becoming problematic and long-term antibiotics were needed, treatment was changed to oral linezolid and oral rifampicin. Four days after the commencement of linezolid, the patient was acutely disorientated with generalized cerebellar signs and no autonomic dysfunction. A computed tomography scan of the head and lumbar puncture revealed no abnormal findings. A diagnosis of serotonin toxicity was made. The patient recovered when linezolid and venlafaxine were discontinued and supportive measures were provided. Linezolid is a popular choice of antibiotic, especially for the treatment of orthopedic-related MRSA infections. Patients who commonly require linezolid as an antimicrobial are those with complex infections where other antibiotic treatment has failed. It is therefore important to be vigilant with linezolid use. Physicians should be aware of the nonspecific presentation of serotonin symptoms and the treatment.

Pediatric Emergency Care, 2011

Elbow injuries make up to 3% to 4% of all emergency department presentations and are often diffic... more Elbow injuries make up to 3% to 4% of all emergency department presentations and are often difficult to diagnose. These injuries are often missed on radiographs because of the large cartilaginous component of the pediatric elbow resulting in malunion. Fractures around the elbow joint are one of the leading causes of litigation claim, and awareness of the pitfalls in diagnosis of these subtle injuries is necessary for a prompt diagnosis. Fracture of the olecranon epiphysis is rare and often being described around puberty and in association with osteogenesis imperfecta. Management using K-wire tension band fixation has been described in the past, which can lead to growth arrest in younger patients.We hereby present a missed rare sleeve-type open olecranon epiphyseal fracture in a young child, highlighting the pitfalls in the diagnosis of these injuries. This article also reviews various options to manage such a rare fracture and also suggests an alternative method of transosseous suture fixation with an excellent result.

Journal of Orthopaedic Surgery and Research, 2013

Background: Osteoporosis is one of the commonest bone diseases in which bone fragility is increas... more Background: Osteoporosis is one of the commonest bone diseases in which bone fragility is increased. Over 300,000 patients present to hospitals in the UK with fragility fractures each year, with medical and social care costsmost of which relate to hip fracture care-at around £2 billion. The number of these fractures rises by 2% a year. The 30 days mortality is 10% and 30% at 1 year. The purpose of this study is to review the current practice according to NICE and BOA guidelines of secondary prevention of osteoporosis and to suggest changes to these guidelines. Methods: Patients over 50 years old admitted as inpatients to our facility with non-neck-of-femur (NOF) fragility fractures in March and September 2008 were studied. Retrospectively (March), looking for risk factors and if treated or not, then prospectively (September), after introducing the new trauma admission sheet. Also cross-sectional study was performed by comparing the services provided for NOF and non-NOF fragility fractures in September. Two-sample t test is used to compare between percentages. Results: Twenty-nine percent of fragility fractures are non-NOF fractures with a mean age of 70 years, while the remaining 71% are NOF fractures with a mean age of 80 years. There is a great difference in the care provided to these patients: non-NOF fragility fractures got less attention for assessment of osteoporosis (25%) and obtained less interest in investigations by medical staff (11%) and, finally, less intentions to treat osteoporosis (35%), compared to NOF fractures in which 35% of cases were assessed, 47% were investigated and 71% were treated for osteoporosis. Twenty-five percent of NOF fracture patients were found to have previous fragility fractures in the preceding years, while only 6% were on osteoporosis treatment before the fracture. Conclusion: Osteoporosis (a new epidemic) is the most common disease of the bone and its incidence is rising rapidly as the population ages. Though treatable, it is often left untreated. We believe that treating patients with non-NOF fragility fractures from osteoporosis before proceeding to NOF fractures would improve their quality of life and reduce the burden on hospital services and funding.

Internet J Orthop Surg, 2007

The authors' report the case of an eleven month old Sudanese girl, who presented to the Accident ... more The authors' report the case of an eleven month old Sudanese girl, who presented to the Accident and Emergency department with a femoral fracture. The fracture was apparently sustained following a minor, unsupervised fall. Subsequent radiographic imaging demonstrated changes which raised the concern of Non Accidental Injury. Only when a more detailed history was taken, and subsequent biochemical results became available was a diagnosis of nutritional rickets and scurvy made. Following appropriate orthopaedic management, and dietary supplementation, the child made a full recovery. We highlight the importance of underlying biochemical abnormalities as a differential diagnosis in fractures presenting as Non Accidental Injury (NAI).

International Orthopaedics, 2014

Legg-Calve-Perthes disease is a paediatric condition encompassing idiopathic osteonecrosis of the... more Legg-Calve-Perthes disease is a paediatric condition encompassing idiopathic osteonecrosis of the femoral head (ONFH). Preventing collapse and the need for subsequent joint replacement remains the major goal of clinical management. This exploratory study utilises a porcine model of surgically induced ONFH. rhBMP-2 with and without zoledronic acid (ZA) was delivered by intra-osseous injection in the phase-transitioning sucrose acetate isobutyrate (SAIB) in an attempt to prevent femoral head collapse. Epiphyseal quotient (EQ) at eight weeks post-surgery was the primary outcome measure. Heterotopic ossification in the joint capsule and bisphosphonate retention in the femoral head were key secondary outcomes. Femoral heads with ONFH and no treatment all collapsed (3/3, EQ < 0.4, P < 0.05 compared to no ONFH). Local delivery of rhBMP-2/SAIB into the femoral head prevented collapse by EQ measurement one of four samples; however, this specimen still showed evidence of significant collapse. In contrast, the combination of local rhBMP-2 and local ZA prevented collapse in two of four samples. Confocal fluorescence microscopy showed locally dosed bisphosphonate entered and was retained in the femoral head. This group also showed strong Calcein signal, indicating new bone formation. Treatment with rhBMP-2 was associated with a limited amount of heterotrophic ossification in the joint capsules in some specimens. Operators reported SAIB to be an efficient way to deliver rhBMP-2 to the femoral head. These data suggest that rhBMP-2 is ineffective for preventing femoral head collapse without the addition of bisphosphonate. Further research will be required to validate the clinical efficacy of a combined local rhBMP-2/bisphosphonate approach.

Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used ... more Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used in the UK in 2004. It corrects deformity by gradual distraction and manipulation. We report the outcomes of a two centre combined experience of the UMEX frame for the treatment of complex congenital foot deformities. Method: The frame was used in the management of 27 complex foot disorders, the majority of which were resistant club feet. All patients had at least 18 month follow up. Results: Good deformity correction was achieved in all cases, with a plantigrade foot immediately post-treatment. However, minor degrees of relapse have been noted when the strict postoperative regimen was not followed. Conclusions: The application of external fixators for the correction of foot deformities can be a complex procedure for the surgeon, and cumbersome for the patient. This frame is simple to apply and manage and allows multi-planar deformity correction in one stage. Our experience and patient outcome data suggest that this technique is a useful surgical option for the Paediatric Orthopaedic surgeon dealing with a relapsed club foot and other complex foot deformities.