Introduction: COVID-19 has had a significant impact on healthcare. It has forced orthopaedic surgeons to limit face-to-face patient contact. This resulted in the ad hoc creation of a virtual arthroplasty clinic (VAC) in Irish National Orthopaedic Hospital. We aimed to assess this new VAC and ascertain its effectiveness as an alternative to physical appointments during and following the pandemic. Materials and methods: Patients were followed-up in this VAC six weeks post-operatively. A service evaluation of this virtual arthroplasty clinic was carried out using a questionnaire created by the orthopaedic department. Results: A total of 30 patients requiring 6-week follow-up after the arrival of COVID-19 in Ireland were included. Average pre- and post-operative visual analogue scale score (VAS) was 8.1 and 2.3, respectively. Average pre- and postoperative Oxford hip and knee score was 19.1 and 39.2, respectively. Twenty-one patients (70%) were happy to have their six weeks post-operative e-outpatient consultation virtually. Twenty-six patients (86%) were happy with future virtual follow-up. Twenty-eight patients (93%) would be happy experiencing the whole process again. Eleven patients would be interested in having future joint replacement surgery, though ten of them (91%) stated COVID-19 would impact that decision. Conclusion: Most patients were happy to have their six-week appointment and future appointments virtually. Functional outcome scores had improved and pain scores had reduced at six-week follow-up, supporting the idea that virtual clinics are not inferior to physical clinics. Patients expressed concern about having a further joint replacement in the context of COVID-19.

Information graphics, abbreviated to infographics, convey information using visualisations and images. This format of presenting research has been shown to be preferred by 80% of clinicians when compared to text articles. The weekly Journal Club was audited within our institution over a period of 10 weeks. Five weeks of article presentations using plain text abstract displays preceded 5 weeks of infographic display. A multiple-choice questionnaire was constructed weekly so as to test the attendees' recall and comprehension. A total of 1036 multiple-choice questions were answered across the 10 weeks, which included 553 questions (53.4%) based on the standard Journal Club format, and 483 questions (46.6%) on infographic displays. The use of infographics saw significantly improved test results from 42% to 65.8% (p < 0.001). Questions were answered correctly 1.5 times more often following infographic introduction. Infographics were preferred over plain text abstracts by 78% of team members. Infographics enhanced the audience's comprehension and recall of orthopaedic research when used as a presentation tool at the Journal Club. The majority of clinicians preferred infographic displays to plain text abstracts. Research was perceived as being more engaging, and thus more suitable for dissemination, such that key messages could be shared with surgeons, researchers and patients worldwide. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Background: Periprosthetic fractures about the hip are increasingly common. The literature estimates a failure rate of approximately 10% in Vancouver B1 type fractures which have undergone fixation. There is currently no guidance available on the next step of management for this patient group. This study presents a series of nine Vancouver B1 fractures with failed osteosynthesis and proposes that repeated fixation has poorer results than revision. Methods: A total of nine patients (five women, four men) with a mean age of 71.2 years (52-83) underwent operative treatment for failed osteosynthesis of periprosthetic fractures of Vancouver type Bl. Three patients were revised to a long revision stem while six patients had repeated osteosythesis. Failure was defined as the need for further operative intervention. Results: The three patients revised to a long revision stem at first failure of osteosynthesis required no further surgical intervention. All six patients who had repeat osteoynthesis failed again. Five patients were subsequently successfully treated with revision of the primary stem, three were revised to a long revision stem while two patients required proximal femoral replacement. One patient died prior to revision. The mean follow up following initial B1 fracture was 49.3 months and following definitive operative intervention was 37.7 months. Six patients had died at 1st July 2017. Conclusion: Failed osteosynthesis of B1 fractures may necessitate revision rather than repeat fixation, regardless of how well fixed the stem appears. Revision to a long stem provided good results in this cohort. (C) 2018 Elsevier Ltd. All rights reserved.

Introduction Traditionally orthopaedic injections were performed in a theatre setting. A dedicated outpatient injection clinic was established at our institution to attempt to provide injections more cost effectively. Our aim was to perform a cost analysis of orthopaedic injections performed in theatre, compared to those performed in a dedicated OPD injection clinic. Methods Patient data for all orthopaedic injections performed at a single institution from 2013 to 2014 was obtained using HIPE data. A detailed breakdown of costings for two scenarios; those performed in theatre and those in the dedicated OPD injection clinic was obtained from the hospital finance department. A unit cost per injection for theatre and OPD was derived from this financial information. Results A total of 487 injections were performed in 2013, with 491 performed in 2014. 134 (27.5%) injections were performed in the OPD in 2013 compared to 388 (79%) in 2014. The unit cost per injection was calculated as €52.13 for theatre and €23.85 for OPD, this represented a 115% decrease in cost per injection. Conclusion The creation of a dedicated orthopaedic injection clinic resulted in considerable cost savings at our institution. We propose this may be a more cost-efficient model for delivery of injections in the orthopaedic setting.

The purpose of this study was to report both the radiographic and functional outcomes of patients undergoing knee arthrodesis with the Wichita Fusion Nail (WFN) within the Republic of Ireland and compare the results to existing literature. Patient charts and radiographs were reviewed on all patients who had a WFN implanted in Ireland to date. Patients were invited to complete a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score as a functional assessment. Twenty-three patients were identified. Patients had an average of 8 (range: 0-26) knee surgeries prior to arthrodesis. The most common indication was failed arthroplasty due to recalcitrant infection (69.5%). Successful fusion occurred in 60.8% of patients. The mean time to fusion was 9.21 months. The mean WOMAC score was 58.55 with a range of 31 to 96. We found a rate of arthrodesis lower than that reported in other published series. However, the rate of major complications was comparable to those published previously, reflecting the often-challenging patient cohort. Our study shows that the WFN should not be viewed as a near-universally successful option to salvage an unreconstructable knee.

Introduction: Little research has examined postrehabilitation functional outcomes of periprosthetic hip fractures. Predicted functional deficits and acceptable rehabilitation outcomes for these patients are not established. This study aimed to compare functional outcomes of periprosthetic fractures to matched patients with total hip arthroplasty (THA). Materials and Methods: Cases with periprosthetic fracture (PPF) were matched for age, gender, and surgeon to primary THA cases. Only patients who had completed at least 1 year of rehabilitation were included. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were calculated for all surviving cases with PPF and primary THA. Secondary outcomes included length of stay and mortality. Statistical analysis was performed using Microsoft Excel and the 2-tailed Wilcoxon signed rank test. A P value of <.05 was accepted as indicative of statistical significance. Results: We identified 25 patients with PPF. Three patients were unsuitable for functional assessment. Of the cases with PPF suitable for functional assessment, 14 (14/22) were male. The median age of the PPF and the THA groups was 71 years and 68 years respectively. The median WOMAC score for the PPF group was 26 (interquartile range [IQR] 5.5-49.5) compared to that of the primary THA group, 3 (IQR 2.0-24.5; P < .05). In the PPF group, there were 7 deaths and 3 of the surviving patients had significant complications. The median length of stay in the PPF group was 13 days (IQR 10.5-35) compared to the matched group of 5 days (IQR 5-8.5; P < .05). Conclusion: Patients with PPF have markedly poorer functional outcomes than age-, gender-, and surgeon-matched patients with THA as well as prolonged length of stay. Future research should target the identification of factors that may improve functional outcomes in this growing cohort.

BACKGROUND:Presentation of scientific research at national and international meetings is an important forum for the dissemination of knowledge. Subsequent publication of a full-text paper in a peer-reviewed journal is the expected outcome of such presentations. The publication rate from these meetings is highly variable.AIMS:To determine the publication rate of abstracts presented at the Irish Orthopaedic Association's Annual Conference and to determine which factors are associated with progression to full-text publication.METHODS:We reviewed the proceedings from the Irish Orthopaedic Association's National Meeting over a 4 year period. We searched the Pubmed database using author names, institution names, and keywords from each abstract's title, to determine how many presented articles progressed to full-text publication.RESULTS:Sixty-six of 203 were published, 97 % within 5 years of presentation. Laboratory based studies presenting novel or innovative findings were more likely to be published than clinical studies. Clinical studies were more likely to be published if they were prospective and had a longer period of follow-up. Retrospective audits were less likely to be published, even with a large cohort size. Changes in authorship of presented papers were related to a longer delay in time to full-text publication.CONCLUSIONS:Thorough planning of research studies is essential to ensure a timely progression to full-text publication in a peer-reviewed journal. Most studies will be published within 5 years of initial presentation.

BACKGROUND:Ireland is currently in the process of establishing a National Joint Registry.AIM:We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland.METHODS:The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland.RESULTS:We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used.CONCLUSIONS:The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.

Ireland is unfamiliar with extreme weather conditions. Such conditions occurred in winter 2009–2010 and 2010–2011, with much of the country being affected by snow and ice. We reviewed the effect that these conditions had on the treatment of ankle fractures in our trauma unit.

BACKGROUND:Orthopaedic higher surgical trainees in Ireland are allocated to one of eight training rotations. Each trainee is expected to publish at least one research paper per year during training.AIM:To assess the research productivity of each training rotation over a 10-year period.METHODS:A PubMed search was performed for each orthopaedic unit affiliated to higher surgical training (HST) in order to identify full-text research papers published between 2001 and 2010. The results were analysed to determine which training rotations are most productive in terms of research.RESULTS:We identified 267 papers published from 16 units over the 10-year period. There were substantial differences in the number of papers published from each unit, and substantial differences between the eight set trainee rotations.CONCLUSIONS:It is essential that each trainee makes an honest assessment of their potential for conducting and producing valuable and relevant research, and chooses an HST rotation that is appropriate to their needs. Publication of research articles is easier to achieve on some HST rotations than on others.

Skin puckering is a sign that is well associated with certain fractures such as supracondylar humeral fractures in children. To our knowledge, there has been only one clinical report of skin puckering associated with fractured neck of humerus of an adult. This is a second such case of fractured proximal humerus in an adult presenting with skin puckering and the first from the Republic of Ireland. Skin puckering is suggestive of soft tissue interposition and may be an important clinical sign indicating the need for internal fixation.

Introduction: Fasting overnight NPO (Nulla per os) has been routine before surgery for the past century. The practice was previously designed to reduce the risk of pulmonary aspiration on induction. However this practice has been challenged over the recent years and is changing anaesthetic practices are now more liberal. There are many new concepts aimed at improving patient outcome by regulating metabolic, endocrine, inflammatory and immune responses. This combined with better patient satisfaction and lower anxiety has led to research in this area. Overnight fasting can induce post operative insulin resistance. Insulin resistance is related to infectious morbidity and increased hospital length of stay (HLOS). Previously this concept was only important in diabetic patients. Surgery places the body under metabolic stress and even a short period of fasting will change the metabolic state of the patient. Indeed physical trauma can cause a triad known as the “diabetes of injury”: insulin resistance, hyperglycaemia and glucose intolerance. Preparation for surgery by maintaining a fasted state and catabolic metabolism may have deleterious consequences for the patient. Previous studies on elective patients has shown that pre operative carbohydrate loading can reduce insulin resistance and mitigate the inflammatory response by immunomodulation. It has not previously been shown to have an effect in the hip fracture population. This particular group of patients are often elderly and require medical and anaesthetic work up. This delay can mean that the patient is kept fasting for prolonged periods and often overnight. Methods: With full ethical approval at Connolly Hospital we prospectively randomised all femoral and hip fractures for surgery. We excluded diabetics and pregnant women from the study. A high carbohydrate drink called Nutritia Pre Op was selected. Random serum glucose was taken on admission. Patients were randomised and selected for the trial by hidden ballot. Anaesthetic approval was sought for each case. We compared our standard treatment for hip and femoral fractures of strict NPO prior to surgery versus giving patients the Pre Op drink. Each carton was 200ml and up to 4 were given the night before surgery. In the morning the patients were given another 2 drinks. There was a strict minimum 2 hour NPO period before leaving the ward. Glucose levels were then taken at 1 and 12 hours post operatively to assess whether hyperglycaemia was present. As per laboratory values a normoglycaemia was considered as 4–6mmol/l. Gender, age, type of operation, HLOS, complications and re-admissions were noted. Results: In total 17 patients were enrolled in the study. Group A had 9 patients and were kept NPO as the control group. Group B had 8 patients enlisted in the Pre Op Drink group. In group A, 6 of 9 (67%) patients had a post operative hyperglycaemia. Average age in group A was 79.6 years with an average HLOS of 15.8 days. 4 patients between them required 8 readmissions over a 3 month post operative period. Group B showed 2 out of 8 (25%) patients had a hyperglycaemia. They had an average age of 69 years with an average HLOS of 11.75 days. 4 patients required 4 readmissions. Conclusions: Pre Op high carbohydrate drinks significantly decrease post operative hyperglycaemia as per the laboratory ranges. This in turn supports that it decrease insulin resistance by preparing the body for surgery in a fed state. In the same way that one would not prepare for a marathon by fasting 24 hours before hand so the body recognizes that the surgical stress is not best dealt with when in a fasted state. The control group had twice as many readmissions and a longer HLOS. Previous studies show that there is decreased anxiety, thirst and hunger both pre and post operatively. We have shown that this is a safe drink to give and that post operative hyperglycaemia was better controlled.

Six patients with a clinical diagnosis of chronic posterior cruciate ligament (PCL) rupture, based on a positive posterior drawer test, had a normal appearance of the PCL on an MRI scan. It is postulated that the PCL had been ruptured but healed in a lengthened state. 12 volunteers with no history of knee trauma underwent an MRI scan of the knee. In this control group (n = 12), there was a close correlation between the lateral femoral condylar width in the sagittal plane and the PCL length, with a ratio of 2:1 (95% confidence interval (CI) = 1.817-2.095). In the clinically abnormal group (n = 6), the ratio was 1.49:1 (95% CI = 1.206-1.782) (p< 0.0005). In conclusion, the ratio of the lateral femoral condylar width in the sagittal plane to the PCL length is a useful index for diagnosing PCL attenuation and lengthening in the presence of a normal morphological MR appearance.

Conservative management remains the gold standard for many fractures of the humeral diaphysis with union rates of over 90% often quoted. Success with closed management however is not universal. Phase 1 A retrospective review of all conservatively managed fractures between 2001 and 2005 was undertaken to investigate a suspected high non-union rate and identify possible causes. The overall non-union rate was 39.2% (11 of 28 cases). There was no difference in axial distraction at presentation, however following application of cast there was significantly more distraction in the non-union group (1.2 v 5.09mm, p Changes to practise All humeral fractures were admitted, lightweight U-slabs were applied by a technician, distraction was avoided, patients abstained from NSAIDS, consultant reviewed radiographs before discharge and patients were converted early to functional brace. Phase 2 Prospective collection of data over the following two year period showed a decrease in the amount of distraction when first placed in cast (2.73 v 0.74, p Conclusion Over-distraction at first application of cast is a causal factor in the development of non-union. Lightweight cast, avoidance of distraction, abstinence from NSAIDS and early conversion to functional brace is recommended. The initial surgical management of the patient who displays evidence of distraction will prevent evolution of non-union with conservative management. This will avoid lengthy delays in the treatment of the non-union and also help to prevent secondary stiffness in adjacent joints and disuse osteopenia.

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

The fracture of the tibial tray is a rare complication post total knee arthroplasty. We present the case of a 74-year-old lady who had pain in the left knee due to an anteromedial fracture of her metal tibial tray post total knee arthroplasty with a kinematic (Howmedica) prosthesis. There are 25 reported cases of fractures of the posterior-medial aspect of the tibial tray. This is the first case describing an anteromedial tibial tray fracture. We performed a retrieval analysis of the polyethylene component and the fractured tibial base plate and reviewed the literature to determine the predisposing factors contributing to tibial tray fractures. Tibial component malalignment, excessive polyethylene wear and subsequent bone lysis, inherent metallurgical weakness and certain design features of the tray have been identified as the possible contributing factors to failure in this case.

This study was carried out to determine the incidence of shoulder injuries in the ipsilateral shoulder of patients who attended our unit with fractures of the humeral diaphysis. This was a prospective study. 22 patients with fractures of the humeral diaphysis had an early (within 10 days of injury) MRI scan of the shoulder. The contralateral shoulder was also scanned as an internal control. There were 10 male and 12 female patients. The average age was 45 years. 20 were treated non-operatively, and 2 had retrograde intra-medullary nailing of the humerus. 6 patients in our study had a symmetrical MRI scan. The remaining 16 patients had some acute abnormality evident in the ipsilateral shoulder. 11 patients had a significant subacromial bursitis. 2 of these patients had a tear of the supraspinatus tendon. 1 patient had an undisplaced fracture of the coracoid process. The remaining 4 patients had significant AC joint inflammation, 3 being acute, the 4th being acute-on-chronic. This study shows a high incidence of asymmetrical MRI scans, indicating a definite shoulder injury sustained at the time of the fracture of the humeral diaphysis. We therefore surmise that shoulder pain and dysfunction post antegrade intra-medullary nailing of the humerus may not be due to iatrogenic causes, but may in fact result from concomitant ipsilateral shoulder injury. To our knowledge, this is the first study demonstrating such an association.