Purpose: In patients with pelvic trauma, the need to quickly and accurately rule out sources of bleeding is paramount. We sought to determine the predictive value of CT angiography in determining the need for therapeutic angiography and to ascertain if definable arterial bleeding correlated with anatomic injury. Method: Over a 2 year period 58 patients with a high-energy mechanism and pelvic injury underwent pelvic CT angiography as part of their initial trauma CT scan. This was performed as a 25 second delayed scan (after contrast introduction) using a GE light speed VCT64 scanner. The decision to proceed to therapeutic angiography was made on clinical grounds and was later compared with the CT angiographic findings. The anatomic location of bleeding on CT angio and interventional angio were compared. Results: There were 36 male and 22 female patients, aged 43 (17 – 86), with average ISS of 18.6. The 18 (31%) patients with positive extravasation on CT angiography had higher initial blood requirements compared to those without extravasation. Two of the CT(+) group died prior to therapeutic angiography being performed. 11 of the remaining 16 had interventional angiography; 8 had (+) findings, including 7 major vessels coiled and 1 cutoff vessel observed. 1 patient of 40 with negative CT angiogram met clinical criteria had an interventional angiography; no arterial bleeding was discovered. The negative predictive value of CT angiography for pelvic arterial bleeding requiring therapeutic angiography was 100%; the positive predictive value of angiographically treatable bleeding was 70% (counting the two early deaths). The vessel location on CT angio and therapeutic angio was consistent in all cases. The CT angio (+) group had a higher percentage of unstable pelvic injuries (67% vs. 40%). Conclusion: In this pilot study, CT angiography added to the initial trauma scan in patients with pelvic trauma demonstrated a 100% NPV for arterial bleeding that required therapeutic angiography on clinical grounds. Positive findings correlated well with the anatomic location of pelvic injury and had a 70% PPV for angio-graphically treatable bleeding. Further study of this technique is warranted

Background: The recent significant surge in disc arthroplasty surgery has popularised the minimally invasive anterior approach to access the target disc. However, as the abdomen and its great vessels are not the natural territory for the spinal or neurosurgeon, extra care must be taken to access the disc whilst still minimising the risk of the not too uncommon vascular injury. Three dimensional CT angiography has been routinely used in this centre as part of pre operative planning of disc surgery. This was prompted by the frequent intraoperative observation that the vascular pattern has often been far from consistent. Aim of Study: To assess the anatomic variations of the major abdominal vessels. Methods: The pre operative 3D CT angiograms of eighty nine patients who had lumbar disc replacements were examined studying specific vascular anatomic parameters. Parameters studied included position of the Aorta and Inferior Vena Cava, the levels and angles of their bifurcation and the all too important ascending lumbar vein. We also commented on the most accessible (visible) disc part in relation to surrounding vessels. Results: We found significant variations in vessels anatomy in all parameters studied, confirming inconsistency of the abdominal vasculature. In particular, the angio-grams suggested an alternative approach to access the L4/5 disc in 30% of cases. Discussion: The incidence of vascular complications in disc arthroplasty surgery is reported to be around 3%. This includes laceration particularly to the left common iliac vein, thrombosis, both arterial and venous and intimal tears. Most of these complications are more than often the result of excessive traction and failure to adequately visualise and mobilise the vessels. Pre operative imaging is therefore critical to plan best vascular approach to the disc. Although MRI scanning is useful in assessing the vasculature, it is less superior to 3D CT angiograms in delineating vessels topographic relation to vertebra and disc. Conclusion: We have noticed significant variations in abdominal vasculature anatomy. This may have a direct influence on access to L4/5 and higher discs in a siginificant number of cases

Introduction

Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with bundled payment programs. It has been thought that many of these patients may have undiagnosed CAD because of sedentary life styles brought on by chronic osteoarthritis.

The purpose of this study is to assess with Coronary Computed Tomographic Angiography (CCTA) the prevalence and severity of CAD in patients >65 y/o for elective TJA.

Aims. Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components. Methods. Patients were defined as at risk to vascular injuries when components or cement migrated 5 mm or more beyond the ilioischial line in any of the pelvic incidences (anteroposterior and Judet view). In those patients, a serial investigation was initiated by a CT angiography, followed by a vascular surgeon evaluation. The investigation proceeded if necessary. The main goal was to assure a safe tissue plane between the hardware and the vessels. Results. In ten at-risk patients undergoing revision hip arthroplasty and submitted to our algorithm, six were recognized as being high risk to vascular injury during surgery. In those six high-risk patients, a preventive preoperative stent was implanted before the orthopaedic procedure. Four patients needed a second reinforcing stent to protect and to maintain the vessel anatomy deformed by the intrapelvic implants. Conclusion. The evaluation algorithm was useful to avoid blood vessels injury during revision total hip arthroplasty in high-risk patients. Cite this article: Bone Jt Open 2022;3(11):859–866

Introduction. The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology. Materials & Methods. Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap. Results. Union rate of 100% (11/11) was noted with periosteal flap osteotomies, versus those without flaps at 28.6% (2/7) (p = 0.0025). Time to union was also reduced in the periosteal flaps at 8.5 months versus 16.75 months in the control group (p = 0.023). Survival curves with a hazard ratio of 4.1, equating to a 4 times higher chance of union with periosteal flaps (log-rank p = 0.0016) was observed. Conclusions. The chimeric fibula-periosteal flap provides an option for atrophic recalcitrant non-unions where use of vascularised fibula graft alone may not provide an adequate biological environment for consolidation

Helical plates potentially bypass the medial neurovascular structures of the thigh. Recently, two plate designs (90°- and 180°-helix) proved similar biomechanically behaviour compared to straight plates. Aims of this study were: (1) Feasibility of MIPO-technique with 90°- and 180°-helical plates on the femur, (2) Assessment of distances to adjacent anatomical structures at risk, (3) Comparison of these distances to using medial straight plates instead, (4) Correlation of measurements performed in anatomic dissection with CT-angiography. MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (Group1) or a 180°-helical 15-hole-LCP-DF (Group2). CT angiography was used to evaluate the distances between the plates and the femoral arteries as well as the distances between the plates and the perforators. Subsequently, the specimens were dissected, and the distances were determined again manually. Finally, all helical plates were removed, and all measurements were repeated after application of straight medial plates (Group3). Closest overall distances between plates and femoral arteries were 15 mm (11 − 19 mm) in Group1, 22 mm (15 − 24 mm) in Group2 and 6 mm (1 − 8 mm) in Group3 with a significant difference between Group1 and Group3 (p < 0.001). Distances to the nearest perforators were 24 mm (15 − 32 mm) in Group1 and 2 mm (1 − 4 mm) in Group2. Measurement techniques (visual after surgery and CT-angiography) demonstrated a strong correlation of r. 2. = 0.972 (p < 0.01). MIPO with 90°- and 180°-helical plates is feasible and safe. Attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distal insertion. Measurements during anatomical dissection correlate with CT-angiography

Abstract. Aims. The association between body mass index (BMI) and venous thromboembolism (VTE) is well studied, but remains unclear in the literature. We aimed to determine whether morbid obesity (BMI≥40) was associated with increased risk of VTE following total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA), compared to those of BMI<40. Methods. Between January 2016 and December 2020, our institution performed 4506 TKAs and 449 UKAs. 450 (9.1%) patients had a BMI≥40. CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) and ultrasound scan for suspected proximal deep vein thrombosis (DVT) were recorded up to 90 days post-operatively. Results. When comparing those of BMI<40 to those with BMI≥40, there was no difference in incidence of PE (1.0% vs 1.1%, p=0.803) or proximal DVT (0.4% vs 0.2%, p=0.645). There was no difference in number of ultrasound scans ordered (p=0.668), or number of CTPAs ordered for those with a BMI≥40 (p=0.176). The percentage of patients with a confirmed PE or proximal DVT were 24.2% and 3.9% respectively in the BMI<40 group, compared to 20.0% (p=0.804) and 2.3% (p=0.598) in the BMI≥40 group. Conclusion. Morbid obesity was not associated with increased risk of PE or proximal DVT within 90 days of TKA or UKA. Overall, 76.3% of CTPAs and 96.2% of ultrasound scans were negative. Increasing the threshold for VTE investigation would reduce the rate of negative investigations. Establishing more effective risk stratification protocols, to guide investigation, would likely reduce unnecessary imaging

Introduction. The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded. Methodology. Pre-operative requirement for fasciotomy was recorded. A vascular surgery consultation was obtained. CT angiography and DSA were performed if needed only. Venous blood samples from the injured limb were withdrawn for lactate and bicarbonate analysis. Serum CPK was estimated at the time of admission and repeated at 6, 12, 24, 48 and 72 hours after admission. A record was maintained about the type and duration of surgery, blood loss, type of anaesthesia used and fasciotomy in the post-operative period. Results. Of the 74 patients included in the study, 55 patients were taken up for a revascularization procedure, 13 patients for primary amputation and in remaining six patients, no vascular surgery was required. If the level of bicarbonate in the injured limb was less than 16.5 mmol/L, pH < 6.89 the probability of survival of the limb after a revascularization procedure is low and the injured limb will need an amputation eventually. Lactate levels and creatinine kinase were not of any predictive value regarding the outcome of the injured limb. Conclusion. Along with clinical signs, low levels of bicarbonate (<16.5 mmol/L), pH (<6.89), and high levels of pCO2, base deficit in the injured limb at the time of presentation were associated with the less favorable outcome-amputation

Prosthetic reconstruction of high-riding hips is technically demanding. Insufficient bony coverage and osteopenic bone stock frequently necessitate transacetabular screw fixation to augment primary stability of the metal shell. We sought to determine the validity of the previously reported quadrant system, and if needed, to define a specialized safe zone for augmentation of screw fixation to avoid vascular injuries in acetabular cup reconstruction for high-riding hips. Volumetric data from computed tomography enhancement scanning and CT angiography of eighteen hips (twelve patients) were obtained and input into a three-dimensional image-processing software. Bony and vascular structures were reconstructed three-dimensionally; we virtually reconstructed a cup in the original acetabulum and dynamically simulated transacetabular screw fixation. We mapped the hemispheric cup into several areas and, for each, measured the distance between the virtual screw and the blood vessel. We found that the rotating centers of the cups shifted more anterior-inferiorly in high-riding hips than those in ordinary cases, and thus the safe zone shifted as well. Screw fixation guided by the quadrant system frequently injured the obturator blood vessels in high-riding hips. We then defined a specialized safe zone for transacetabular screw fixation for high-riding hips. We conclude that the quadrant system can be misleading and of less value in guiding screw insertion to augment metal shells for high-riding hips. A new safe zone specific to high-riding hips should be used to guide transacetabular screw fixation in these cases

Background: The standard diagnostic approach in patients suspected of having pulmonary embolism starts with D-dimer and perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography will perform. Aims: This study evaluates the effectiveness of D-dimer as a screening tool for Pulmonary Embolism (PE) and to determine the accuracy and potential clinical utility of VQ scan in the diagnosis of pulmonary embolism in orthopaedic trauma patient. Methods: We retrospectively reviewed 757 consecutive trauma admissions involving lower extremity and spinal injuries over 12 months and identified 20 patients with symptoms mimicking PE, without typical clinical symptoms, which underwent rotten investigations for PE (ABG, Blood test, D dimer, Chest X-ray and VQ scan). Plasma D-dimer levels were measured as a prerequisite test in all patients before undergoing VQ scan to confirm the absence of PE. All patients had either mechanical, such as foot pumps, or chemical DVT prophylaxis. Results: The mean age was 65 (ranging from 45–88) years, there were 11 female and 9 male. D-dimer levels in the postoperative or post traumatic period were elevated. Mean value was 3.63 (sd=2.72, range 0.60–14.34), Comparing D-dimer levels between those treated operatively (14 patients) and those treated conservatively (6 patients) we found that both groups displayed the same trend; however levels were higher following surgery. The classical triad of dyspnoea, pleuritic chest pain and haemoptysis occurred in only 2 patients. Signs of DVT were present in 3 patients. The electrocardiographs were normal in only 4 patients, though changes particularly suggestive of PE (S1Q3T3, Right bundle branch block or right heart strains) were absent in all of the patients. Chest X-ray changes were of limited value. None showed any of the supposedly characteristic changes. All of the patients had a VQ scan were started on chemical treatment for PE and non of them had definite PE, 12 the patients had probable PE Those patient with probable scan were not subsequently given anticoagulants owing to their medical conditions. Conclusion: The D-dimer level is never normal (< 0.5mg/l), following total trauma, and so cannot exclude a DVT or PE. The level it raises to is indistinguishable form that seen in the population with a PE and so cannot identify those patients in whom further investigation is warranted. VQ scan is not a definitive diagnosis we should rely more and more on a CT Angiography scan for the diagnosis of PE in this group of patients. This should be organised by medical team, especially with shortening of training time, to avoid wasting of resources and time which are of paramount. Requesting a D-dimer test in this population wastes time and resources and is of no benefit

Aims

The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?

Introduction. Venous Thromboembolism is a well documented complication of Total hip and total knee replacement, and NICE guidelines recommend use of pharmacological prophylaxis routinely after these procedures. Current practice in our department is use of mechanical prophylaxis routinely, and chemical prophylaxis in high risk cases only. Previous departmental audit has shown VTE rates to be lower than the national average, however medical and haematology audit has contradicted this, and suggested that practices should be revised to include chemical prophylaxis routinely. This study seeks to determine whether we are seeing the full extent of the problem and whether our practices should be revised accordingly. Methods. Retrospective study of all patients presenting to our hospital with suspected DVT/PE from February 2009 – August 2009. Patients were identified through radiology records; every patient undergoing venous Doppler studies or CT pulmonary angiography were included. The casenotes of patients with positive scans were reviewed; and relevant information extracted from the notes. Results. 475 patients presenting with suspected DVT/PE between February 2009 and August 2009. 39 confirmed DVT; 37 confirmed PE. 87% admitted under acute medical intake. 2 confirmed DVT's in post operative THR/TKR patients, accounting for 5.1% of DVT's in this timeframe. No PE's following THR/TKR in this timeframe. Overall postoperative THR/TKR accounts for 2.6% of confirmed VTE in this hospital. Rates of DVT 1.19% of total hip replacements; 0.93% of total knee replacements. Discussion. Actual rates of VTE low amongst our post operative patients, suggesting current methods of thromboprohylaxis are effective. Changes in thromboprophylaxis practices probably not cost-effective; however it is difficult to justify not changing practices due to recent publication of NICE guidance. Rates comparable to previous audit, suggesting that patients are not being ‘missed by orthopaedic audit’

Aim. Ten years ago at the EMSOS 2000 meeting we have presented our experience concerning the non-surgical treatment of stage IIB osteosarcoma of extremities. The purpose of study was to evaluate long-term results and complications related to this non-standard and controversial treatment modality. Methods. Since 1988 definitive radiation gamma therapy (RT) in the median dose of 60 Gy was administrated to 36 patients who refused surgery after preoperative chemotherapy. Until 1999 induction consisted in 3-5 cycles of intra-arterial doxorubicin (DOX) 75 mg/m2 or cis-platin (CDDP) 120 mg/m2. Since 2000 induction comprised 4 cycles of DOX 90 mg/m2+CDDP 120 mg/m2 intra-arterially. Tumour response before local treatment was assessed non-invasively by means of X-ray, CT, MRI, angiography, 3-phase bone scans and alkaline phosphatase measurement. The end-points were overall (OS), metastases free (MFS) and local progression free (LPFS) survival at 10 years. Results. OS, MFS and LPFS by Kaplan-Meier method were 48±9%, 51±9%, and 45±11% respectively. The outcome was significantly related to response assessed before RT. In 12 good responders OS, MFS and LPFS were 74±13%, 91±9%, and 69±19% respectively compared with 29±11%, 27±11%, and 34±13% in 24 non-responders, p- value 0.03, 0.003, 0.009, respectively. In 14 patients 5 years survival after local progression and delayed surgery was 38±10%. Median survival time after local relapse was 36 months. Two types of major complications were seen: 7 pathological fractures and one osteomyelitis. 21 patients (58%) remained with a functional limb until the last examination or death. Conclusions. Long-term results were higher than expected in this radioresistant tumour. In good responders to induction chemotherapy RT could be an option for local treatment. Majority of patients had a functional limb during and long time after treatment. Isolated late local relapses did not influence considerably systemic control

Aims

The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

The December 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Vitamin E infusion helpful in polyethylene; Hip replacement in fracture and arthritis; Non-surgical treatment for arthritis; Cost and approach in hip surgery; Who does well in FAI surgery?; AAOS Thromboembolism guidelines; Thromboprophylaxis and periprosthetic joint infection; Fluid collections not limited to metal-on-metal THR

The December 2014 Knee Roundup³⁶⁰ looks at: national guidance on arthroplasty thromboprophylaxis is effective; unicompartmental knee replacement has the edge in terms of short-term complications; stiff knees, timing and manipulation; neuropathic pain and total knee replacement; synovial fluid α-defensin and CRP: a new gold standard in joint infection diagnosis?; how to assess anterior knee pain?; where is the evidence? Five new implants under the spotlight; and a fresh look at ACL reconstruction

Objectives

Overlap between the distal tibia and fibula has always been quoted to be positive. If the value is not positive then an injury to the syndesmosis is thought to exist. Our null hypothesis is that it is a normal variant in the adult population.

The “Universal Protocol” (UP) was launched as a regulatory compliance standard by the Joint Commission on 1st July 1 2004, with the primary intent of reducing the occurrence of wrong-site and wrong-patient surgery. As we’re heading into the tenth year of the UP implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable never-events. This article opens the debate on the potential shortcomings and pitfalls of the UP, and provides recommendations on how to circumvent specific inherent vulnerabilities of this widely established patient safety protocol.