Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning. The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty. All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation. A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%). Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses

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

Summary Statement. With increasing emphasis on evidence-based medicine in healthcare, there is global increase in proportion of Level-1 and -2 articles in PUBMED. This study shows the trend of orthopaedic publications from different countries in comparison to other specialties. Introduction. New medical knowledge is expected to improve health through change in existing practices. Articles need to convince readers of the validity of conclusions in order to bring about a change in practice. The last few decades have witnessed an increasing interest in critical appraisal of research aimed at assessing the ‘quality’ of evidence, a trend towards ‘Evidence Based Medicine’. Whether orthopaedic publications are also becoming more evidence-based has hitherto not been reported. This study aimed to compare the trend of publications originating from orthopaedic services versus other specialties, across different countries, with respect to major categories of levels of evidence. Methods. PUBMED was used to collect data on yearly publication of articles, categorised by country, specialty (from author address) and article category (Guideline, Review, Case Report, Comparative Study, Clinical Trial and Meta-Analysis). Results. PUBMED shows 20,572,125 articles published between 1900 and 2010. Of these, 64% were published within the quarter century 1986–2010. Publication type was specified in 25% of articles, of which 8% were review articles, 7% each were case reports and comparative studies while 3% were clinical trials. The top ten countries from which articles originated were US, UK, Japan, Germany, France, Canada, Italy, Australia, Netherlands and Sweden. Comparing the decade of 1990s with 2000s, the number of meta-analyses showed greatest increase from Australia, Japan, Germany, UK and Italy (9.5x-6.1x). When comparing types of articles between the beginning and end of the quarter century, the proportion of clinical trials increased by 2x, guidelines by 5x and meta-analyses/systematic reviews by 28x. There were 121,859 articles from orthopaedic departments/institutes (0.6% of all articles). There was a consistent increase in the proportion of orthopaedic publications from 0.5% to 1.1% over the quarter century; this 231% increase was lower than vascular, cardiothoracic and paediatric surgery but greater than urology, neurosurgery, otolaryngology and obstetrics/gynecology. Among the different types of publications, in orthopaedics the greatest increase between the decades of 1990s and 2000s was in meta-analyses (8.5x) followed by guidelines (5.4x). This increase in number of meta-analyses was higher than other surgical specialties except cardiothoracic and vascular surgery, both of which showed a 13x increase. Among the meta-analyses from surgical specialties, the proportion from orthopaedics and vascular surgery was increasing consistently, with the former now contributing to 13% of all meta-analyses. In comparison, increase in number of clinical trials has been relatively modest for orthopaedics (2.4x), being lower than vascular surgery (3.3x), plastic surgery (2.8x) and neurosurgery (2.6x). Dicussion/Conclusion. The proportion of clinical trials and guidelines was increasing in a linear fashion in the last 25 years, while the proportion of meta-analyses/systematic reviews was increasing logarithmically. Among European countries, Germany, UK and Italy contributed to the highest number of meta-analyses. Publications from orthopaedic departments showed an overall intermediate rate of increase, but meta-analyses/systematic reviews showed a consistently higher increase compared to other surgical specialties. This analysis shows the trend of orthopaedic evidence in published literature and may be used as a guide to future country-specific research directions in the discipline of orthopaedics

Aims

Glucose-insulin-potassium (GIK) is protective following cardiac myocyte ischaemia-reperfusion (IR) injury, however the role of GIK in protecting skeletal muscle from IR injury has not been evaluated. Given the similar mechanisms by which cardiac and skeletal muscle sustain an IR injury, we hypothesized that GIK would similarly protect skeletal muscle viability.

To determine the bony outcomes of patients treated at our Institution after sustaining femur fracture and arterial injury, due to gunshot, in the ipsilateral limb, studied over a four-year period. The database at the Department of Vascular Surgery at our Institution was searched for cases that had sustained both arterial injury and femur fracture of the ipsilateral leg. Their case notes and X-rays were reviewed for the following:. Time line from injury to discharge. Procedure performed. Duration of external fixation. Complications (infection, iatrogenic vascular injury, amputation,. bony union achieved). Incidence of fasciotomy. During the period from 2002 to the end of 2005 there were 12 patients who qualified to be included in the audit group. Three of the 12 (25%) had to undergo a primary amputation upon arrival. The other nine cases underwent surgery. One of these received an intra-medullary device, another skeletal traction and the rest external fixation following the vascular surgery. Five of the 7 external fixation devices were converted to an intramedullary device in due course. All nine cases went on to union. There were no reported cases of iatrogenic vascular repair disruption. Of the 12, only three cases reported any infection. One case developed severe osteomyelitis of the femur. Primary vascular repair with temporary external fixation that was later converted into an intramedullary device (within 14 days) provided satisfactory results

Aims

Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial.

Objectives. The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT). . Methods. We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail. . Results. A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action. . Conclusions. There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement. Cite this article: Bone Joint Res 2013;2:276–84

Purpose: Since 1996, our multidisciplinary medicosurgical team has decided to propose orthopaedic treatment for diabetic perforating ulcers with osteitis, cellulitis, or necrosis (“cooling down” the acute infected ulcers before programmed surgery) rather than conservative treatment with prolonged antibiotic therapy. We present here a prospective study of 44 cases of diabetic perforating ulcers. Material and methods: Thirty-two diabetic patients underwent surgery: 77% males, mean age 65.2±8.6 year (range 43–86 years), 87% type 2 diabetes, 52% with a history of perforating ulcers, 45% with minor amputations, and 14% with history of vascular surgery. The lesions—perforating ulcer with osteitis (n=34), vascular necrosis of the toes (n=2), “acute feet” with cellulitis (n=8)—had progressed over 13.2±15.1 weeks. The preoperative work-up included: bacteriology samples 89%; standard x-rays of the foot 100% (osteitis 84%); duplex Doppler of the lower limb arteries 77% (tibial arteriopathy 87%); double bone scintigraphy 34% (osteitis 93%); TcPO2 (40±14mmHg); arteriography 27%; vascular surgery consultation 18%. Before surgery, 77% of the patients were hospitalised in an endocrinology unit (13±3 days) and 88% were on an antibiotic regimen for 26±18 days (50% i.v.). Orthopaedic surgery (without tourniquet, anaesthesia block, mean duration 53±24 min) involved: partial resection of a toe 23%; amputation of a ray 36% (first ray one, second ray five, third ray one, fourth ray two, fifth ray six); transmetatarsal amputation 32%; resection of the metatarsal heads 4%; calcanectomy (n=1); below knee amputation (n=1); and systematic and multiple samples for bacteriology (deep soft tissue and bone tissue) and for pathology. Results: Mean hospital stay in the surgery unit was 4±1 days, followed by 18±10 days in the endocrinology unit with antibiotics (oral for 88%) for 34±22 days, 91% of the lesions healed within 33±18 days; four required repeated procedures (two transmetatarsal amputations, one amputation of the first ray, one lower limb amputation); three lesions relapsed. The peroperative bacteriology samples of the deep soft tissue and bone tissue demonstrated, in comparison with the preoperative samples, that antibiotics had sterilised only 14% of the lesions; with discordant comparison in 40%, partial concordance in 24%, and total concordance in 24%. For the diagnosis of osteitis (confirmed by histology of peroperative bone samples), the x-ray interpretations were largely confirmed (79% exact diagnosis, 87% sensitivity, false positives 12%), as were the bone scintigrams with labelled polymorphonuclears (exact diagnosis 93%, sensitivity 93%, false positives 7%). Conclusion: This prospective study demonstrated the advantages of programmed surgery over emergency surgery, including for “acute feet”: limited resection, primary suture, rapid wound healing, short antibiotic treatment. It raises some questions concerning the validity of non-surgical bacteriological samples for perforating ulcers, even when performed under rigorous conditions (unique strain isolated from 76% of the samples) and on the possibility of antibiotic pressure on bacterial selection

Long-term regeneration of cartilage defects treated with tissue engineering constructs often fails because of insufficient integration with the host tissue. We hypothesize that construct integration will be improved when implants actively interact with and integrate into the subchondral bone. Growth and Differentiation Factor 5 (GDF-5) is known to support maturation of chondrocytes and to enhance chondrogenic differentiation and hypertrophy of mesenchymal stromal cells (MSC). Therefore, we investigated whether GDF-5 is capable to stimulate endochondral ossification of MSC in vitro and in vivo and would, thus, be a promising candidate for augmenting fibrin glue in order to support integration of tissue engineering constructs into the subchondral bone plate. To evaluate the adhesive strength of fibrin glue versus BioGlue. ®. , a commercially available glue used in vascular surgery, an ex vivo cadaver study was performed and adhesion strength was measured via pull-out testing. MSC were suspended in fibrin glue and cultivated in chondrogenic medium with and without 150 ng/mL GDF-5. After 4 weeks, the formed cartilage was evaluated and half of the constructs were implanted subcutaneously into immunodeficient mice. Endochondral ossification was evaluated after 2 and 4 weeks histologically and by microCT analysis. BioGlue. ®. and GDF-5-augmented fibrin glue were tested for 4 weeks in a minipig cartilage defect model to assess their orthotopic biocompatibility. Pull-out testing revealed sufficient adhesive strength of fibrin glue to fix polymeric CellCoTec constructs in 6 mm cartilage defects, however, BioGlue. ®. showed significantly higher adhesive power. In vitro chondrogenesis of MSC under GDF-5 treatment resulted in equal GAG deposition and COLIIa1 and ACAN gene expression compared to controls. Importantly, significantly increased ALP-activity under treatment with GDF-5 on day 28 indicated enhanced hypertrophic differentiation compared to controls. In vivo, MSC-fibrin constructs pre-cultured with GDF-5 developed a significantly higher bone volume on day 14 and 28 compared to controls. When pre-cultured with GDF-5 constructs showed furthermore a significantly higher bone compactness (bone surface/bone volume coefficient) than controls, and thus revealed a higher maturity of the formed bone at 2 weeks and 4 weeks. Orthotopic biocompatibility testing in minipigs showed good defect filling and no adverse reactions of the subchondral bone plate for defects treated with GDF-5-augmented fibrin glue. Defects treated with BioGlue. ®. , however, showed considerable subchondral bone lysis. Thus, BioGlue. ®. – despite its adhesive strength – should not be used for construct fixation in cartilage defects. GDF-5-augmented fibrin glue is considered promising, because of a combination of the adhesive strength of fibrin with an enhanced osteochondral activity of GDF-5 on MSC. Next step is to perform a large animal study to unravel whether GDF-5 stimulated endochondral ossification can improve scaffold integration in an orthotopic cartilage defect model

Aims

The purpose of this study was to explore a simple and effective method of preparing human acellular amniotic membrane (HAAM) scaffolds, and explore the effect of HAAM scaffolds with juvenile cartilage fragments (JCFs) on osteochondral defects.

The purpose of this study is to present a series of soft tissue sarcomas requiring complex vascular reconstructions, and to describe their management and outcomes. Soft tissue sarcomas are rare mesodermal malignancies accounting for approximately 1% of all cancers diagnosed annually. Sarcomas involving the pelvis and extremities are of particular interest to the orthopaedic surgeon. Tumours that encase and invade large calibre vascular structures present a major surgical challenge in terms of safety of excision with acceptability of surgical margins. Technical advances in the fields of both orthopaedic and vascular surgery have resulted in a trend towards limb salvage with vascular reconstruction in preference to amputation. Limb-salvage surgery is now feasible due to the variety of reconstructive options available to the surgeon. Nevertheless, surgery with concomitant vascular reconstruction is associated with higher rates of complications including infection and amputation. We present a case series of soft tissue sarcomas with vascular compromise, requiring resection and vascular reconstruction. We treated four patients (n = 4, three females, and one male) with soft tissue masses, which were found to involve local vascular structures. Histology revealed leiomyosarcoma (n = 2) and alveolar soft part sarcomas (n = 2). Both synthetic graft and autogenous graft (long saphenous vein) techniques were utilised. Arterial reconstruction was undertaken in all cases. Venous reconstruction was performed in one case. One patient required graft thrombectomy at one month post-operatively for thrombosis. We present a series of complex tumour cases with concomitant vascular reconstructions drawn from our institution's experience as a national tertiary referral sarcoma service

Background:. Injuries inflicted by gunshot wounds (GSW) are an immense financial burden on the South African healthcare system. The cost of treating an abdominal GSW has previously been estimated at R30 000 per patient. No study has been conducted to estimate the financial burden from an orthopaedic perspective. Objective:. To estimate the average cost of treating GSW victims requiring orthopedic interventions in a South African tertiary level hospital. Methods:. The study surveyed over 1,500 orthopedic admissions to our institution during 2012 to indentify GSW patients. A folder review yielded data on theatre time, implant cost, duration of admission, diagnostic-imaging studies performed, blood products used, laboratory costs and medicines issued to analyze costs. Results:. A total of 111 patients with an average age of 28 years (range 13–74) were identified. Each patient was hit by an average of 1.69 bullets (range 1–7). One hundred and forty seven fractures were sustained. Ninety-five patients received surgical treatment for a total of 128 orthopedic procedures, 15 concurrent general/vascular surgery procedures, and a cumulative surgical time of 198 hours 42 minutes. Cumulative anaesthetic time was 277 hours 33 minutes. Theatre costs (excluding implants) were estimated to be in excess of ten million rands. Ninety three of the patients received an implant during surgery which raised theatre costs even more. Total costs were in excess of R130 000.00 forward admissions, R180 000.00 for imaging, R190 000.00 for blood products, R16 000.00 for laboratory investigations and R16 000.00 for discharge medication. Conclusion:. Using varying calculations it was estimated that on average an orthopaedic GSW patient costs about R100 000.00 to treat, utilises about 2 hours of theatre time per operation and occupies a bed for an average period of 9 days

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

57 year old healthy woman, with a non-symptomatic aortic aneurysma after a traffic accident 30 years ago and a 70:ty degree thoracolumbar kyfo-scoliosis, was referred for treatment because of severe postural back-pain. The anticipated treatment was correction of spinal balance with an apical osteotomy, a long instrumentation and maximal number of atachments. A careful preoperative investigation, including DEXA, bending films, internal medical judgement and vascular surgery consultaion, was performed. The latter ended up in an aortic stent, because of the risks of rupture of the aneurysma, due to elongation of the spine and aorta. Correction was performed with an oblique 1,5 segment reduction osteotomy in L1 and L2. Blood loss 2 700 ml. Normal neurophysiology during and after the surgery. The patient could return back home after two weeks, protected by a soft brace. Six weeks after index surgery she became unconscious, got heart arrest and was acute transported to the regional hospital, after resuscitation. Great amounts of blood were found in the lungs and a CT scan demonstrated a severe elongation of aorta as well as a possible rift at the junction between normal and stented vessel. Two weeks later the patient died, still unconscious. Autopsy confirmed aortic rupture. CONCLUSION. What are the risks with aneurysma at spinal correction? Should the correction have been performed without the aortic stent?

Introduction. Around the knee high-energy fractures/dislocation may present with vascular injuries. Ischaemia time i.e. the time interval from injury to reperfusion surgery is the only variable that the surgeon can influence. It has been traditionally taught that 6-8 hours is revascularisation acceptable. There are only limited case series that have documented the time-dependent lower limb salvage rate (LSR) or the lower limb amputation rate (LAR). We have conducted a meta-analysis to look at LSR and LAR to inform clinical standard setting and for medicolegal purposes. Methods. Two authors conducted an independent literature search using PubMed, Ovid, and Embase. In addition the past 5 years issues of Journal of Trauma, Injury and Journal of Vascular surgery were manually scrutinised. Papers included those in the English language that discussed limb injuries around the knee, and time to limb salvage or amputation surgery. The Oxman and Guyatt index was used to score each paper. Results. 21 retrospective case series articles were identified from 8 different journals. A total of 1575 patients were compiled, 92 patients were lost or died. 263 lower limbs underwent amputation and 1220 limbs were salvaged. 984 lower limbs were salvaged within the 8 hours. The LAR increased with time from 3% with reperfusion surgery in less than 4 hours to 13% at 6 hours and 32% at 8 hours. A lower LAR of 20% for patients presenting after 12 hours was seen

It is well recognised that there is a requirement for military surgeons to treat the victims of penetrating trauma while on operations. Casualty templates from recent and past conflicts demonstrate that a high proportion of survivable injuries affect the limbs; expertise in the management of penetrating trauma to the limbs is clearly important. While it is widely agreed that a combined specialities approach to limb injuries is necessary, debate has been ongoing for some time in the UK military as to the most appropriate means to gain the necessary experience for treating the wounds encountered on operations. This study examines the operational requirement, looking at data and individual cases from Iraq, and considers the relevance of a training placement at The Johannesburg General Hospital, a level 1 trauma centre in South Africa. Surgeon Lt Cdr Mercer RN is currently a Specialist Registrar in Vascular Surgery at MDHU Portsmouth and Surgeon Lt Cdr Ayers is a Specialist Registrar in Plastic Surgery at Frenchay Hospital in Bristol

Study Design: Case report of four consecutive case reports of revision surgery for anterior dislocation of the Acroflex disc (DePuy Acromed, MA, USA) all of whom required vascular surgery are described. Objective: To describe vascular complications of explanting an artificial inter-vertebral disc replacement following spontaneous anterior displacement. Subjects: Four consecutive patients required explantation of the Acroflex disc. Two patients were male and two female with median age 44 years (range 33–51). All patients gave informed consent to enter a clinical trial, which had ethical approval. Outcome measures: Symptom relief, vascular injury and deep vein thrombosis. Results: All patients gained good symptomatic relief following disc replacement. Four patients suffered anterior displacement of the disc with a deterioration in symptoms during the 1. st. year. Three suffered vascular damage to the iliac vessels. In two cases division and re-anastomosis of the iliac vein was required to allow disc removal. Ilio-femoral deep vein thrombosis occurred pre-operatively in one patient and post-operatively in a second, no deaths occurred. Conclusions: Anterior intervertebral disc displacement is associated with vascular injury. Preventing anterior disc displacement must form an essential part of disc design with (i) rapid fixation to bone and (ii) a failsafe design to prevent local damage in case of failure. In the case of displacement, disc removal should be planned and performed with a vascular surgeon

Purpose. To study the initial presentation and subsequent investigation and management of acute knee dislocations at a regional trauma centre. Introduction. Knee dislocation requires high energy trauma, and often affects young working adults. The high incidence of associated arterial, neurological, ligamentous, and other soft tissue injuries, can produce potentially devastating outcomes. Rapid mobilisation of traditionally distinct surgical teams, with urgent vascular imaging and emergency surgery are often necessary. The extent and severity of ligamentous damage may require multiple operations to repair. Methods. A retrospective nine-year study of knee dislocations managed in the Trauma and Orthopaedic Department of the Royal Hospitals, Belfast was performed using a Fractures Outcomes Research Database (FORD), a chart review, and a review of relevant radiology. Demographic data, mechanisms of injury, associated neurovascular injuries, ligamentous damage, and operative intervention were recorded. Results. 15 patients were identified over 9 years (2000-2008 inclusive). Mean age at injury was 38 years, median 37. 14 (93%) of patients were male, 1 (7%) was female. 6 injuries (40%) were sport-related, 3 (20%) occurred as a result of road traffic collisions, 5 (33%) were accidents in the workplace, and 1 (7%) was a result of a fall while intoxicated with alcohol. 5 (33%) patients experienced a common peroneal nerve palsy. 10 (67%) received vascular imaging, and 2 (13%) underwent vascular surgery as part of the initial theatre episode. All 15 dislocations led to some degree of structural soft tissue knee injuries. These included 12 (80%) anterior cruciate ligaments, 8 (53%) posterior cruciate ligaments, 7 (47%) lateral collateral ligaments, and 5 (33%) medial collateral ligaments. 3 posterolateral corner injuries required repair. Of the 15 patients, 2 (13%) underwent no operative procedures following closed reduction, and the remaining 13 patients had 21 distinct theatre episodes recorded between them. 2 fasciotomies for compartment syndrome, and 2 common peroneal nerve decompression/explorations were performed in the initial theatre episode. 3 patients (20%) were managed with an external fixator initially. 1 patient (7%) developed complications and required trans-femoral amputation. Conclusions. Knee dislocation remains uncommon, and even major centres may receive only a few injuries per year. Orthopaedic, Vascular and Plastic surgeons, as well as Emergency Physicians and Radiologists must remain vigilant to the challenge which this injury can present, and the opportunity for excellent outcomes through a coordinated approach with close communication, awareness of injury patterns, and availability of theatre and imaging resources