Aims. The aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown. Methods. A prospective analsysis of all patients attending our hand trauma unit throughout the UK COVID-19 lockdown period (24 March to 10 May 2020) was carried out. Prospectively collected departmental data from the same period in 2019 was obtained and reviewed for comparison. The number of patients attending clinic, undergoing surgery, the type of surgical procedure, and rate of surgery was compared. Results. In all, 463 patients attended hand trauma services during the lockdown period compared to 793 in 2019 (32% reduction); 190 surgical procedures were carried out during lockdown compared to 236 in 2019 (20% reduction). Intervention rate was higher during the lockdown period (41% compared to 30%). There was no difference in the type of cases. In the first half of lockdown, 47% fewer procedures were performed than in 2019, but in the second half of lockdown 13% more procedures were carried out than the same period in 2019. Conclusion. Requirements for hand trauma surgery remain high during a pandemic lockdown. Attendances and surgical requirements can be expected to steadily return to normal levels during a prolonged lockdown period. Throughout any future lockdown period adequate surgical provision must be maintained for patients with hand injuries. Cite this article: Bone Joint Open 2020;1-10:639–643

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

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. Methods. A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. Conclusion. This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529–535

Aims. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

Aims. This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures. Methods. Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events. Results. Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events. Conclusion. COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic. Cite this article: Bone Jt Open 2023;4(9):704–712

Background: The purpose of this study is to evaluate the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with 3-dimensional imaging (SIREMOBIL ISO-C-3D) in trauma surgery. Patients & Methods: Between November, 2004 and September, 2005, the ISO-C-3D was used at our institution for intraoperative CT-quality visualization of 33 trauma cases with the fractures of calcaneus (13), tibial plateau (7), tibial plafond (6), acetabulum (4), distal radius (2) and talus (1). The mean patient age was 42 and male to female ratio 25 to 8. In 30 cases ISO-C-3D was used during the surgery after the reduction and fixation of the fracture to assess the accuracy of reduction and implant position prior to wound closure and in 3 cases the device was used before starting the operation to obtain real-time CT images which were transferred to a navigation system to perform computer navigated procedures. Results: This novel technique was highly beneficial from 4 aspects; intraoperative diagnosis, proper reduction, correct implant placement and feasibility in combining the CT images to computer navigation. In 40% of the cases (13/33) who had no regular CT scan before the surgery, intraoperative three dimensional imaging with ISO-C-3D has been a superior modality in diagnosis. In one case the reduction and implant position was corrected during the surgery after the ISO-C-3D scan. In all the procedures with ISO-C-3D navigation, satisfactory reconstruction of the articular surfaces with precise fixation was achieved. Conclusion: Intraoperative 3-dimensional visualization with ISO-C-3D provides useful information in trauma surgery which enables the surgeon to re-evaluate the injury diagnostically and to judge the reduction and implant position before wound closure. Combining the ISO-C-3D images with computer navigation makes the reduction and implant placement highly accurate

Complication rates are an increasingly topical issue. Figures are widely published in elective surgery. We were unable to find any overall rates published solely for trauma surgery involving metal implants. We wanted to identify our overall rate as a matter of good practise and to produce a figure for others to compare against. We wanted to identify the overall infection rate and study those infections in terms of fracture healing, implant survival and chronic soft tissue infection. A wound infection was any wound where there was a positive culture, prolonged pus drainage with or without a sinus or presence of pus at further surgery with or without a positive culture. Metal implants were any metalwork covered primarily or secondarily with soft tissue. 708 implants were inserted over the 11 month period studied. The causative organism was staphylococcus aureus in 65% of cases and a third of these were MRSA. Other organisms included coliforms, acinobacter, pseudomonas and bacillus. Of 52 patients who had a wound infection, 6 (11.5%) had no treatment with no detrimental effect, 34 patients had antibiotics alone and 27 had no further problems. 2 died from sepsis related causes, 3 died from other causes, 1 had delayed union but no evidence of continuing infection and 1 had chronic soft tissue discharge but bony union. 12 patients had further surgery and antibiotics. 6 retained their metal work and of these 3 died from sepsis related causes, 1 had no further problems, 1 tibial nailing became a chronic discharging osteomyelitis and 1 olecrannon fracture became an uninfected non-union. For the 6 patients who had their metalwork removed 2 died, 1 from sepsis, 2 had successful revisions and 2 were continuing treatment at most recent follow-up. Conclusion: overall deep wound infection rate was 7.3%. Most deep wound infections were treated with antibiotics alone with a satisfactory outcome. Re-operation rate for deep wound infection was 1.7%. There is very little information available on overall deep wound infection rates for implants in trauma surgery; we offer our findings as a comparison for future reference

Introduction: Trauma surgery creates enormous mental stress for operating surgeons, especially in trainees. This is responsible for sympathetic hyperactivity which can be measured by various cardio vascular variables. Air Traffic control is recognised as one of the most stressful occupations with accepted risks and incorporated remedies. We compared the stress during surgery with that experienced by air traffic controllers. Materials & Methods: The study included 40 trainee doctors. We obtained multiple readings of heart rate, diastolic and systolic Blood Pressure with ambulatory monitoring methods when they operated. This was compared to their resting measurements obtained at home. Similar measurements were performed for Air Traffic controllers, while at work and at home. Results: The heart rate and blood pressure were increased at the beginning and during surgery. Student t test was applied to compare the mean values obtained intra-operatively and in resting conditions. This suggested the increase to be statistically significant. This increase in autonomic function variables was compared with the values similarly obtained for Air Traffic Controllers. Operating surgeons manifested significant increase in comparison to the other group. Discussion: Stress can not be eliminated but can be over come with experience. Recurrent sympathetic hyperactivity may contribute to various stress related ailments. As in Air Traffic controllers, stress should be accepted as integral part of occupation. Stress relieving manoeuvres should form an important part of surgeons’ occupational health and medical school/ foundation years curriculum. Conclusions: Surgeons experience more emotional and mental stress than occupations accepted to be most stressful

Mobility plays an important role, in particular for patients with osteoporosis and after trauma surgery, both as an outcome and as treatment. Mobility is closely linked to the patient”s quality of life and exercise is a powerful additional treatment option. In order to be able to generate an evidence base to evaluate various surgical and non-surgical treatment options, objective measurements of patient mobility and exercise over a certain time period are needed. Wearables are a promising candidate, with obvious advantages compared to questionnaires and/or PROs. However, when extracting parameters with wearables, one often faces the problem of algorithms not performing well enough for special cases like slow gait speeds or impaired gait, as they typically appear in this patient group. We plan to further extend the applicability of the actibelt system (3D accelerometer, 100Hz), in particular to improve the measurement precision of real-world walking speed in slow and impaired walking. We are using a special measurement wheel including a rotating 3D accelerometer that allows to capture high quality real-world walking speed and distance measurements, and a mobile high resolution camera system. In a first block 20 patients with osteoporosis were included in the study at the Ludwigs-Maximilians-University”s Department of General, Trauma and Reconstructive Surgery in Munich, Germany and equipped with an actibelt. Patients were asked to walk as “normal” as possible, while wearing their usual apparel, in the building and outside the building. They climbed stairs and had to deal with all unexpected “stop and go” events that appear in real-world walking. Various gait parameters will be extracted from the recorded data and compared to the gold standard. We will then tune the existing algorithms as well as new algorithms (e.g. step detection based on continuous wavelet transformation) to explore potential improvements of both step detection and speed estimation algorithms. Further refinement and validation using real world data is warranted

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy.

300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:

Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs.

Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D.

This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance.

Aims. The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods. A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results. From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m. 2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion. During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670

Aims

Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service.

Objective. To investigate the effects of trauma and fracture surgery on leukocyte maturation and function. Background. Unbalanced inflammation triggered by trauma has been linked to multiorgan dysfunction (MOD) and death. In animal and cellular models, changes in neutrophil function and failure of monocyte infiltration and resolution have been implicated as possible causes. The investigators combine assays on neutrophil function with surface antigen expression on circulating neutrophils and monocytes. These are correlated with severity of traumatic injury, type of surgery and clinical outcome to help explain the aetiology of distant organ injury, and pose a case for damage control surgery. Results. A total of 20 patients requiring internal fixation of femoral shaft fractures, acetabular fractures and pelvic fractures were recruited. Those undergoing surgery following an interval period were used as control, with blood and plasma samples pre-operatively, and 2 and 5 days post-operatively, whilst patients with acute trauma also had an admission sample. Using flow cytometry, the neutrophils were gated on CD15+ CD14- with high side scatter whilst the monocytes were gated on CD14+ CD15- with low side scatter. Two days following surgery the neutrophils showed reduced CXCR2 expression and increased CXCR1, CD11b and IL-6R expression whilst the monocytes showed reduced CCR2 and HLA-DR receptor expression. The change in receptor expression was enhanced in the trauma patients in comparison to the control patients, and correlated with cellular function, using respiratory burst, elastase release and transmigration assays. Conclusions. This first human trial evaluating the immunologic/anti-inflammatory effects of trauma and trauma surgery on the specific antigen expression helps explain one mechanism for organ damage in the post-trauma patient

The surgical community is plagued with a reputation for both failing to engage and to deliver on clinical research. This is in part due to the absence of a strong research culture, however it is also due to a multitude of barriers encountered in clinical research; particularly those involving surgical interventions. ‘Trauma’ amplifies these barriers, owing to the unplanned nature of care, unpredictable work patterns, the emergent nature of treatment and complexities in the consent process. This review discusses the barriers to clinical research in surgery, with a particular emphasis on trauma. It considers how barriers may be overcome, with the aim to facilitate future successful clinical research.

Cite this article: Bone Joint Res 2014;3:123–9.

Graphene is a two-dimensional structure that is made of a single-atom-thick sheet of carbon atoms organised in hexagonal shapes. It is considered to be the mother of all graphite or carbon-based structures. It has shown exceptional physical and chemical properties which possess potential future applications. Graphene has an elasticity index similar to rubber and a hundred times tensile strength of steel and is even sturdier than diamonds. It is a very efficient biosensor with its exceptional electronic conductivity far greater than even copper. It is a potential future low cost material and its scalable production ability makes it even more attractive. The rediscovery of Graphene in 2008 saw few potential medical applications, specifically in the field of drug delivery, gene and cancer therapy.

Nao graphene has extensive thermal conductivity and reflexivity, which can conceivably change imaging especially muskeloskeletal imaging and notably as a contrast material. It has been found to be a safe and a cheaper IV contrast agent in USA in 2012. Being an efficient biosensor especially in conducting electricity, it could assist in prosthetic and bionic limbs or prosthesis. Its durable stubborn properties, a composition which exceeds the strength of steel and light weight structure may create a potential material to develop into a new generation of a low profile internal fixing devices like plats. Most importantly, its scaffolding cell culturing assets could change the whole concept of prosthesis from mechanical press fit fixation to more dependence on bio adhesiveness.

Introduction

Four weeks after the earthquake in Kashmir, multidisciplinary surgical teams were organised within the UK (MiST). The aim was to help with disaster victims who had been transferred to Rawalipindi. We reviewed the work carried by one such team from the 5-18 November 2005.

Background: The experimental use of maggots (sterile larvae of Lucilia sericata) can prevent the amputation of an extremity in case of severe infection after trauma injury. Maggots destroy bacteria by secreting enzymes such as tryptase, peptidase and lipase. An alkaline environment is created by the secretion of allantoin, ammonia and calcium carbonate, which reduces bacterial growth and stimulates new formation of granulation tissue.

Material and Methods: In the period 4.1999–12.2003 42 patients (mean age 54 yrs (25–83), were included in cur prospective study for maggot treatment of severe infections after trauma (Osteomyelitis n=26, lower leg 13x, femur 6x, pelvis 4x, upper extremity 3x), necrotizing fasciitis n=7, soft tissue infection n=3, gangrene n-3, ulcus cruris n=3). Maggots were applied to the wound in a polyvinyl alcohol bag (Biobag) and were replaced every 3–4 days.

Results: The mean duration of treatment was 32,1 days (n~37) for the patients who had received one continuous treatment and 62,2 days if more treatments were applied (n=5). The average number of biobag changes per patient was 11.5 (range 4–30); the average number of maggots applied per patient was 863 (range 80–6840). In only 1 patient with osteomyelitis a lower leg amputation was necessary (1/26=3.8%) although in almost patients there was severe (multiple) co morbidity.

Conclusion: In our study the experimental use of maggots could reduce the amputation rate of limbs in case of severe infections after trauma. Our laboratory research investigations with analysis of the secreting enzymes of maggots will be presented to support that this «ancient» method has a place in modern traumatology to diminish invalidating amputations.

Anecdotal concern exists over the ability of current UK trainees to manage complex orthopaedic trauma.

A 15 item web-based survey sent to a sample of orthopaedic trainees. Power calculations deemed 222 responses from 888 trainees necessary to achieve a 5% error rate with 90% confidence limits.

232 responses were received. For cases involving external fixation or intramedullary nailing, perceived confidence and training adequacy was high despite infrequent exposure. Perceived confidence and adequacy of training in complex trauma is significantly lower. Less than 20% of trainees have full confidence in their ability to debride and stabilize mutilating hand injuries. 35% of trainees lack confidence in their assessment of limb viability and 56% lack confidence in amputation for extremity trauma. 71% of trainees are not confident in the management of junctional trauma and 68% regard their training in this field as inadequate. With regard to advanced resuscitation using novel blood product combinations; 65% of trainees are lacking confidence and 44% perceive their training as inadequate. For simple fracture stabilisation, vacuum dressings, antibiotic pro-phylaxis and fasciotomy, trainee perceived confidence increased with time in training. This increase did not occur in more complex trauma cases.

Perceived confidence amongst orthopaedic trainees in the management of routine extremity trauma is high despite limited exposure and concerns over changes in surgical training. This is in marked contrast to that reported in complex trauma. For military trainees, the value of supervised training on military deployment to gain experience in such cases is now apparent.