Historically rib fractures have been managed conservatively but over recent years evidence has continued to grow in support of fixation in select cases. Rib fractures can affect patients’ ability to adequately ventilate and increase the morbidity and mortality of patients with multiple injuries. There is increasing evidence that rib fracture fixation in certain patients is of benefit, reducing length of stay both in the Intensive Care Unit (ICU) and overall hospital stay, as well as resulting in a decreased rate of tracheostomy and pneumonia. We commenced rib fracture fixation two years ago as a combined procedure between Trauma Orthopaedics and Cardiothoracic surgery for carefully identified patients. We instituted a multi-disciplinary decision making process involving the Orthopaedic, Cardiothoracic and ICU teams. We present the initial results for these patients. Fourteen patients with a total of 49 ribs were fixed between November 2015 and August 2017. Nine patients were acute and multiply injured, with five patients treated with delayed fixation for ventilation problems following non-union of existing fractures. The average length of stay was 13 days. Follow up is ongoing with a mean follow up of 192 days. There have been no deep infections or acute complications and no incidence of peri-operative pneumothorax in this initial cohort. There have been no deaths, and all of these patients have since been discharged to their own home. The initial outcomes following the introduction of this new procedure to our unit have been encouraging, although the long term results are awaited.
Tranexamic Acid (TXA) is widely used to decrease bleeding by its antifibrinolytic mechanism. Its use is widespread within orthopaedic surgery, with level one evidence for its efficacy in total hip and knee replacement surgery; significantly reducing transfusion rates without increased thromboembolic disease. There is limited evidence for its use during hip fracture surgery, and we therefore sought to investigate its effects with a prospective cohort study. We recorded intra-operative blood loss, pre and post-operative haemoglobin and creatinine levels, post-operative complications and mortality in all hip fracture patients over a six month period. During this time, we introduced one gram of TXA into our standardised hip fracture theatre checklist. It was subsequently given to all patients unless contra-indicated. A total of 99 patients were included. 90-day mortality in the control group was 16%, there was no mortality in the TXA group (p<0.05). 14 patients required a transfusion in the control group and 3 in the TXA group (19% vs 11% transfusion rate, 0.36 units RCC vs 0.22 per patient respectively) Mean blood loss was 338 vs 235mls, Haemoglobin drop 23 vs 18g/dl control and TXA groups respectively. We have demonstrated a significantly lower mortality rate with TXA. We have also shown lower rates of transfusion, blood loss and recorded haemoglobin drop with the use of TXA. We intend to continue this study to demonstrate this significantly, and fully clarify the safety profile of TXA in this frail cohort of patients.
In 2004 the Scottish Sarcoma Network (SSN) was established with the aim of optimising management of patients with sarcoma. Clinical, radiological, oncological and pathological details of all bone and soft tissue sarcomas presenting in Scotland are registered and cases discussed in a multi-centre, tele-link multidisciplinary team (MDT) forum. The aim of this study was to establish any difference in referral patterns, time to specialist review, preoperative MRI scanning and appropriate biopsy before and after establishment of the Scottish Sarcoma Network in Grampian. A database was established of all patients presenting with sarcomas of the trunk or extremity in Grampian between 1991 and 2010. One hundred and fifty eight patients were randomly selected, 79 (50%) presenting prior to the establishment of the Scottish Sarcoma Network. Since the initiation of the Scottish sarcoma network we found that the median time of referral to review by the sarcoma service has improved from 19.5 days to 10 days (P=0.016). There has been an increase in the number of patients referred from other specialities while the number of general practice has remained fairly constant. This has resulted in a slight increase in the median total patient journey from 35 days to 41 days, this does not reach statistical significance. A greater number of patients are undergoing pre biopsy MRI scan, 53 (67%) before 2004 and 68 (86%) after (P=0.009). More patients are also undergoing appropriate biopsy 45(57%) before the network and 62(79%) after. The creation of the Scottish Sarcoma Network has had a positive impact on the care of sarcoma patients presenting in Grampian.
Chondrosarcoma is an uncommon primary malignancy of cartilage. This tumour tends to be resistant to both chemotherapy and radiotherapy making surgical resection the primary treatment. These tumours can present on the chest wall, requiring multidisciplinary team input at the time of surgery, involving orthopaedic, cardiothoracic and plastic surgeons. Complete excision, ensuring adequate resection margins, requires removal of ribs and pleura resulting in a full thickness chest wall defect. Complex reconstruction techniques are necessary to prevent post-operative morbidity of chest wall indrawing and reduced pulmonary function. Reconstruction can be considered in two parts, the reconstruction of the rigid support and the necessary soft tissue cover. In the past a number of options have been available to provide the rigid support, marlex sandwich, prolene mesh and autologous bone grafting. Each of these techniques has potential disadvantages. We describe two patients who underwent resection of chest wall chondrosarcomas. These patients had reconstruction of the rigid chest wall support using STRATOS (STRASBOURG Thoracic Osteosyntheses System). This system utilises clamps around the cut ends of the ribs to provide the necessary rigid support, eliminating some of the disadvantages of the older techniques. Both patients made an uncomplicated post-operative recovery. The STRATOS implant was easily used and versatile, providing an immediately secure and rigid fixation in chest wall reconstruction.
Five patients with recurrent disease were treated prior to establishment of the sarcoma network. Two patients, before the establishment of the network underwent resection and staging in another unit and the exact time to recurrence is unknown. One patient is currently under investigation for recurrence. The average time to recurrence was 29.2 months (Range 12–48 months). Three of the five patients with original pathology available had complete resection with mean margins of 6.25mm (range 5–7.5mm). Two had incomplete excisions carried out by other specialities, only presenting to our unit with recurrent disease.
