The Victorian state government introduced a trial electronic scooter sharing scheme on 1^st February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme.

Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death.

In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months.

58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10.

Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers.

Complications are an inevitable part of orthopaedic surgery, how one defines complications can have an impact on the ability to learn from them. A group of general surgeons headed by Clavien and Dindo et al.¹ have previously published their classification system for surgical complications based on the type of therapy required to correct the complication.

Our aim was to evaluate a modification of this classification system and its use over a 12-month period at our institution via our departmental audits, our hypothesis being that this would direct appropriate discussion around our complications and hence learning and institutional change.

A modified Clavien-Dindo Classification was prospectively applied to all complications recorded in the Orthopaedic departmental quarterly audits at our institution for a 12-month period (4 audits). The audit discussion was recorded and analysed and compared with the quarterly complication audits for the preceding 12-month period.

The modified Clavien-Dindo classification for surgical complications was applicable and reproducible to Orthopaedic complications in our level 1 trauma centre. It is a transparent system, objective in its interpretation and avoids the tendency to down-grade serious complications. It was easy to apply and directed discussion appropriately at our quarterly audit meetings on complications where there was a preventable outcome or important learning point. In particular modifications to VTE and Death classes allowed the unit to focus discussion on cases where complication was preventable or unexpected.

The modified Clavien-Dindo classification system is an easy to use and reproducible classification system for Orthopaedic complications in our unit it directed audit discussion towards cases where complications were preventable or had a learning point.

Aims

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA).

The Orthopaedic Unit at The Alfred has been using an external fixator in a novel configuration for protecting lower limb wounds after free flap surgery (sometimes even in the absence of a concomitant bony injury). This soft-tissue frame allows the limb to be elevated without contact so that there is no pressure on the flap and its pedicle. Thus, optimising the arteriovenous circulation. We report our initial experience with these soft tissue frames.

The soft tissue frame is not necessarily applied for definitive fracture care, but constructed or modified to optimise elevation of the leg, remove direct pressure from the soft tissues, and stabilise the muscles adjacent to the flap. All ankle-spanning frames held the foot in a plantargrade position to optimise blood flow and recovery (prevent equinus), and minimise intra-compartmental pressure.

During 2007, the Plastic Surgery Unit performed 23 free flaps to the lower limbs of 22 patients. Five of these patients had a soft-tissue frame constructed. One patient had a frame applied purely to manage the soft tissue injury, and the other four, who required an external fixator for a bony injury, had their frame modified. Four of the five patients study patients were injured in motor vehicle accidents and one was injured in a simple fall. All five free flaps survived and none required any further surgery. No patients suffered complications (such as bleeding, pin-track infections, or osteomyelitis) related to the soft tissue frame.

We strongly recommend considering an external fixator in a modified configuration after lower limb free flap surgery. Constructing a soft tissue frame has no added risks if the fixator is already required. In the case where there is no bony injury, a soft tissue frame has the benefits of providing optimal flap conditions and maintaining anatomical joint alignment. However, this must be balanced against the small risk associated with the insertion of pins (such as infection) and the need for an extra procedure to remove the frame. As always, treatment must be tailored to the individual patient.

Despite the publication of numerous studies, controversy regarding the non- operative treatment of type II dens fractures remains. The halo-thoracic vest (HTV) and cervical collar are the most commonly used devices. We sought to compare the outcomes of patients managed with these devices in terms of non-union risk factors and associated complication rates.

This study was a retrospective review of adult patients with type II dens fractures treated non-operatively at a level one trauma centre between 2001 and 2007. The patients were identified using a hospital trauma database. Each patient included in the study had a minimum follow up of six months. Patient medical records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union, measured at three months. A p-value of < 0.05 was considered statistically significant.

Sixty-seven patients were included. Thirty-five patients were treated using a HTV and 32 with a collar. Non-union was found to be associated with increased time in HTV or collar (p = 0.011) and with a mechanism of injury involving a low fall (p = 0.008). In addition, the proportion of patients with stable union at three months was 60% for the HVT group versus 35% for the cervical collar group (p = 0.10). There were trends to support an increased risk of non-union with a patient age of greater than or equal to 65 years at the time of presentation (p = 0.13) as well as with a fracture displacement of greater than or equal to 2 mm at time of presentation (p = 0.17). Clinically significant complications of the HTV were of greater prevalence than those experienced by collar patients. Sixty percent of HTV patients suffered one or more complications compared with 6% of collar patients.

We were unable to demonstrate any clear advantage or disadvantage of either device. Further investigation of mortality would be beneficial, particularly in the patient group injured with a mechanism involving a low fall (which tends to include more elderly patients).

Despite increasing use of vena cava filters (VCFs) for pulmonary embolism (PE) prophylaxis after major trauma, there is continued debate regarding their safety and efficacy. We aimed to evaluate the impact of prophylactic VCFs on the incidence of PE after major trauma and to describe VCF related complications.

Prospectively collected data from The Alfred Hospital Trauma Registry were used to identify all major trauma patients admitted between 1 July 2001 and 1 July 2008. Data for each patient was collated from the registry. This included patient demographics, injury specific data, management details (including prophylactic VCF use) and clinical outcomes (including the occurrence of PE). Medical record and radiology chart review was used to verify all PEs. Potential PE risk factors were assessed as covariates in a univariate analysis, with PE as the dependent variable. A multivariate analysis was then performed using multiple logistic regression adjusting for baseline imbalances and known covariates.

During this period, 6,344 major trauma patients were treated, with 73.2% male, mean age of 44.2 +/− 21.0 SD, 90.2% with a blunt mechanism of injury and mean ISS of 24.3 +/− 12.0 SD. Of these patients, 511 (8.1%) received prophylactic VCFs, (inserted in absence of PE) at the discretion of the treating clinician. There were 45 PE (incidence of 0.71%), of which two were fatal. Three variables were independently associated with the occurrence of PE in the multivariate analysis: (i) presence of prophylactic VCF (OR 0.28; 95%CI 0.09 - 0.89); (ii) number of injuries to the AIS body region lower limb (OR 1.31; 95%CI 1.17 - 1.47) and (iii) central venous catheterisation (OR 1.87; 95%CI 1.88 - 6.17). Data was available on the VCF database for 429 of the 511 patients with VCFs (84.0%). The mean time to prophylactic VCF insertion was 3.6 +/− 0.2 SEM days after admission. The VCF major complication rate was 2.6% (n=11), including four non-fatal PE. The technical success rate for retrieval was 92.4% (279 retrievals from 302 attempts) and the overall retrieval rate was 65.0% (279 retrievals from 429 placements).

Prophylactic VCFs are associated with a reduced rate of PE when used in selected major trauma patients. In addition, prophylactic VCFs have a low major complication rate and high rate of technical success for retrieval.

Background: Hip fractures are a common cause of hospitalisation amongst elderly patients, imposing a burden on resources and resulting in significant morbidity and mortality. Despite the high incidence questions remain surrounding the efficacy of current treatment protocols. There has also been relative neglect, within current literature, of the ‘young’ hip fracture patient.

Objectives: To analyse clinical and patient-reported outcomes for patients with hip fractures treated at two Australian level-1 trauma centres, and, to highlight key differences between the ‘typical’ patient (age> 60 years) and those aged 60 years or less.

Methods: Patients with traumatic proximal femoral fractures treated at The Royal Melbourne and Alfred hospitals between 2003 and 2006 were identified via the Victorian Orthopaedic Trauma Outcomes Registry. Patient-reported outcomes were prospectively measured at 6 and 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12) and a Numerical Pain Scale. A priori defined clinical outcomes were also determined by reviewing medical records and X-rays.

Results: A total of 695 patients were identified with similar distribution between institutions. The male: female ratio was 1:2 and 13.8% were aged 60 years or less at presentation. ‘Community-dwellers’ accounted for 69.9% with 25.6% presenting from an institutional setting. Displaced subcaptial fractures (AO-31B3) occurred most commonly.

Median hospital length of stay was 12 days. Inpatient mortality reached 5.5% whilst mortality at 6 and 12 months post-injury was 17.1% and 22.6% respectively. Upon discharge 16.1% returned to the community and 60.5% required rehabilitation. At 6 months 48.0% were residing at home and 30.5% at an institutional setting. Institutionalisation decreased to 27.7% at 12 months, approaching pre-injury levels. Mean physical SF-12 scores remained well below population norms at 12 months (36.4 vs 48.9). Younger patients demonstrated significantly different results with reference to presentation, management and outcomes. Several factors were highlighted as predictors of mortality and/or functional recovery.

Conclusions: Mortality following hip fracture treatment at an Australian level-1 trauma centre is comparable to statistics achieved by similar international institutions. The rise in mortality is greatest within the initial 6 months representing a period during which close medical attention is paramount. The Mortality predictors highlighted may be useful in guiding this resource allocation. Patient-reported health status also plateaus following the initial 6 months, warranting a review of current protocols to ascertain whether this represents a golden ‘window-period’ for successful rehabilitation or whether appropriate care is not being provided beyond 6 months. Patients aged 60 years or younger represent a significant and unique group. Approach to management and goals of treatment should be tailored accordingly.

Introduction: The aim of this study was to assess the learning curve of spinal internal fixation with pedicle screws of a spinal fellow (AG) with no previous experience with the technique, during a 2-year fellowship at a referral spinal surgery centre in Australia.

Methods: Patients treated with pedicle screw (PS) placement by the spinal fellow under the supervision of the attending orthopaedic or neurosurgery consultant were included in this study. Postoperative plain x-rays and, in some cases, computed tomography scans (CT scans) were obtained. PS position was assessed by two blinded independent reviewers, one radiologist (observer 1) and one spinal surgeon (observer 2), using a grading scale. PS placed by the attending consultants were included in the evaluation as distractors. The screws were classified using a grading scale in 3 groups: Correct, Border-line, and Incorrect. After assessment, the PS were rearranged in groups of 40 screws, in chronological order, for comparison and assessment of the progress in the learning curve.

Results: 94 patients underwent internal fixation of the spine from upper thoracic to the sacral region with PS (584 screws in total) between February 2006 and December 2007. Eight cases (40 screws) were excluded because of lack of image studies or severe spinal deformities. Among the 544 screws under evaluation, 320 (58.8%) were performed by the spinal surgery fellow, 187 (34.4%) by the attending consultant and 37 (6.8%) by orthopaedic and neurosurgery registrars, the latter evaluated but excluded for the statistical analysis. The overall precision for the 507 screws analysed was 84.2% according to observer 1 and 77.9 % according to observer 2. When the analysis was narrowed down to the 320 screws done by the fellow, this precision increased to 84.7% for observer 1 and decreased to 76.6% according to observer 2. A learning curve was created consisting of 8 groups of 40 screws in chronological order. There was a statistical significance (p< 0.05) in the rate of Incorrect and Border-line PS when comparing the first 100 PS with the rest of the series. None of the patients (included and excluded) developed neurological complications because of the misplaced PS.

Discussion: The findings reveal a learning curve of PS placement. In this series, the inflexion point in the learning curve for this technique was between 80 and 120 screws, which in the present series represented the spinal fellow intervention in 20 to 30 cases. After approximately 150 PS no significant changes can be observed: the learning curve remains stable, with a constant decreasing trend. With appropriate expert supervision the fellowship training system is a safe and appropriate method to learn this technique.

Introduction Spinal cord monitoring in posterior scoliosis surgery has become a standard of care. It has been our practice since 1999, to monitor the somato-sensory potential (SEP) and motor evoked potential (MEP) in all posterior cases. We report on and discuss the meaning of alteration in the spinal cord monitor signal that occurred in 15 cases from a total of 165 procedures.

Methods This is a retrospective review of patients from a hospital database. Over a six year period, 167 posterior scoliosis instrumented fusion procedures were performed by paired combinations of the four authors. In 13 cases we have been alerted to a change in one or both signals during the procedure. Associated with these, were two cases of intra-operative cardiac arrest, and six cases of post-operative neurological deficit. All patients remain under continued regular review.

Results In the two cases of intra-operative cardiac arrest, the SEP and MEP signals were lost approximately three minutes prior to the arrest. Both patients had neurological deficits post-operatively, one has totally recovered, and one has a residual complex regional pain syndrome of the right leg. This last patient is the only one of six who has not had complete resolution of the post-operative neurological deficit. In five of the six cases who sustained post-operative neurological deficits, the SEP and usually the MEP was lost and did not return. In the sixth case, the SEP did return. In the remaining seven cases, there were changes of decreased amplitude or increased latency in the SEP or MEP that did not appear to result in a postoperative clinical consequence, however; in two patients, signal changes were directly related to changes in blood pressure, and in two other patients, signal changes were directly related to concave hook placement.

Discussion On review of the management and outcome of these cases, we conclude that profound hypotension will alter the SEP and may herald a catastrophic cardiovascular or neurological event. Furthermore, the modality of continuous spinal cord monitoring can provide specificity in the diagnosis of an actual or impending neurological insult and allow for appropriate and timely intervention. We believe spinal cord monitoring in the posterior approach for spinal deformity is an invaluable tool, and is in fact, mandatory for all idiopathic and ambulant non-idiopathic spinal deformities.

Introduction: The principles of treatment of deep wound infection around bony implants involves appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals.

Methods: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from 4 years to 3 months.

Results: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics.

Discussion: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care.

INTRODUCTION: The principles of treatment of deep wound infection around bony implants involve appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals.

METHODS: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from four years to three months.

RESULTS: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics.

DISCUSSION: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care.