The August 2024 Trauma Roundup³⁶⁰ looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.

Aims

The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery.

Aims. Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice. Methods. This retrospective cohort study included consecutive patients undergoing TKA at a specialist centre in the UK between November 2010 and December 2012. Data were collected using a bespoke electronic database and cross-referenced with national arthroplasty audit data, with variables including: preoperative characteristics, intraoperative factors, complications, and mortality status. Patient-reported outcome measures (PROMs) were collected by a specialist research team at ten years post-surgery. There were 536 TKAs, of which 308/536 (57.5%) were in female patients. The mean age was 69.0 years (95% CI 45.0 to 88.0), the mean BMI was 32.2 kg/m. 2. (95% CI 18.9 to 50.2), and 387/536 (72.2%) survived to ten years. There were four revisions (0.7%): two deep infections (requiring debridement and implant retention), one aseptic loosening, and one haemosiderosis. Results. Kaplan-Meier analysis demonstrated no difference in implant survival according to sex, age, or obesity status. Ten-year PROMs were available for 196/387 (50.6%) surviving patients and were excellent: mean Oxford Knee Score 34.4 (95% CI 32.7 to 36.1); mean Forgotten Joint Score (FJS) 51.2 (95% CI 16.1 to 86.3); mean EuroQol five-dimension five-level questionnaire score 69.9 (95% CI 46.8 to 93.0); 141/196 (71.9%) achieved the 22-point FJS patient-acceptable symptom state (PASS); and 156/196 (79.6%) were “very satisfied or satisfied”. Conclusion. This is the only large study reporting ten-year implant survival and functional outcomes of TKA using a cemented single-radius design and with a CS tibial bearing construct. The findings of excellent implant survival, safety, and functional outcomes indicate that this combination is a safe and effective option in routine TKA. Further investigation of this single-radius design TKA with CS tibial bearings with well-matched patient study groups will allow further insight into the performance of these implants. Cite this article: Bone Joint J 2024;106-B(8):808–816

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

Aims

Weightbearing instructions after musculoskeletal injury or orthopaedic surgery are a key aspect of the rehabilitation pathway and prescription. The terminology used to describe the weightbearing status of the patient is variable; many different terms are used, and there is recognition and evidence that the lack of standardized terminology contributes to confusion in practice.

Aims

Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Introduction. VTE is a possible complication of foot and ankle surgery, however there is an absence of agreement on contributing risk factors in the development of VTE. The primary outcome of this study was to analyse the 90-day incidence of symptomatic VTE following foot and ankle surgery and to determine which factors may increase the risk of VTE. Methods. This was a national, multi-centre prospective audit spanning a collection duration of 9 months (2022/2023). Primary outcomes included incidence of symptomatic VTE and VTE related mortality up to 90 days following foot and ankle surgery and Achilles tendon rupture, and analysis of risk factors. Results. In total 11,363 patients were available for analysis. 5,090 patients (44.79%) were elective procedures, 4,791 patients (42.16%) were trauma procedures (excluding Achilles ruptures), 398 patients (3.50%) were acute diabetic procedures, 277 patients (2.44%) were Achilles ruptures undergoing surgery and 807 patients (7.10%) were Achilles ruptures treated non-operatively. There were 99 cases of VTE within 90 days of admission across the whole group (Total incidence = 0.87%), with 3 cases of VTE related mortality (0.03%). On univariate analysis, increased age and ASA grade showedhigher odds of 90-day VTE, as did previous cancer, stroke, history of VTE, and type of foot and ankle procedure / injury (p<0.05). However, on multivariate analysis, the only independent predictors for 90-day VTE were found to be the type of foot and ankle procedure (Achilles tendon rupture = Odd's Ratio 11.62, operative to 14.41, non-operative) and ASA grade (grade III/IV = Odd's Ratio 3.64). Conclusion. The incidence of 90-day post procedure VTE in foot and ankle surgery in this national audit was low. Significant, independent risk factors associated with the development of 90-day symptomatic VTE were Achilles tendon rupture management and high ASA grade

Objectives. The primary aim was to determine the differences in COVID-19 infection rate and 30 day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns. Design. Multicentre retrospective national audit. Setting. This was a combined retrospective (Phase 1) and prospective (Phase 2) national audit of foot and ankle procedures in the UK in 2020. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway. Results. 10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (p < .001). There was no significant difference in COVID-19 related mortality between pathways. Conclusions. There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways; however the success of the pathways only became significant in phase 2 of the study. The study shows a developing success in using green pathways in reducing the risk to patients undergoing foot and ankle surgery

Aims

During total knee replacement (TKR), surgeons can choose whether or not to resurface the patella, with advantages and disadvantages of each approach. Recently, the National Institute for Health and Care Excellence (NICE) recommended always resurfacing the patella, rather than never doing so. NICE found insufficient evidence on selective resurfacing (surgeon’s decision based on intraoperative findings and symptoms) to make recommendations. If effective, selective resurfacing could result in optimal individualized patient care. This protocol describes a randomized controlled trial to evaluate the clinical and cost-effectiveness of primary TKR with always patellar resurfacing compared to selective patellar resurfacing.

The June 2024 Knee Roundup³⁶⁰ looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants.

Aims

The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Introduction. The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK. Methods. A National collaborative study in affiliation with BOTA was conducted and data retrospectively collected between January 1. st. – June 30. th. 2019. Adult patients with open and closed complex ankle fractures (AO43/44) were included. Complex fractures included the following patient characteristics: diabetes ± neuropathy, rheumatoid arthritis, alcoholism, polytrauma and cognitive impairment. We obtained data on fixation choice and patient outcomes. Institutional approval was obtained by all centres, and statistical analysis was performed including propensity matching. Results. Fifty-six centres provided data for 1360 patients. The average age of the cohort was 53.9 years ±19 (SD) with a male/female ratio of 1:1.3. 920 patients were ASA 1/2, 440 were ASA 3/4; 316 had diabetes, and 275 were open fractures. Most fractures were AO44 (71.2%) and more commonly associated with diabetes (P<0.001), alcoholism (P<0.007), open (P<0.013), and advanced age (55.7 vs. 46.3). 1227 patients underwent primary-fixation (111 HFN), with the remainder treated with external-fixation (84 definitive). Of the 111 HFN, 35% underwent primary fusion. Wound complication and thromboembolic rates were greater in the HFN group compared to ORIF groups (P<0.003), being more evident in the HFN group with primary fusion even after propensity matching. However, 1081 patients were non-weightbearing post-op contrary to the BOAST guidance. Conclusion. This is the first National collaborative audit of complex ankle fractures. Hindfoot nails were used in 9% of patients and we observed more complications in this group when compared to other cohorts. Despite BOAST guidance, only 21% of patients undergoing operative management were instructed to fully weightbear post-operatively

Objectives. The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. Design. Multicentre retrospective national audit. Setting. UK-based study on foot and ankle patients who underwent surgery between the 13. th. January to 31. st. July 2020 – examining time periods pre- UK national lockdown, during lockdown (23. rd. March to 11. th. May 2020) and post-lockdown. Participants. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Main Outcome Measures. Variables recorded included demographics, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. Results. 6644 patients were included. In total 0.52% of operated patients contracted COVID-19 (n=35). The overall all cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n=9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n=3 deaths). Matching for age, ASA and comorbidities, the OR of mortality with COVID-19 infection was 11.71 (95% CI 1.55 to 88.74, p=0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and amongst patients with and without COVID-19 infection. After lockdown COVID-19 infection rate was 0.15% and no patient died of COVID-19 infection. Conclusions. COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and post-operative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions

Aims

Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures.

Introduction. Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. Methods. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded. Results. Forty-four patients underwent fibular nail fixation in the two centres. The average age was 59 (range 21–91). Using Pettrones criteria, 86% were malreduced at time of operation. A further 34% deteriorated by at least 1 grade by 6 weeks and an additional 16% (n=7) deteriorated by at least 1 grade by 1 year. 57% had developed radiographic evidence of osteoarthritis by 1 year. Only 4.5% (2ankles) maintained complete reduction by 1 year. Other significant complications were reported in 43% of patients. Conclusion. Both major trauma centres report the same experience in the use of fibular nails for ankle fracture fixation. As previously reported in smaller number studies, initial reduction is challenging. Worryingly, the majority of well-reduced lose position with time. We suggest that the fibula nail is used with caution and as part of an appropriately approved audit

Lateral approach open calcaneal osteotomy is the described gold standard procedure in the management of hindfoot deformity. With development of minimally invasive surgery, a MIS approach has been described, citing fewer wound complications and lower risk of sural nerve injury. This audit compares MIS to the traditional procedure. A retrospective review of all patients undergoing calcaneal osteotomy in Northumbria Trust in the past 5 years was performed. A total of 105 osteotomies were performed in 97 patients; 28 (13M:15F) in MIS group and 77 (40M:37F) had an open approach. The average age was 52.1 (range 16–83) for MIS and 51.5 (range 18–83) in the open group. All patients were followed up for development of wound complication, nerve injury and fusion rate. Wound complications were similar (10.7% in MIS group vs 10.3% in Open group) with no significant difference (p=0.48). Patients were treated for infection in 3(3.8%) cases in the open group and 2(7.1%) in the MIS group. This difference was not significant (p=0.43). 4 (14.3%) patients in the MIS group had evidence of sural nerve dysfunction post-operatively (managed expectantly), compared to 12(15.5%) patients in the open group (p=0.44). Of these, 2 went on to undergo neuroma exploration. There was no difference in nerve dysfunction in varus or valgus correction. Mean translation in the open group was measured as 7.3mm(SD=1.91;3 to 13mm) and 7.5mm(SD=1.25;5 to 10mm) in the MIS group. Translation was similar in varus or valgus correction. Non-union occurred in 2 patients in the MIS group and none in the open group (p= 0.06). MIS calcaneal osteotomy is a safe technique, that works as effectively as osteotomy performed through an open approach. There were lower rates of nerve injury, wound complication and infection, but this was not significantly different comparing groups. There was a higher risk of non-union in MIS technique

Total Hip Arthroplasty (THA) and Hip Hemiarthroplasties (HA) are successful, cost-effective procedures that improve quality of life. Dislocation is a well recognised complication with a significant health and economic burden. We aim to establish the current management practices across the United Kingdom (UK) for Prosthetic Hip Dislocations (PHD). Our definition of a PHD includes; THA, HA and revision THA. This national study builds on our regional pilot study and records one of the largest datasets of Prosthetic Hip Dislocation management within the UK. A trainee-led collaborative; the North West Orthopaedic Research Collaborative (NWORC). Conducted a retrospective audit, registered as Quality Improvement (QI) projects, collected data from 38 hospital trusts across the UK. Data was collected on patient-related factors, inpatient management, and outpatient follow up of each PHD episode between January and July 2019. Primary outcome measured definitive management, in the form of revision surgery or the consideration for this through a referral pathway. A total of 673 (THA 504, Revision THA 141, HA 28) patients were included with a total of 740 dislocation episodes. Mean age was 75.6 years with female to male ratio 2:1. The majority of PHDs were a result of a low energy mechanism (98.7%) and presented over 6 months post index procedure (80.5%). Over half (53.8%) attended with a first or second time dislocation. Only 29.9% patients received onward revision referral; whereas 70.1% followed diverse management patterns, including local non-arthroplasty and primary arthroplasty surgeon follow-ups. Revision THAs had higher rates of referral for revision (p<0.001) compared to primary THA and HA dislocations. A high number of PHDs present across the UK, with under a third receiving definitive management plans. This variation increases the economical burden to the National Health Service, highlighting the need for national guidance to manage these complex patients

The benefits of cell salvage autotransfusion are well reported. There is a common non-evidenced belief amongst revision arthroplasty surgeons that auto-transfusion is potentially contraindicated in infected revisions. The aim is to study the immediate and delayed outcomes of using cell saver on patients undergoing PJI surgery. Prospective cohort service evaluation registered with the local audit department. 20 PJI cases in 18 patients where cell saver was used over a period of 4 years. Intraoperative fluid and tissue samples were taken for culture. Blood culture from salvaged blood pre and post leucodepletion filter were sent for microbiological analysis. Data on type of surgery, blood loss, further allogenic transfusion and SIRS response was collected. Success of infection clearance was assessed using 2019 MSIS ORT. Five patients receiving autologous blood in non-infection cases were used as controls. Mean age for the PJI group was 67.7 years, 67% female. 11 patients (67%) had 1st stage surgery and 5 (25%) underwent 2nd stage whereas 4 patients had single stage surgery. The mean calculated blood loss was 1398 mls (range 400–3000mls). 6 Patients required further allogenic transfusion. 16 patients received blood via a leuco-depletion filter. The same organism grown from tissues was identified in post-filter blood in 8/17 patients (47%). 2/20 have grown a different organism in post-filtered blood, _P.Acne._. 2 patients developed SIRS upon auto-transfusion, however one was thought to be secondary to cementing. The control group had 443 mls mean amount of blood loss and 1 patient developed a SIRS response. 14/20 (70%) patients had successful clearance of infection (tier 1) 2 patients died prior to undergoing 2nd stage. Using cell saver did not impact main outcome of infection clearance in PJI surgery. We would advocate its routine usage whilst avoiding direct collection of heavily contaminated blood