Objectives. The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) versus a manual TKA (MTKA) approach. Methods. A total of 12 fresh-frozen pelvis-to-toe cadaver specimens were included. Four surgeons each prepared three RATKA and three MTKA specimens for cruciate-retaining TKAs. A RATKA was performed on one knee and a MTKA on the other. Postoperatively, two additional surgeons assessed and graded damage to 14 key anatomical structures in a blinded manner. Kruskal–Wallis hypothesis tests were performed to assess statistical differences in soft-tissue damage between RATKA and MTKA cases. Results. Significantly less damage occurred to the PCLs in the RATKA versus the MTKA specimens (p < 0.001). RATKA specimens had non-significantly less damage to the deep medial collateral ligaments (p = 0.149), iliotibial bands (p = 0.580), poplitei (p = 0.248), and patellar ligaments (p = 0.317). The remaining anatomical structures had minimal soft-tissue damage in all MTKA and RATKA specimens. Conclusion. The results of this study indicate that less soft-tissue damage may occur when utilizing RATKA compared with MTKA. These findings are likely due to the enhanced preoperative planning with the robotic software, the real-time intraoperative feedback, and the haptically bounded saw blade, all of which may help protect the surrounding soft tissues and ligaments. Cite this article: Bone Joint Res 2019;8:495–501

Aims. The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups. Methods. This prospective randomized controlled trial included 30 patients with osteoarthritis of the knee undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localized knee temperature were collected preoperatively and postoperatively at six hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned postioning of the components in both groups. Results. Patients undergoing conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory and localized thermal response at six hours, day 1, day 2, and day 28 after surgery. Robotic TKA had significantly reduced levels of interleukin-6 (p < 0.001), tumour necrosis factor-α (p = 0.021), ESR (p = 0.001), CRP (p = 0.004), lactate dehydrogenase (p = 0.007), and creatine kinase (p = 0.004) at day 7 after surgery compared with conventional TKA. Robotic TKA was associated with significantly improved preservation of the periarticular soft tissue envelope (p < 0.001), and reduced femoral (p = 0.012) and tibial (p = 0.023) bone trauma compared with conventional TKA. Robotic TKA significantly improved the accuracy of achieving the planned limb alignment (p < 0.001), femoral component positioning (p < 0.001), and tibial component positioning (p < 0.001) compared with conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (< 48 hours) or late (day 28) postoperative systemic inflammatory response compared with conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced femoral and tibial bone trauma, and improved accuracy of component positioning compared with conventional TKA. Cite this article: Bone Joint J 2021;103-B(1):113–122

Introduction. While manual total knee arthroplasty (MTKA) procedures have demonstrated excellent clinical success, occasionally intraoperative damage to soft tissues can occur. Robotic-arm assisted technology is designed to constrain a sawblade in a haptic zone to help ensure that only the desired bone cuts are made. The objective of this cadaver study was to quantify the extent of soft tissue damage sustained during TKA through a robotic-arm assisted (RATKA) haptically guided approach and conventional MTKA approach. Methods. Four surgeons each prepared six cadaveric legs for CR TKA: 3 MTKA and 3 RATKA, for a total of 12 RATKA and 12 MTKA knees. With the assistance of an arthroscope, two independent surgeons graded the damage of 14 knee structures: dMCL, sMCL, posterior oblique ligament (POL), semi-membranosus muscle tendon (SMT), gastrocnemius muscle medial head (GMM), PCL, ITB, lateral retinacular (LR), LCL, popliteus tendon, gastrocnemius muscle lateral head (GML), patellar ligament, quadriceps tendon (QT), and extensor mechanism (EM). Damage was defined as tissue fibers that were visibly torn, cut, frayed, or macerated. Percent damage was averaged between evaluators, and grades were assigned: Grade 1) complete soft tissue preservation to ≤5% damage; Grade 2) 6 to 25% damage; Grade 3) 26 to 75% damage; and Grade 4) 76 to 100% damage. A Wilcoxon Signed Rank Test was used for statistical comparisons. A p-value <0.05 was considered statistically significant. Results. Significantly less damage occurred to the PCL in the RATKA than the MTKA specimens (p=0.004). RATKA specimens had less damage to the dMCL (p=0.186), ITB (p=0.5), popliteus (p=0.137), and patellar ligament (p=0.5). The sMCL, POL, SMT, GMM, GML, LR, LCL, QT, and EM were grade 1 in all MTKA and RATKA specimens. No intentional soft tissue releases were performed in either group to balance the knee. Discussion/Conclusion. The results of this study indicate that RATKA may result in less soft-tissue damage than MTKA, especially to the posterior cruciate ligament. This finding can potentially be attributed to RATKA using a haptic boundary to constrain the sawblade, which can help prevent unwanted soft-tissue damage. However, since any damage was post-operatively assessed and in a cadaveric model, further investigations on soft-tissue damage from patients with clinical outcomes should be performed

Patients with bilateral femur fractures are known to be at a high risk for the Systemic Inflammatory Response Syndrome; however the impact of fracture-associated soft tissue injury in the induction of systemic inflammation following bilateral femur fracture is poorly understood. To address this, the systemic inflammatory response and remote organ dysfunction following bilateral femur fracture with various degrees of soft tissue injuries were investigated in this study. 6–8 weeks old male C57/BL6 mice (n = 4–8 animals per group) were grouped as follows: Control-group (no anaesthesia, no femoral catheterisation); Sham-group (6 hour anaesthesia, femoral catheterisation); Fx-group (6 hour anaesthesia, femoral catheterisation, bilateral femur fracture with minor soft tissue injury); Fx+STI-group (6 hour anaesthesia, femoral catheterisation, bilateral femur fracture with severe soft tissue injury). Six hours after bilateral femur fracture serum levels of IL-2, IL-4, IL-6, IL-10, IL-12, TNF-α, KC and MCP-1 were measured. Furthermore, IL-6 levels of homogenized liver tissue were assessed. Neutrophil accumulation in liver and lung was determined with a myeloperoxidase (MPO) assay. Changes in liver permeability were assessed by measuring the wet-dry-ratio. The Fx+STI-group showed significantly increased serum cytokine levels as compared to the Fx- or Sham-group. The homogenized liver tissue of the Fx+STI-group showed significantly increased IL-6 levels as compared to the Sham-group. The MPO activity in lung and liver in the Fx+STI-group was significantly increased in comparison to the Fx- or Sham-group and in the Fx-group in comparison to the Sham-group. The wet-dry-ratio of the liver was significantly increased in the Fx+STI-group as compared to the Sham-group. The degree of fracture-associated soft tissue injury appears to modify systemic inflammation following bilateral femur fracture and is able to induce remote organ dysfunction. These results may have implications that have been underestimated, thus warranting clinical follow-up studies

Aim

The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality.

Introduction and Objective. Despite the low incidence of pilon fractures among lower limb injuries, their high-impact nature presents difficulties in surgical management and recovery. Current literature includes a wide range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm that was applied consistently over the span of this study. Materials and Methods. This retrospective study was conducted at a single institution, including 141 pilon fractures in 135 patients, from August 2014 to January 2021. AO/OTA classification was used to classify fractures. Among closed fractures, 12 had type 43A, 18 had type 43B, 61 had type 43C. Among open fractures, 11 had type 43A, 12 had type 43B, 27 had type 43C. Open fractures were further classified with Gustilo-Anderson (GA); type 1: n=8, type 2: n=10, type 3A: n=12, type 3B: n=20. Our treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency. All open fractures, and closed fractures with severe soft tissue injury (skin contusion, fracture blister, severe oedema) were initially treated with temporary ankle-spanning external fixation. For all open fracture patients, surgical debridement, soft tissue cover with a free or pedicled flap were performed. For GA types 1 and 2, this was done with ORIF in the same operating session. Those with severe soft tissue injury (GA type 3) were treated with FWF four to six weeks after soft tissue management was completed. Primary outcome was AOFAS Ankle-Hindfoot score at 3, 6 and 12-months post-treatment. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time. All complications were recorded. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of the 141 fractures healed without further intervention (84.4%). Average time to bone union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). Union took longer in closed fracture patients treated with FWF than ORIF (p=0.025). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042; OR=2.558, 95% CI 1.016–6.441), bone defect (p=0.001; OR=5.973, 95% CI 1.986–17.967), and superficial infection (p<0.001; OR=4.167, 95% CI 1.978–8.781). Conclusions. The use of a two-staged approach involving temporary external fixation followed by definitive fixation, provides a stable milieu for soft tissue recovery. FWF combined with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Aims. The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques. Methods. We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates. Results. The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes. Conclusion. The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results. Cite this article: Bone Jt Open 2024;5(3):227–235

Intimate partner violence (IPV) causes significant morbidity and its unlikely to be reported compared to other forms of gender-based violence (GBV). For early detection, understanding Orthopaedic injuries from GBV is vital. This study assesses the pattern of musculoskeletal injuries from GBV and determines the factors associated with it. It is a retrospective observational study of patients aged ≥18 years, with GBV-related acute Orthopaedic injuries. Data was reviewed from January 2021 to December 2021, including, demographic information, soft tissue and bony injuries, relationship to assailant, substance abuse and the day and time of injury. Frequencies and percentages for categorical data were analysed. Chi-square test was used to calculate association. T-test was used to compare groups for continuous & categorical variables. Multivariate analysis was conducted to find the odds ratio and a p-value <0.05 was statistically significant. 138 patients were included, the mean age at presentation being 35.02 years (SD=11). 92.75% of GBV victims were females. Most were unemployed (66.7%). 30.43% (n-42) had a soft tissue injury; superficial laceration being the most common (23.1%), flexor tendon injury (10.87%), hand abscess (5.8%), and extensor tendon injury (5.07%). 71.02 % (n=98) sustained appendicular fractures. 51.45% (n=71) sustained upper limb fractures; distal radius fractures (10.86%) and distal 3rd ulnar fractures (9,42%). 19.57% (n=27) had lower limb fractures; 7.25% (n=10) had lateral malleolus ankle fractures. 63.7% (n=80) of cases were by an intimate partner on weekends (50.73%). 62.31% occurred between 16h00 and 0h00. 41.1% (n=65) reported alcohol abuse. 63.04% had surgery. GBV likely occurs in early middle-aged females by intimate partners influenced by alcohol over the weekends between 16h00 to 0h00. Distal radius/distal 3rd ulnar fractures are the most common bony injuries. Superficial wrist laceration is the commonest soft tissue injury. These findings may assist with early detection and intervention to prevent adverse outcomes in GBV

Introduction. The objectives of this study were to compare the systemic inflammatory reaction, localised thermal response and macroscopic soft tissue injury outcomes in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic total knee arthroplasty (robotic TKA). Methods. This prospective randomised controlled trial included 30 patients with symptomatic knee osteoarthritis undergoing conventional TKA versus robotic TKA. Predefined serum markers of inflammation and localised knee temperature were collected preoperatively and postoperatively at 6 hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned limb alignment and implant positioning in both treatment groups. Results. Conventional TKA and robotic TKA had comparable changes in the postoperative systemic inflammatory reaction and localised thermal response at 6 hours, day 1, day 2 and day 28 after surgery. Robotic TKA had reduced levels of interleukin-6 (p<0.001), tumour necrosis factor-α (p=0.021), erythrocyte sedimentation rate (p=0.001), C-reactive protein (p=0.004), and creatine kinase (p=0.004) at day 7 after surgery compared to conventional TKA. Robotic TKA was associated with improved intraoperative preservation of the periarticular soft tissue envelope (p<0.001) and reduced bone trauma (p=0.015) compared to conventional TKA. Robotic TKA improved accuracy of achieving the planned limb alignment (p<0.001), femoral component positioning (<0.001), and tibial component positioning (<0.001) compared to conventional TKA. Conclusion. Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (<48 hours) or late (day 28) postoperative systemic inflammatory responses compared to conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced bone trauma and improved accuracy of implant positioning compared to conventional TKA

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Abstract. Objectives. Current literature on pilon fracture includes a range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm applied consistently over the span of this study. Methods. 135 patients over a 6-year period were included. Primary outcome was AOFAS score at 3, 6, 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB), full weight-bear (FWB), bone union time, follow-up time. AO/OTA classification was used (43A: n=23, 43B: n=30, 43C: n=82). Treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis was performed in combination with FWF to improve joint congruency. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of 141 fractures healed without further intervention (84.4%). Average time to union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). On average, open, and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042;OR=2.558,95% CI 1.016–6.441), bone defect (p=0.001;OR=5.973,95% CI 1.986–17.967), and superficial infection (p<0.001;OR=4.167,95% CI 1.978–8.781). Conclusions. FWF with minimally invasive osteosynthesis, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Introduction. Being challenging, multifragmentary proximal tibial fractures in patients with severe soft tissue injuries and/or short stature can be treated using externalized locked plating. A recent finite element study, investigating the fixation stability of plated unstable tibial fractures with 2-mm, 22-mm and 32-mm plate elevation under partial and full weight-bearing, reported that from a virtual biomechanical point of view, externalized plating seems to provide appropriate relative stability for secondary bone healing under partial weight-bearing during the early postoperative phase. The aim of the current study was to evaluate the clinical outcomes of using a LISS plate as a definitive external fixator for the treatment of multifragmentary proximal tibial fractures. Methods. Following appropriate indirect reduction, externalized locked plating was performed and followed up in 12 patients with multifragmentary proximal tibial fractures with simple intraarticular involvement and injured soft tissue envelope. Results. Among all patients, the average follow up period was 22 months (range14–48 months), revealing uneventful healing in all of them. Time to fracture union was 21.8 weeks on average (range 16–28weeks). The mean HSS knee score was 87 (range 72–98) at 4 weeks postoperatively and 97 (range 88–100) at the final follow up. The average AOFAS score was 92 (range 84–100) at 4 weeks postoperatively and 98 (range 94–100) at the final follow up. Conclusions. Externalized locked plating seems to be a successful surgical alternative treatment in selected cases with unstable proximal tibial fractures and severe soft tissue injury, following appropriate indirect fracture reduction

Introduction. Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS. Methods. This project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September. Results. Between the two cycles there was an average 19% improvement in quality of the referrals, significant reduction in number of inappropriate referrals for soft tissue knee and shoulder injuries from 15.1% (n=50) to 4.5% (n=15) following our intervention. There was an 8% increase in number of fracture clinic appointments to 74.4% (n=247), primarily due to an increase number of referrals from nurse practitioners. Radial head fractures were targeted as one group that were able to be successfully managed in VFC, despite this 64% (n=27) of patients were still seen in the outpatient department following VFC referral. Conclusion. Despite the decrease in the number of inappropriate referrals, and the increase in quality of referrals following our intervention. The percentage of VFC referrals in CAVUHB is still higher than other centres in with established VFCs in England. This possibly highlights the need for further education to emergency staff around describing what injuries are appropriate for referral, specifically soft tissue injuries and radial head fractures. In order to optimise the VFC process and provide further cost savings benefits while reducing the strain on fracture clinics

Determine the prevalence, etiologies, and risk factors of unplanned return to the OR (UROR) in adult orthopaedic trauma patients. Retrospective review of a trauma prospective registry from 2014 – 2019 at a Level 1 academic hospital. An UROR was defined as a patient returning to OR unexpectedly following a planned definitive surgery to either readdress the presenting diagnosis or address a complication arising from the index procedure. Univariate and multivariate logistic regression was performed comparing those patients with an UROR versus those without. A total of 1568 patients were reviewed. The rate of UROR was 9.8% (153 patients). Symptomatic implant was the leading cause of UROR (60%). Other significant UROR causes were infection (15%) and implant failure (9%). The median time between index procedure and UROR was 301 days. For the univariate and multivariate analysis, open fracture (p< 0.05), fracture complexity (p<0.01), and weekend procedure (p< 0.01) were all associated with increased risk of UROR. All other variables were not statistically significant for any associations. Those patients with an UROR for reasons other than symptomatic implants were more likely to have polyorthopaedic injuries (p < 0.05), ISS > 15 (p < 0.05), osteoporosis (p < 0.01), ICU status (p < 0.05), psychiatric history (p < 0.05), compartment syndrome (p < 0.05), neurovascular injury (p < 0.01), open fracture (p < 0.05), and fracture complexity (p < 0.05). The rate of UROR in the orthopaedic trauma patient population is 10%. Most of these cases are due to implant-related issues. UROR for reasons other than symptomatic implants tend to be polytraumatized patients with higher-energy injuries, multiple complex fractures, and associated soft tissue injuries. Future focus on improved implant development and treatments for polytraumatized patients with complex fractures is warranted to decrease a relatively high UROR rate in orthopaedic trauma

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Over half of postpartum women experience pelvic ring or hip pain, with multiple anatomic locations involved. The sacroiliac joints, pubic symphysis, lumbar spine and pelvic girdle are all well documented pain generators. However, despite the prevalence of postpartum hip pain, there is a paucity of literature regarding underlying soft tissue intra-articular etiologies. The purpose of this systematic review is to document and assess the available evidence regarding underlying intra-articular soft tissue etiologies of peri- and postpartum hip pain. Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until April 11, 2021. The inclusion criteria were English language studies, human studies, and those regarding symptomatic labral pathology in the peri- or postpartum period. Exclusion criteria were animal studies, commentaries, book chapters, review articles and technical studies. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. Descriptive characteristics including the study design, sample size, sex ratio, mean age, clinical and radiographic findings, pathology, subsequent management and outcomes were documented. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. The initial search identified 2472 studies. A systemic screening and assessment of eligibility identified 5 articles that satisfied the inclusion criteria. Twenty-two females were included. Twenty patients presented with labral pathology that necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with post-traumatic osteoarthritis necessitating a hip replacement. The mean MINORS score of these 5 non-comparative studies was 2.8 (range 0-7) demonstrating a very low quality of evidence. The contribution of intra-articular soft tissue injury is a documented, albeit sparse, etiology contributing to peri- and postpartum hip pain. Further research to better delineate the prevalence, mechanism of injury, natural history and management options for women suffering from these pathologies at an already challenging time is necessary to advance the care of these patients

Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries. A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway. 570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury. The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres

Background. Use of a robotic tool to perform surgery introduces a risk of unexpected soft tissue damage due to the uncommon tactile feedback for the surgeon. Early experience with robotics in total hip and knee replacement surgery reported having to abort the procedure in 18–34 percent of cases due to inability to complete preoperative planning, hardware and soft tissue issues, registration issues, as well as concerns over actual and potential soft tissue damage. These can result in significant morbidity to the patient, negating all the desired advantages of precision and reproducibility with robotic assisted surgery. The risk of soft tissue damage can be mitigated by haptic software prohibiting the cutting tip from striking vital soft tissues and by the surgeon making sure there is a clear workspace path for the cutting tool. This robotic total knee system with a semi-active haptic guided technique was approved by the FDA on 8/5/2015 and commercialized in August of 2016. Two year clinical results have not been reported to date. Objective. To review an initial and consecutive series of robotic total knee arthroplasties for safety in regard to avoidance of known or delayed soft tissue injuries and the necessity to abort the using the robot to complete the procedure. Report the clinical outcomes with robotic total knee replacement at or beyond two years to demonstrate no delayed effect on expected outcome. Methods. The initial consecutive series of 65 Triathlon. TM. total knee replacements using a semi-active haptic guided system that were performed after commercialization that would be eligible for two year follow-up were reviewed. Pre-operative planning utilizing CT determined the implant placement and boundaries and thus the limit of excursion from any part of the end effector saw tip. Self-retaining retractors were also utilized. Operative reports, 2, 6, and 12 week, and yearly follow-up visit reports were reviewed for any evidence of inadvertent injury to the medial collateral ligament, patellar tendon, or a neurovascular structure from the cutting tool. Operative notes were also reviewed to determine if the robotic procedure was partially or completely aborted due to any issue. Knee Society Knee Scores (KS-KS) and Functional Scores (KS-FS) were recorded from pre-operative and yearly. Any complications were recorded. Results. 40 cases had two year follow-up. The average follow-up for this series was 1.51 years. No cases were unable to be completed robotically. No case had evidence for acute or delayed injury to the medial collateral ligament, patellar tendon, or neurovascular structure. The only complication was a revision total knee for tibial component loosening after a fall induced periprosthetic tibial fracture. Average pre-operative KS-KS and KS-FS improved from 46.9 and 52.1 to 99.2 and 88.6 at one year follow-up, 100.5 and 86.9 at two year follow-up. Conclusions. A semi-active haptic guided robotic system is a safe and reliable method to perform total knee replacement surgery. This series of initial robotic arm assisted surgery had no intraoperative or delayed soft tissue injuries. Preliminary short-term outcomes at up to two years show excellent outcomes

Aims. We wished to quantify the extent of soft-tissue damage sustained during minimally invasive total hip arthroplasty through the direct anterior (DA) and direct superior (DS) approaches. Materials and Methods. In eight cadavers, the DA approach was performed on one side, and the DS approach on the other, a single brand of uncemented hip prosthesis was implanted by two surgeons, considered expert in their surgical approaches. Subsequent reflection of the gluteus maximus allowed the extent of muscle and tendon damage to be measured and the percentage damage to each anatomical structure to be calculated. Results. The DA approach caused substantially greater damage to the gluteus minimus muscle and tendon when compared with the DS approach (t-test, p = 0.049 and 0.003, respectively). The tensor fascia lata and rectus femoris muscles were damaged only in the DA approach. There was no difference in the amount of damage to the gluteus medius muscle and tendon, piriformis tendon, obturator internus tendon, obturator externus tendon or quadratus femoris muscle between approaches. The posterior soft-tissue releases of the DA approach damaged the gluteus minimus muscle and tendon, piriformis tendon and obturator internus tendon. Conclusion. The DS approach caused less soft-tissue damage than the DA approach. However the clinical relevance is unknown. Further clinical outcome studies, radiographic evaluation of component position, gait analyses and serum biomarker levels are necessary to evaluate and corroborate the safety and efficacy of the DS approach. Cite this article: Bone Joint J 2016;98-B1036–42

Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

Virtual Fracture Clinic (VFC) is a consultant-led orthopaedic trauma outpatient triage and management service. The use of VFC has recently become commonplace in the United Kingdom. It allows multiple referral sources to the orthopaedic team, with clinical information and imaging reviewed by a consultant in VFC who formulates an appropriate management plan with the patient contacted; either to attend clinic for consultation or discharged with advice over the phone. The VFC is more efficient than a traditionally delivered outpatient fracture clinic service. We have utilized VFC for 1 year at our hospital, East Kent University Hospital Foundation Trust (EKHUFT), and undertook a closed loop audit to evaluate the service and highlight potential areas of improvement. The Objective of the study was to identify whether the implementation of new re-designed VFC referral guidelines together with teaching set across one of the hospitals in EKHUFT improved the effectiveness and standards of VFC referrals. An initial audit was performed of all referrals made to VFC over a 2 weeks period in December 2018. Changes to the VFC referral pathway were implemented, and teaching sessions performed by the orthopaedic team to all referring units, including minor injury units (MIU) and the emergency department (ED). After implementation, re-audit of VFC referrals was performed in February 2019 over a similar 2 weeks period. Patient demographics, diagnosis and outcomes were collected from the online patient record with images reviewed using PACS software. Following intervention, referral rates dropped by 27.7% (136 vs 188 patients) over the 2 weeks periods. Patient demographics, injury type and severity remained the same between the 2 groups. 51.5% (70/136) did not meet VFC pathway criteria after the intervention and were considered inappropriate, compared to 70% in the original group. 15.4% (21/136) referrals could have been managed in the emergency department using the new guidelines and leaflet discharge. 5.1% (7/136) of the referrals should have been referred to orthopaedic on-call acutely and 22% (30/136) of the referrals had a soft tissue injury or no injury identified. This did not change between the 2 groups despite intervention. Referring MIU and ED units require continued support and teaching over a prolonged time period to hopefully see further improvements. Immediate hot reporting of radiographs may further benefit the service, but staffing and funding issues particularly out of hours, means this remains an aspiration

Osteosynthesis of high-energy metaphyseal proximal tibia fractures is still challenging, especially in patients with severe soft tissue injuries and/or short stature. Although the use of external fixators is the traditional treatment of choice for open comminuted fractures, patients' acceptance is low due to the high profile and therefore the physical burden of the devices. Recently, clinical case reports have shown that supercutaneous locked plating used as definite external fixation could be an efficient alternative. Therefore, the aim of this study was to evaluate the effect of implant configuration on stability and interfragmentary motions of unstable proximal tibia fractures fixed by means of externalized locked plating. Based on a right tibia CT scan of a 48 years-old male donor, a finite element model of an unstable proximal tibia fracture was developed to compare the stability of one internal and two different externalized plate fixations. A 2-cm osteotomy gap, located 5 cm distally to the articular surface and replicating an AO/OTA 41-C2.2 fracture, was virtually fixed with a medial stainless steel LISS-DF plate. Three implant configurations (IC) with different plate elevations were modelled and virtually tested biomechanically: IC-1 with 2-mm elevation (internal locked plate fixation), IC-2 with 22-mm elevation (externalized locked plate fixation with thin soft tissue simulation) and IC-3 with 32-mm elevation (externalized locked plate fixation with thick soft tissue simulation). Axial loads of 25 kg (partial weightbearing) and 80 kg (full weightbearing) were applied to the proximal tibia end and distributed at a ratio of 80%/20% on the medial/lateral condyles. A hinge joint was simulated at the distal end of the tibia. Parameters of interest were construct stiffness, as well as interfragmentary motion and longitudinal strain at the most lateral aspect of the fracture. Construct stiffness was 655 N/mm (IC-1), 197 N/mm (IC-2) and 128 N/mm (IC-3). Interfragmentary motions under partial weightbearing were 0.31 mm (IC-1), 1.09 mm (IC-2) and 1.74 mm (IC-3), whereas under full weightbearing they were 0.97 mm (IC-1), 3.50 mm (IC-2) and 5.56 mm (IC-3). The corresponding longitudinal strains at the fracture site under partial weightbearing were 1.55% (IC-1), 5.45% (IC-2) and 8.70% (IC-3). From virtual biomechanics point of view, externalized locked plating of unstable proximal tibia fractures with simulated thin and thick soft tissue environment seems to ensure favorable conditions for callus formation with longitudinal strains at the fracture site not exceeding 10%, thus providing appropriate relative stability for secondary bone healing under partial weightbearing during the early postoperative phase

Introduction: Wrist injuries are common presentations at Accidents and Emergencies. Distal radius fractures are by far the most common. Scaphoid injuries constitute about 60% of carpal injuries. 35% occult wrist fractures are undiagnosed on 2nd visit radiography (50% distal radius/ulna). Moreover 30% patients with significant soft tissue injuries not diagnosed. Aim: To compare the MRI (magnetic resonance imaging) and bone scans in the diagnosis of X-Ray negative wrist injuries. To functionally score these wrist at the end of 1-year to assess the outcome. Materials and methods: A prospective study was done in 33 wrists that did not have a fracture wrist detectable on plain X-ray. The MRI and bone scan were done on the same day within 5-7 days after the injury. PD Fat Saturation Axial and Coronal images were undertaken with MRI. Clinical scoring was done after 1 year after the injury to assess the outcome of these injuries. Results: We detected fractures in 10 wrists on bone scans and 8 fractures on MRI scans. There was a correlation between MRI and bone scan in 5 Cases. We noted 9% (3/33) of false positive cases with bone scan. Bone scans correlated with the site of injury in 10% of cases. 1 fracture was missed in both MRI and bone scan. MRI identified 4 significant soft tissue injuries and capsular edema in 29/33 cases, which were not identified on bone scans. MRI findings showed superior correlation than bone scans with clinical findings on re-examination, which was done following the scans. PRWE (patient rated wrist evaluation) was used to score the outcome of the wrists at the end of 1 year. The patients who had soft tissue or bony damage detected on MRI had significantly higher scores at 1 year of follow-up. Conclusion: Though bone scan has high sensitivity in diagnosis of fracture, significant soft tissue injuries will be missed. On the other hand, MRI had a high sensitivity and specificity in diagnosis of a fracture and soft tissue injuries. MRI can differentiate between a bone edema and a fracture. MRI has a disadvantage of limited exposure. Clinicians must be aware of the limitations of both investigations. Though majority of these injuries do not active intervention apart from plaster or splinting, detection of these injuries is essential to prognosticate the outcome

There is a high incidence of ipsilateral knee injuries with the Floating knee, which makes these fractures even more challenging to manage. We present the impact knee injuries have on the final outcome of the floating knee. We propose a protocol for assessment & management of knee injuries with the Floating knee. This prospective study included 29 patients with floating knee injuries. Knee injuries encountered were divided into bony, ligamentous and soft tissue. Bony injuries were assessed with radiographs and managed surgically along with the floating knee injury. Patients were assessed clinically for knee ligament injuries after fixation of the fractures intra-operatively and managed surgically. Soft tissue injuries around the knee were managed conservatively. Final outcome was assessed using the Karlstrom criteria. Ten of the 29 patients had knee injuries: 3 patella fractures, 2 anterior cruciate ligament injuries, 1 posterior cruciate ligament injury, 1 medial meniscus injury and 3 extensive soft tissue injuries. The complications were knee stiffness and superficial infection. The end results according to the Karlstrom criteria were Good – 6, Acceptable – 1 and Poor – 3. The associated knee injury in the floating knee is an important prognostic indicator. Soft tissue injury seems to have a very poor prognosis. We propose clinical evaluation of the knee after fixation of the fractures, surgical management of ligament & bony injuries and a proper rehabilitation programme to improve outcomes

29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries

Introduction. Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre. Methods. We reviewed the results of 40 ankle fractures (14 open and 26 closed) with significant soft tissue injuries and open fractures that were treated with a fibula rod between 2012 and 2015. The median age of patients was 60 (17–98 years). Results. Satisfactory fracture reduction was achieved in all of these patients Two patients had loss of syndesmosis fixation. All fibula fractures healed but 3 medial malleolus non unions occurred which did not need further surgery. 1 patient developed post-operative deep infection and had removal of metalwork. The median physical component Short-Form 12 (PSF12), Olerud and Molander score (OMS), and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores (AOFAS) were 40 (19 to 52), 57 (0 to 85) and 75 (20 to 95), respectively. The median PSF12, OMS and AOFAS were 33, 35 and 47 for open fractures and 42, 60 and 78 for closed fractures respectively. Conclusion. Using the fibula rod resulted in good radiological and satisfactory functional outcomes with minimal complications. In spite of lower scores in the open fracture group, only one patient needed removal of metal work for deep infection. We recommend using the fibula rod in unstable ankle fracture in patients with significant soft tissue injuries and consider its use in open injuries

Introduction: Rotational forces in ankle injuries can present as isolated lateral malleolus fracture with talar shift or ankle subluxation. It results in medial joint space [clear space] widening, and more than 4 mm is considered significant. The extent of medial soft tissue injury and exploration as a routine is always a debate. Aim: To see if medial clear space widening correlate with medial soft tissue injury. Also to evaluate the out come of these fracture fixation. Materials and Methods: Retrospective study on the management of isolated lateral malleolus fractures with significant medial clear space widening. N=40. Patient group A [25] under went only lateral side fixation and in group B [15] had additional medial side soft tissue exploration as a routine based on medial clear space widening. Fractures were Classified based on the Weber’s system. Pre-operative medial clear space measurement was done by 2 independent observer using PACS measurement tool. Intraoperative details for the method of fixation and the medial soft tissue were analysed. Most common method of fixation is Neutralisation plate for the lateral side. In Weber B type 1/3 rd of the cases had both plate on the lateral side and syndesmotic screw fixation. 2/3rd of them had only plate fixation. In Webers C type, only syndesmotic screw in n=3, Plate and screw n=4, only plate in n=9 cases. Radiological measurement of medial clear space average = 9.08mm, range= 5 –22 mm. Less than 50% of the patients only had medial clinical signs. 26.6% had soft tissue (periosteal injury) and only 6.6% had deltoid ligament injury Out come assessment criterias:. The failure of fixation or any on going medial symptoms in group A. – one case of failure of fixation. Final clinical assessment with ankle score (Olerud and Molander score.) at 6 months average (between 3–18 months). No significant difference in the score, on follow up. Conclusion:. Medial clear space does not correlate with any degree of medial soft tissue injury. Exploration is indicated if widening persist after lateral side fixation. Routine exploration of the medial side has no long term impact on the clinical outcome

Introduction. The COL5A1 gene encodes for the α1 chain of type V collagen, a minor fibrillar collagen that is an important regulator of collagen fibrillogenesis. Several polymorphisms, including rs12722 (C/T), within the 3′-UTR of COL5A1 are associated with chronic Achilles tendinopathy and other musculoskeletal soft tissue injuries as well as exercise-related phenotypes. It is hypothesised that polymorphisms within the 3′-UTR regulate the amount of the α1(V) chain synthesised and type V collagen production. This in turn influencing the mechanical properties of tendons and other musculoskeletal soft tissues. In our laboratories, two major functional forms, namely the T- and C-allelic forms of the COL5A1 3′-UTR, were identified and associated predominately with severe chronic Achilles tendinopathy and healthy asymptomatic control individuals, respectively. Materials and Methods. To further investigate the functional differences between the two major 3′-UTR functional forms as well as to start mapping the regions which are responsible for the tendinopathic phenotype, skin biopsies from donors having a known genotype at rs12722 and primary fibroblast cell lines were established in order to quantify COL5A1 and COL1A1 expression levels in a pilot study. Lastly, in preliminary RNA EMSAs, biotinylated C- and T-allelic RNA probes for a specific 57bp functional region within the 3′-UTR were incubated with either fibroblast nuclear or cytoplasmic protein extracts to investigate putative distinguishing RNA:RBP complex formation. Results. An overall higher relative mRNA expression of both COL5A1 (p<0.001) and COL1A1 (p=0.0015) were observed in primary skin fibroblasts from donors having a rs12722 TT genotype compared to donors with a CC genotype. A unique RNA:RBP complex was also identified with the C-allelic probe. Discussion. These novel results have important implications for our understanding of the proposed role of type V collagen in the aetiology of tendon and other musculoskeletal soft tissue injuries, as well as, other exercise-related phenotypes

Introduction/Aim. The NAVIO robotic-assisted TKA (RA-TKA) application received FDA clearance in May 2017. This semi-active robotic technique aims to improve the accuracy and precision of total knee arthroplasty. The addition of robotic-assisted technology, however, also introduces another potential source of surgery-related complications. This study evaluates the safety profile of NAVIO RA-TKA. Materials and Methods. Beginning in May 2017, the first 250 patients undergoing NAVIO RA-TKA were included in this study. All intra-operative complications were recorded, including: bleeding; neuro-vascular injury; peri-articular soft tissue injury; extensor mechanism complications; and intra-operative fracture. During the first 90 days following surgery, patients were monitored for any post-operative complications, including: superficial and deep surgical site infection; pin-tract infection; pin site fractures; peri-prosthetic fractures; axial or sagittal joint instability; axial mal-alignment; patello-femoral instability; DVT/PE; re-operation or re-admission due to surgical-related complications. Surgical technique and multi-modality pain management protocol was consistent for all patients in the study. A combined anesthetic technique was employed for all cases, including: low-dose spinal, adductor canal block and general anesthetic. Patients were mobilized per our institution's rapid recovery protocol. Results. No patients were lost to follow-up. During the study period, no intra-operative complications were recorded. Specifically, no complications related to the introduction of the high-speed burr associated with the NAVIO RA-TKA were noted. Within the 90-day follow-up period, there was one case of deep infection. One patient sustained a fall resulting in a peri-prosthetic femoral fracture, that occurred remote from the femoral pin tracts. No cases of axial or sagittal joint instability, axial mal-alignment, patello-femoral instability, pin site infections or fractures; or DVT/PE were identified. Four patients underwent manipulation under anesthesia. No other patients required a re-operation or re-admission due to surgical-related complications. Discussion/Conclusions. The initial experience with the NAVIO robotic assisted total knee arthroplasty has demonstrated excellent safety profile. Relative to known risks associated with total knee arthroplasty, no increased risk of peri-operative complications, re-operation or re-admission for surgical related complications was identified with the introduction of the NAVIO RA-TKA

A reverse total shoulder arthroplasty (RSA) is frequently performed in the revision setting. The purpose of this study was to report the clinical outcomes and complication rates following revision RSA (RRSA) stratified according to the primary shoulder procedure undergoing revision, including failed hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA), RSA, soft tissue repair (i.e., rotator cuff repair), and open reduction internal fixation (ORIF). A systematic review of the literature was performed using four databases (EMBASE, Medline, SportDISCUS, and Cochrane Controlled Trials Register) between January 1985 and September 2017. The primary outcomes of interest included active range-of-motion (ROM), pain, and functional outcome measures including the American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), and Constant-Murley (CS) Score. Secondary outcomes included complication rates, such as infection, dislocation, perioperative fracture, base plate failure, neurovascular injury, soft tissue injury, and radiological evidence of scapular notching. Clinical outcome data was assessed for differences between preoperative and postoperative results and complication results were reported as pooled complication rates. Forty-five studies met the inclusion criteria for analysis, which included 1,016 shoulder arthroplasties with a mean follow-up of 45.2 months (range, 31.1 to 57.2 months) (Fig. 1). The mean patient age at revision was 60.2 years (range, 36 to 65.2 years). Overall, RSA as a revision procedure for failed HA revealed favorable outcomes with respect to forward elevation (FE), CS pain, ASES, SST, and CS outcome assessment scores, with mean improvements of 52.5° ± 21.8° (P = < 0 .001), 6.41 ± 4.01 SD (P = 0.031), 20.1 ± 21.5 (P = 0.02), 5.2 ± 8.7 (P = 0.008), and 30.7 ± 9.4 (P = < 0 .001), respectively. RSA performed as a revision procedure for failed TSA demonstrated an improvement in the CS outcome score (33.8 ± 12.4, P = 0.016). RSA performed as a revision procedure for failed soft tissue repair demonstrated significant improvements in FE (60.2° ± 21.2°, P = 0.031) and external rotation (20.8° ± 18°, P = 0.016), respectively. Lastly, RSA performed as a revision procedure for failed ORIF revealed favorable outcomes in FE (61° ± 20.2°, P = 0.031). There were no significant differences noted in RSA performed as a revision procedure for failed RSA, or when performed for a failed TSA, soft tissue repair, and ORIF in any other outcome of interest. Pooled complication rates were found to be highest in failed RSA (10.9%), followed by soft tissue repair (7.1%), HA (6.8%), TSA (5.4%) and ORIF (4.7%). When compared to other revision indications, RRSA for failed HA demonstrated the most favorable outcomes, with significant improvements in ROM, pain, and in several outcome assessments. Complication rates were determined and stratified as per the index procedure undergoing RRSA, patients undergoing revision of a failed RSA were found to have the highest complication rates. With this additional information, orthopaedic surgeons will be better equipped to provide preoperative education regarding the risks, benefits and complication rates to those patients undergoing a RRSA. For any figures or tables, please contact authors directly

Introduction. Ligament reconstruction following knee soft tissue injuries, such as posterior cruciate ligament (PCL) tears, aim to restore normal joint function and motion; however, persistant pathomechanical joint behavior indicates that there is room for improvement in current reconstruction techniques. Increased attention is being directed towards the roles of secondary knee stabilizers, in an attempt to better understand their contributions to kinematics of knees. The objective of this study is to characterize the relative biomechanical contributions of the posterior oblique ligament (POL) and the deep medial collateral ligament (dMCL) in PCL-deficient knees. We hypothesized that, compared with the POL, the dMCL would have a more substantial role in stabilizing the medial side of the knee, especially in flexion (slack POL). Methods. Seven fresh-frozen cadaveric knees were used in this study (age 40–62, 4 female, 3). Specimens were potted and mounted onto a VIVO joint motion simulator (AMTI). Once installed, specimens were flexed from 0 to 90 degrees with a 10 N axial load and all remaining degrees of freedom unconstrained. This was repeated with (a) a 67 N posterior load, (b) a 2.5 Nm internal or external rotational moment and (c) a 50 N posterior load and 2.5 Nm internal rotational moment applied to the tibia. During each resulting knee motion, the relative AP kinematics of the dMCL tibial insertion (approximated as the most medial point of the proximal tibia) with respect to the flexion axis of the femur (the geometric center axis, based on the posterior femoral condyles) were calculated at 0, 30, 60 and 90 degrees of flexion. These motions were repeated following dissection of the PCL and then further dissection of either medial ligament (4 POL, 3 dMCL). The changes in AP kinematics due to ligament dissection were analyzed using three-way repeated-measures ANOVA with a significance value of 0.05. Results. Dissection of the dMCL or POL did not result in a statistically significant increase in the posterior displacement of the medial tibial point under posterior directed force, internal rotation moments, or the combined posterior force plus internal rotation moment. Interestingly, under external moment loading, there was a statistically significant increase in anterior displacement of the medial tibia at all flexion angles after POL dissection, by up to 3.0+/−2.6 mm at 0 degrees. Dissection of the dMCL, however, did not have a significant affect. Conclusion. Our results showed that neither the POL nor dMCL play a significant role in resisting posterior tibial displacements on the medial side of a PCL deficient knee. Of the two, the POL appears to have a greater contribution towards preventing anterior translations, particularly when in extension. This finding is rational based on the anatomical path of this ligament wrapping around the femoral medial condyle under external rotational moments. In contrast with our hypothesis, it was observed that the dMCL had less of an effect on medial knee stability. Contributions of these ligaments could be further investigated using more complicated loading, such as those more representative of activities of daily living

The aim of this study was to document our experience of acute forearm compartment syndrome, and to determine the risk factors for requiring split skin grafting (SSG) and developing complications post fasciotomy. We identified from our trauma database all patients who underwent fasciotomy for an acute forearm compartment syndrome over a 22-year period. Diagnosis was made using clinical signs and/or compartment pressure monitoring. Demographic data, aetiology, management, wound closure, complications and subsequent surgeries were recorded. Outcome measures were the use of SSG and the development of complications following forearm fasciotomy. 90 patients were identified with a mean age of 33 yrs (range, 13–81 yrs) and a significant male predominance (n=82, p<0.001). A fracture of one or both of the forearm bones was seen in 62 (69%) patients, with soft tissue injuries causative in 28 (31%). The median time to fasciotomy was 12hrs (2–72). Delayed wound closure was achieved in 38 (42%) patients, with 52 (58%) undergoing SSG. Risk factors for requiring a SSG were younger age and a crush injury (both p<0.05). Complications occurred in 29 (32%) patients at mean follow-up of 11 (3–60) months. Risk factors for developing complications were a delay in fasciotomy of >6 hrs (p=0.018), with pre-operative motor symptoms approaching significance (p=0.068). Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following either a fracture or soft tissue injury. Age is an important predictor of undergoing SSG for wound closure. Complications occur in a third of patients and are associated with an increasing delay in the time to fasciotomy

The vast majority of fractures around the knee will heal with well-done internal fixation. TKA has a role in several scenarios. Acute TKA can be effective for fractures of the distal femur (especially periprosthetic) in very elderly patients where internal fixation attempts are likely to fail. Acute TKA for tibia plateau fractures may have a role in fractures in the elderly with pre-existing DJD and relatively simple fracture patterns. There is very little published literature regarding the outcomes of TKA for acute tibial plateau fracture and caution is advised until more data is available. TKA is commonly indicated for failed fixation and post-traumatic arthritis. Challenges include managing retained hardware, soft tissue injury and contracture, unusual ligamentous imbalances, and multiple prior incisions and/or flaps. Occasionally, a partial hardware removal may be appropriate. If extensive or multiple incisions are needed for hardware removal it may be wise to stage the reconstruction after soft tissue recovery. The available data on TKA for post-traumatic reconstructions generally demonstrate predictable functional improvement but higher complications

Purpose. The recent emergence of autologous blood concentrates, such as platelet rich plasma (PRP), as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. Our objective was to determine the effectiveness of autologous blood concentrates compared with control therapy in improving pain in patients with orthopaedic bone and soft tissue injuries. Method. We conducted a systematic review of MEDLINE and EMBASE from 1996 and 1947, respectively, up to July 2010. Additional studies were identified by contacting experts, searching the bibliographies of the included studies as well as orthopaedic meeting archives. We included published and unpublished randomized controlled trials or prospective cohort studies that compared autologous blood concentrates with a control therapy in patients with an orthopaedic injury. Two reviewers, working in duplicate, abstracted data on study characteristics and protocol. Reviewers resolved disagreement by consensus. Results. We identified 18 randomized trials and nine prospective cohort studies. There was a lack of consistency in outcome measures across all studies. Four randomized controlled trials (N=275) and three prospective cohort studies (N=88) reported visual analog scale (VAS) scores when comparing platelet rich plasma with a control therapy across injuries to the acromion, lateral epicondyle, anterior cruciate ligament, patella, tibia and spine. There was no significant benefit for platelet rich plasma up to and including six months across randomized trial (standardized mean difference −0.35; 95% confidence interval, −0.98 to 0.28) or prospective cohort data (standardized mean difference −0.20; 95% confidence interval, −0.64 to 0.23). Conclusion. There is a lack of evidence to support the efficacy of platelet rich plasma and autologous blood concentrates as a treatment modality for orthopaedic bone and soft tissue injuries. The literature is further complicated by a lack of standardization in study protocols, platelet separation techniques, and outcome measures

We describe a new surgical approach designed for use with minimally invasive fixation and a circular frame. Tibial pilon injuries are often associated with significant soft tissue injury, which may not be evident at the time of injury. In such cases standard surgical approaches can lead to problems with wound healing, thus increase the risk of deep infection. AO Type C valgus fractures are commonly associated with fibula fractures. We found that the anterior syndesmotic ligaments are often disrupted with sparing of the lateral soft tissue envelope. Our technique utilizes a direct lateral approach to expose the lateral malleolus/distal fibula, which is reflected postero-laterally through the fracture and intact posterior syndesmotic ligaments. This creates a direct view of posterolateral and anterolateral comminution and talar dome allowing direct fixation of fragments with minimal internal fixation. Fibula fixation is performed with a 1/3. rd. tubular plate and the anterior syndesmotic ligaments are repaired. From 2007–2009, we used this approach in 12 patients (Male 9: Female 3; age 19–42) with AO Type C3 fractures with significant soft tissue injury (open = 2/ closed = 10; Tscherne Grade 1 = 4; Grade 2 = 8). We used circular frame stabilization in all cases (in four patients an additional foot frame was applied to protect the articular surface). All fractures united in satisfactory alignment. Wound healed well in all cases. One case of gouty arthritis developed superficial infection, which went on to heal after wound wash out and oral antibiotic therapy. Follow-up (minimum 3 months and maximum 2 years) showed no ankle instability. Clinical evaluation revealed a mean dorsiflexion of 10° (5–15°) and mean plantar flexion of 35° (15–60°). We conclude that transfibular approach gives good exposure of lower tibial articular surface in selected cases of pilon fractures with least soft tissue disruption

Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years). Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed. Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients. Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases

Aims

The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA.

Objective and Purpose: Pilon fractures are complex fractures of the tibial articular surface usually associated with high energy trauma and major soft tissue injury. We investigated the effectiveness of Ilizarov external fixator in such cases. At our hospital, we obtain excellent results performing reconstruction using vascularised fibular grafts for the infectious non-union. Methods and Materials: We examined 21 cases treated with the Ilizarov apparatus for the fresh pilon fracture from 1999. There were 13 males and 8 females, with an average of 44 years. The AO classification was A2 type in 2 cases, B1 in 4, C1 in 3, C2 in 3, and C3 in 9, with open fractures of Gustilo type?Uor ?Va in 7 cases. 11 cases were treated by the Ilizarov technique only. 10 cases were treated by the additional limited open reduction with screw, K-wire and fibular plating. The average time between injury and surgery was 4 days. We examined 6 cases treated with the vascularised fibular graft for the infectious non-union cases after internal fixation. Age at the surgery was from 19 to 70 (mean 46). Results: All fractures were united and removed at an average of 10 weeks (range 8–12 weeks). Complications included 5 cases of superficial pin tract infections. There is no deep infections and no pseudarthrosies. Conclusion: The use of Ilizarov fixator is a safer method of treatment of pilon fractures, especially for the severe soft tissue injury and we don ft delay surgery for soft tissue considerations

The South Wales Air ambulance is a charity-funded helicopter service that started functioning on 1 April 2001. There are 10 staff involved in the running of the service, including pilot and paramedics. The territory covered is the South and Mid-Wales regions. The service costs on average £500 per flight and the net cost per year is approximately £750,000. A retrospective study was performed to evaluate the extent and appropriateness of the air-ambulance call-outs over a 12-month period. The guidelines for call-out are based on medical and non-medical criteria. During this period the helicopter made 315 sorties. On 159 occasions the helicopter was stood down once airborne or following landing at the scene. £80,000 has been spent on non-patient -carrying call-outs. Of the 156 patient-carrying sorties 70% were transferred to Mor-riston Hospital, Swansea. 67% of these patients were categorised as trauma patients. Transfer distance averaged just 15 miles (range 2.6-41.2 miles). The majority of trauma cases were categorised as spinal soft tissue injuries or soft tissue injuries. 52% of patients were discharged by A& E staff without requiring orthopaedic assessment. 59% of trauma transfers were deemed to be inappropriate for helicopter transfer by the senior author. Our study concludes that the air-ambulance is used inappropriately in at least 50% of the call-outs. The call-out criteria require amending and should place more emphasis on pick-up location rather than the nature of the casualty. It is not used cost effectively and is not always clinically effective

Introduction: Classification systems are useful in research and clinical practise as it provides a common mode of communication and evaluation. Tibial pilon injuries are a complex group of fractures, whose classification and radiological assessment in clinical practise remains undetermined. Methods: 50 CT scans and radiographs of tibial pilon fractures were evaluated independently by 6 orthopaedic surgeons, comprising 3 consultants, 2 registrars and 1 research fellow. Fractures were classified according to ruedi allgower, AO, Topliss et al. Each surgeon was given a period of 48 hours to review copy of the original article as well as written and diagrammatic representations. Assessment was done on two occasions, 4 weeks apart. The kappa coefficient of agreement was calculated with SPSS to determine interobserver reliability and intraobserver reproducibility of the classification systems. The evaluator was blinded as to treatment and functional outcome. Each evaluator was also asked to decide upon the fracture management based on the classification types and was compared with the actual management. Result: The interobserver agreement for ruedi allgower, Ao and Topliss et al., was fair, moderate and poor respectively. The intraobserver agreement for ruedi allgower, AO and Topliss et al., classifications was moderate at best. There was poor agreement amongst observers regarding definite management plan based on these classification systems. Discussion: The interobserver agreement was directly proportional to the familiarity and inversely proportional to the specificity of the classification system. The intraobserver agreement improved with experience. CT scan helped in delineating the fracture segments accurately but did not significantly affect inter or intraob-server agreement. Conclusion: Existing classification systems help in understanding the pathoanatomy of osseous part of tibial pilon fracture complex. However, Soft tissue injury forms an integral part of this complex. Without inclusion of soft tissue injury, these classification systems have limited role in definitive management

The mechanism of traumatic amputation (TA) from explosive blast has traditionally been considered to be a combination of blast wave induced bone injury – primary blast - followed by limb avulsion from the blast wind – tertiary blast. This results in a transosseous TA, with through joint amputations considered to be extremely rare. Data from previous conflicts has also suggested that this injury is frequently associated with a non-survivable primary blast lung injury (PBLI), further linking the extremity injury to the primary blast wave. However, our current experience in the Middle East would suggest that both the mechanism of TA and the link with fatal primary blast exposure need to be reconsidered. The aim of this study was to analyse the injury profile of the current cohort of TA fatalities to further investigate the underlying blast injury mechanism and to allow hypotheses on injury mechanisms to be developed for further analysis. With the permission of the coroners, 121 post-mortem CT (PMCT) scans of UK Armed Forces personnel who died following an IED blast were analysed. All orthopaedic injuries were identified, classified and the anatomical level of any associated soft tissue injury noted. PMCT evidence of PBLI was used as a marker of significant primary blast exposure. 75/121 (62%) sustained at least 1 TA, with 138 TAs seen in total. 31/138 (22%) were through joints, with through knee amputations most common (23/31, 74%). Only 7/31(23%) through joint amputations had an associated fracture proximal to and contiguous with the amputation site. The soft tissue injury profile of through joint and transosseous TAs were not significantly different (p=0.569). When fatality location was considered (i.e. mounted or dismounted), no overall relationship between PBLI and TA was evident. The two pathologies were not seen to consistently occur concurrently, as has been previously reported. The accepted mechanism for traumatic amputation following explosive blast does not adequately explain the significant number of through joint TAs presented here. The previously reported link between TA and PBLI in fatalities was not supported by this analysis of modern combat blast fatalities. Lack of an associated fracture with the majority of through joint TAs in conjunction with a lesser contribution of primary blast may implicate flail and periarticular soft tissue failure as a potential injury mechanism. Analysis of through joint TA incidence and associated injuries in survivors is now indicated. Case studies within the fatality dataset may facilitate generation of injury mechanism hypotheses. To further investigate the injury mechanism, work is required to understand osseous, ligamentous and other soft tissue behaviour and failure at high strain rates. This should allow characterisation and modeling of these injuries and inform mitigation strategies

Background. Use of a robotic tool to perform surgery introduces a risk of unexpected soft tissue damage due to the lack of tactile feedback for the surgeon. Early experience with robotics in total hip and knee replacement surgery reported having to abort the procedure in 18–34 percent of cases due to inability to complete preoperative planning, hardware and soft tissue issues, registration issues, as well as concerns over actual and potential soft tissue damage. These damages to the soft tissues resulted in significant morbidity to the patient, negating all the desired advantages of precision and reproducibility with robotic assisted surgery. The risk of soft tissue damage can be mitigated by haptic software prohibiting the cutting tip from striking vital soft tissues and by the surgeon making sure there is a clear workspace path for the cutting tool. This robotic total knee system with a semi-active haptic guided technique was approved by the FDA on 8/5/2015 and commercialized in August of 2016. One year clinical results have not been reported to date. Objective. To review an initial and consecutive series of robotic total knee arthroplasties for safety in regard to avoidance of known or delayed soft tissue injuries and the necessity to abort the robotic assisted procedure and resort to the use of conventional implantation. Report the clinical outcomes with robotic total knee replacement at or beyond one year to demonstrate satisfactory to excellent performance. Methods. The initial consecutive series of 100 robotic total knee replacements using a semi-active haptic guided system including 34 from the initial IDE series in 2014 and those performed after commercial approval beginning in 2016 were reviewed. Pre- operative planning utilizing CT determined the implant placement and boundaries and thus the limit of excursion from any part of the end effector saw tip. Self-retaining retractors were also utilized. Operative reports, 2, 6, and 12 week, and yearly follow-up visit reports were reviewed for any evidence of inadvertent injury to the medial collateral ligament, patellar tendon, or a neurovascular structure from the cutting tool. Operative notes were also reviewed to determine if the robotic procedure was partially or completely aborted due to any issue. Knee Society and Functional scores were recorded from pre-operative and yearly. Results. No cases were unable to be completed robotically. No case had evidence for acute or delayed injury to the medial collateral ligament, patellar tendon, or neurovascular structure. The average follow-up for this series was 1.54 years. Average pre- operative Knee Society and Functional Scores improved from 44.7 and 50 to 98.1 and 87.8 at one year follow-up, 93.8 and 83.1 at two year follow-up, 98.5 and 87.7 at three year follow-up, and 99 and 85 at four year follow-up. Conclusions. A semi-active haptic guided robotic system is a safe and reliable method to perform total knee replacement surgery. Preliminary short-term outcomes data shows excellent clinical and functional results

Aims

The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

Study Design: A prospective randomised controlled trial. Objective: The early management of acute soft tissue injuries of the neck remains controversial. The aim of this study was to compare an early mobilisation regime versus with treatment with a soft collar for recovery of function and activity levels after soft tissue injuries of the neck. Subjects: Over a one year period, 108 patients presenting with a soft tissue neck injury were enrolled in a prospective trial. Each patient was randomised to either early mobilisation using an exercise regime (55 patients) or 3 weeks treatment in a soft collar followed by the same exercise regime (53 patients). Patients were followed up at 3, 12 and 52 week intervals from injury. Outcome Measures: Visual Analogue Scores for pain, range of neck movements, activities of daily living and time taken to return to work. Results: No differences were found between the two groups for pain, range of neck movements or for activities of daily living at any of the follow up intervals. The collar treatment group took significantly longer to return to work after injury (21 days) compared to the early mobilisation group (9 days), p< 0.05. Conclusions: Treatment in a soft collar had no clinical benefit compared to early mobilisation in terms of recovery of function, pain or range of neck movements, but was associated with an increased time to return to work

Introduction. This study reviews the orthopaedic care of the thirteen patients who were admitted and treated at Royal Manchester Children's' Hospital following the Manchester Arena Bomb blast. Methods. We included all children admitted to Royal Manchester Children's Hospital injured following the bomb blast who either suffered upper limb, lower limb or pelvic fractures, or penetrating upper or lower limb wounds. The nature of each patient's bone and soft tissue injuries, initial and definitive management, and outcome were assessed and documented. Main outcome measures were time to fracture union, time to definitive soft tissue/skin healing, and functional outcome. Findings. Thirteen children were admitted with orthopaedic injuries; 12 were female and mean age was 12.69. All patients had penetrating deep wounds with at least one large nut foreign body in situ, two patients suffered significant burn injury, one patient required amputation of two digits, and two patients required local flap reconstruction. There were a total of 29 upper and lower limb fractures in nine of the patients, with the majority managed without internal or external fixation. In only half of the patients all fractures showed full radiological union at 6 months follow up. There was significant morbidity with several patients suffering long term physical and psychological disability and one patient still in hospital. Conclusion. We found that stable fractures in children secondary to blast injuries can often be appropriately managed without metalwork, and penetrating wounds can be managed without the need for skin graft/flap reconstruction. Our study documents the severe nature of the injuries suffered by paediatric survivors of the Manchester Arena bomb blast. It highlights the demands on a trauma unit following such an event

Purpose: The injury occurs when a child passenger sits behind or in front of the rider; his leg gets caught in the rotating wheel’s spokes, and crushed against the frame. The study aimed at reviewing our experience in managing this common injury. Patients and Methods: Between 2000–2005, 43 children were treated following bicycle spoke injury. All cases were thoroughly reviewed. Results: Mean age was 5.1 years (range 1–15). Twenty-seven were up to 5 years. Thirty-seven were males, and 7 were females. The right leg was injured in 30 children, and the left in 13. Twenty one were seated behind the rider, and 6 in front of him. Most children were injured in the afternoon and between April and September. Twenty six injured the antero-medial aspect of the ankle and lateral calcaneal region. Twenty nine children had deep abrasions, 11 had abrasion with skin defect, and 3 had laceration. All children had edema and ecchymosis. Eighteen children had fractures. Greenstick fracture of the distal and fibula with anterior and varus angulation was observed in 6 cases. Hospital stay ranged 2–12 days. All fractures were treated non-operatively and healed uneventfully. Soft tissue injuries healed well largely by secondary intention within up to 9 weeks. Conclusions: Bicycle spoke injury may lead to considerable morbidity and prolonged healing time. The mechanism of injury and management are discussed. The injury may be initially underestimated due to deceptively mild appearance. The prognosis is determined mainly by soft-tissue damage. Preventive measures include ergonomic changes like installing special carriers and spoke-guards

The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture following hand injuries in different paediatric age groups attending a hand unit. Three hundred and sixty children (237 boys and 123 girls) under 16 years of age who presented with hand injuries between 1st April 2000 and 30th September 2000 were included in the study. Bony injuries accounted for 65.5% (236 injuries), 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children/year. Incidence was low in toddlers (34/100,000), more than doubled in pre-school children (73/100,000) and steeply increased to around 20 fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and pre-school children. Crushing was the most common cause of hand injury (64%) and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpal and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different paediatric age groups

Ankle fractures are among the most common type of fractures of our musculoskeletal system, and their rate has been constantly increasing over the past decades, not only in the young active patients but also in the elderly ones. The stability of the ankle joint is assured by the configuration of the fibula, tibia and talus, as well as by its complex ligamentous system. The optimal treatment of these fractures follows the basic rules of all joint fractures: it is achieved by restoring the ankle mortise and its stability, in order to prevent pain and the development of secondary arthritis. Stable ankle fractures (e.g., isolated fractures of lateral maleolus) can be satisfactorily treated by closed methods, whereas unstable fractures (e.g., bimaleolar, bilameolar equivalents, trimaleolar) must be treated by open reduction and internal fixation. However, one of the aspects that influence the final outcome of these fractures is the coexistence of soft tissue injuries and osteochondral fractures (particularly of the talus), especially if not detected in the X-ray or intra-operative, which will inevitably degenerate in a posttraumatic arthritis. The authors present in this paper a retrospective study of all patients with ankle fractures treated operatively in a period of ten years (January 1993 and December 2003). It where reviewed 376 clinical processes, with a male patient predominance (57%). The fractures where classified according to the Dannis-Weber Classification, and the following items where evaluated: epidemiology, co-morbidities, surgery timing, hospitalization time, surgical options, surgical follow-up and complications. The final evaluation of the patients included clinical, functional and radiological aspects. The authors concluded that in spite of the surgical treatment being well established and indicated in the unstable fractures, its results are frequently influenced by the epidemiologic cofactors, co-morbidities, injury mechanism, coexistence of soft tissue injuries or osteochondral fractures that many times are not detected

The aim of this study was to evaluate the effect of traction on the compartment pressures during intramedullary nailing of closed tibial shaft fractures. The study design was a randomised prospective trial. The period of the study was Sept ’99 to Dec 2000. 30 consecutive patients with Tscherne C1 fractures were randomised into two groups.16 patients underwent intramedullary nailing of the tibia with traction and 14 patients without traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The method described by Gulli and Templeman was used to measure all the four compartments of the injured limb. The pressures were measured with a Stryker® pressure monitor. The absolute and differential compartment pressures were recorded. All patients were followed up for the duration of at least 8 months and until fracture union. The data collected was analysed using paired student t-test. There was no statistically significant difference (p> 0.05) in the preoperative mean compartment pressures for both groups when all the four compartments were measured individually. The mean postoperative measurements were higher (range 9–10 mmHg) in all four compartments in the traction group. This was statistically significant (p< 0.05). None of the pressures reached the critical level as they were more than 30 mmHg below the diastolic pressure (differential pressure). These results show that traction increases compartment pressures during intramedullary nailing of tibial shaft fractures. The group considered did not have compartment syndrome possibly due to less soft tissue injury. With greater soft tissue injury and greater preoperative compartment pressures, compartment pressures can reach a critical level necessitating decompression. We conclude that intramedullary nailing without traction reduces the chances of significant increase in compartment pressures and advocate the procedure be done without traction

During the second Lebanon war, between 12/07/06 to 14/08/06, 241 war injuries were admitted to Rambam Medical Center emergency room: 202 soldiers and 39 citizens. (Post traumatic stress disorders victims were not included). Majority of the injured soldiers (98%) were mobilized by the Israeli Air Force helicopters. More then 40 helicopters had landed in the hospital heliport during the war. Distribution of injuries according to the injury type:. 110 patients (44% of all injured) had Orthopedic injuries (including hand injuries). 76 patients (31% of all injured) had Orthopedic injuries combined with other injuries. Not orthopedic injury – 63 patients (25%) Majority of all wounded (75%) had suffered from an orthopedic injury. Distributions of soldier’s injuries among soldiers were similar to the above :. 81 soldiers (41%) Orthopedic injuries (including hand injuries). 64 soldiers (33%) Orthopedic injuries combined with other injuries. 50 soldiers (26 %) Not orthopedic injury. About 75 % of the injured soldiers suffered from orthopedic injuries. Vast majority of the injuries were shrapnel injuries, which were divided to 3 levels:. Mild soft tissue damage due to few or superficial shrapnel injury – 107 (49%) soldiers. Moderate soft tissue injuries due to multiple shrapnel injuries – 54 (25%) soldiers. Severe soft tissue injuries had muscular and neurovascular damage. Organs injury distribution:. 24 Patients total of 54 fractures, 24 of those had been long bone fractures. 17 Patients had sustained a Major vascular injury. 20 Patients had sustained a nerves injury. Amputation – 5 soldiers were underwent completion of traumatic lower limb amputation. One soldiers had bilateral below knee amputation, 1 above knee amputation and 3 unilateral below knee amputation. Two hundred and three orthopedic surgery interventions were done by Orthopedics’ B’ department in Rambam Medical Hospital, during the Second Lebanon War

Trampoline was used by British & American fighter pilots as a training device during World War II. It became popular among Civilian as a recreational sports during 50s and 60s. Trampoline related injuries including quadriplegia and death have been reported from United States and Europe. We are reporting the incidence, type and distribution of trampoline-related injuries in children in a District General Hospital in United Kingdom. Recently we treated three serious injuries – proximal tibial fracture associated with popliteal artery injury, subtrochanteric fracture of femur and cervical fracture-dislocation leading to quadriplegia, that lead to an audit study. This is a retrospective analysis of trampoline-related injuries in children seen in the Accident & Emergency Department over three months period. The casualty cards and admission records were reviewed. The mechanism of injury was fall on or off the trampoline in 98.15%(53/54). All injuries occurred on back-garden or leisure-centre trampoline. 74% of injuries were sustained while unsupervised. The incidence of soft tissue injuries were 59.25%(32/54) and fractures 40.75%(22/54). Soft tissue injuries commonly involved lower limb(16), upper limb(7) and head and neck(4). Fractures commonly involved upper limb(13), lower limb(8) and nasal bone(1). The fractures involved wrist and forearm in eight cases, ankle in five, elbow in four and one case each involving finger, hip, knee and toe. The treatment of trampoline-related injuries varied from reassurance, analgesia, tubigrip bandage to plaster cast. Fourteen(26%) patients were admitted into the wards and ten(18.5%) required surgical treatment. The incidence of trampoline-related injuries in back-garden and leisure-centre when unsupervised was high. The supervision by an adult has not proved to be very effective in preventing the injuries as 26% of trampoline-related injuries occurred under supervision of an adult. The morbidity related to leisure trampolining is high probably due to lack of training and non-compliance to the manufacturer instructions in the use of trampoline. We would recommend banning the routine use of back garden trampoline without proper training and supervision

Aim: To evaluate the effect of traction on the compartment pressures during intramedullary nailing of closed tibial shaft fractures. Materials and Methods: The study design was a randomised prospective trial. The period of the study was September 1999 to December 2000. 30 consecutive patients with Tscherne C1 fractures were randomised into two groups. 16 patients underwent intramedullary nailing of the tibia with traction and 14 patients with traction. Compartment pressures were measured before the application of traction or commencement of the procedure and at the end of the procedure. The method described by Guilli and Templeman was used to measure all the four compartments of the injured limb. The pressures were measured with a Stryker® pressure monitor. The absolute and differential compartment pressures were recorded. All patients were followed up for the duration of at least 8 months and until fracture union. Results: The data collected was analysed using paired student t-test. There was no statistically significant difference (p> 0.05) in the preoperative mean compartment pressures for both groups when all the four compartments were measured individually. The mean postoperative measurements were higher (range 9–10 mmHg) in all four compartments in the traction group. This was statistically significant (p< 0.05). None of the pressures reached the critical level as they were more than 30 mmHg below the diastolic pressure (differential pressure). Conclusions: These results show that traction increases compartment pressures during intramedullary nailing of tibial shaft fractures. The group considered did not have compartment syndrome possibly due to less soft tissue injury. With greater soft tissue injury and greater preoperative compartment pressures, compartment pressures can reach a critical level necessitating decompression. We conclude that intramedullary nailing without traction reduces the chances of significant increase in compartment pressures and advocate the procedure be done without traction

Background The non-motorised microscooter has become the urban transport of choice for children in Ireland. Recently, Josefson highlighted the rising trend of scooter-related injury in the US and predicted possible significant impacts in human and socioeconomic terms. Materials and Methods. A prospective study was undertaken of all referrals with scooter injuries to accident and emergency departments and fracture clinics in the first three months of the year. These cases were then reviewed at 6 months post injury. Results: There were 151 microscooter injuries seen in the first 3 months of the year, Forming over 4% of all trauma seen over this period. Eighty nine of the patients (59%) were female, and the mean age at presentation was 8.5 years (range 3–15 years). The peak referral rates for January, February and March measured 48%, 29% and 23% respectively. A survey of attending paediatric outpatients over this period revealed that 75% of households possessed at least 1 scooter, and in those households with children aged between 4 and 14 years, the rate of micoscooter possession increased to 83%. Eighty four children suffered fractures and dislocations, 59 suffered soft tissue injuries, 8 had isolated head injuries. Upper limb fractures and dislocations were the most common injury (75 of 84 bone and joint injuries). Fracture of distal third of radius and ulna, was the most common single injury. upper limb fractures wer seen frequently. A high proportion of these had apex dorsal angulation with or without displacement (Smith deformity). Lower limb fractures were relatively rare. The pattern of soft tissue injuries and lacerations mostly affected the head and neck 25 (17%), the lower limb was involved in 19 (13%) and upper limb in 15 (10%) of patients. No major head injuries occurred. Only 5 patients had any adult supervision at the time of their injury. No children wore any formal protective clothing or apparatus. In the 84 patients who had suffered bony injury, at 6 months, 110 patients (73%) had

INTRODUCTION: To audit the workload of an Orthopaedic Surgeon sent on deployment to the Middle East. The cases seen and treated are discussed. The audit was to determine the lessons for the future. DISCUSSION: 86 in patient admissions occurred between 12.01.2002 and 10.04.2002. A break up of speciality was a follows: Orthopaedic 38, Medical 27, General Surgical 16 and Psychiatric 5. A breakdown of the Orthopaedic cases were as follows: Ankle Injury 5, Arthralgia 3, Closed Fracture 4, Elbow Injury 1, Knee Injury 5, Low Back Pain 5, Multiple Soft Tissue Injury 3, Open Injury 3, Sciatica 1, Shoulder Injury 2, Soft Tissue Injury 3, and Stress Fracture 3. The 3 suspected stress fractures and the 2 gun shot wounds required special mention. 31 of 38 Orthopaedic patients were sent back to the UK through the Aeromedical chain. These patients were subclassified according to the requirement of evacuation through the Aeromedical chain. Seventeen patients, though not fit for theatre were able to undertake their own flight back. A trial of sending them back on unaccompanied flights failed. All patients were then evacuated through the Aeromedical chain. On average this meant one medical attendant per 2 patients. If civilian flights were taken this would have meant an extra expenditure of £4,800 (£600 x 8). Illness behaviour was noted in 10 of the 38 Orthopaedic patients. All these patients were evacuated to the UK. Malingering as tested by the Burns bench test, modified Schobers test, Hoover test and Inappropriate Waddells signs were positive in 4 of these patients whose initial complaint was of low back pain. CONCLUSION: It is proposed that the category of patients who are unfit for theatre but fit to fly unaccompanied should be recognised. It is also proposed that patients potentially deployable but showing illness behaviour should be discharged from the services earlier as it causes unnecessary expenditure and enforces extra work on other sincere and fit personnel

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Abstract

Robotic-assisted total knee arthroplasty (TKA) has proven higher accuracy, fewer alignment outliers, and improved short-term clinical outcomes when compared to conventional TKA. However, evidence of cost-effectiveness and individual superiority of one system over another is the subject of further research. Despite its growing adoption rate, published results are still limited and comparative studies are scarce. This review compares characteristics and performance of five currently available systems, focusing on the information and feedback each system provides to the surgeon, what the systems allow the surgeon to modify during the operation, and how each system then aids execution of the surgical plan.

Cite this article: Bone Jt Open 2023;4(1):13–18.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Aims

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs.

Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

Aims

This study investigated vancomycin-microbubbles (Vm-MBs) and meropenem (Mp)-MBs with ultrasound-targeted microbubble destruction (UTMD) to disrupt biofilms and improve bactericidal efficiency, providing a new and promising strategy for the treatment of device-related infections (DRIs).

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications

Aims

Dead-space management, following dead bone resection, is an important element of successful chronic osteomyelitis treatment. This study compared two different biodegradable antibiotic carriers used for dead-space management, and reviewed clinical and radiological outcomes. All cases underwent single-stage surgery and had a minimum one-year follow-up.

Introduction. Stem cells are widely known in the state of the art of cell-based therapies. Recently, ADSCs are becoming a popular resource of adult stem cells across different fields, and latest publications show its wide application for the treatment of soft tissue injuries like tendon injuries, which represent a high percentage of the consultations in orthopaedic practitioners. Molecular-based therapies and local deliveries are necessary for an effective treatment of chronic tendon injuries. In this study, human ADSCs were selected to investigate its differentiation potential into the tendon phenotype. Customised cell culture media was used as the differentiation factor. Materials and Methods. In the present study, ADSCs were used in passage 3 to ensure pluripotency in vitro. Using the customised cell culture media, its time, concentration and frequency of refreshment effects were investigated. On the selected time points different techniques were performed: 1,) cells were harvested, and messenger RNA (mRNA) was examined by Real Time Polymerase Chain Reaction (RT-PCR), analysing the expression of common tendon and extracellular matrix (ECM) markers. Protein expression was determined by Western Blotting. 2) Collagen content was analysed by tissue digestion and colorimetric techniques. 3) Deoxyribonucleic Acid (DNA) was stained, and fluorescent imaging was used to characterise nuclear roundness. 4) Metabolic activity of the cultures was assessed using CellTiter 96® Aqueous One Solution (MTS). 5) Cell proliferation was evaluated using CyQuant® Cell Proliferation Assay. Results. In this work, we systematically evaluated the doses and time effect of the customised media on the differentiation potential of ADSCs. Our results showed significant differences in the cell performance between the conditions investigated. Interestingly, ADSCs presented enhanced tendon marker expression (mRNA and protein level) and collagen content. The different tendon and ECM markers analysed by RT-PCR showed doses and time-dependent effect, establishing a connection with. its role in the tissue. We believe this could offer a possible regenerative treatment without overstimulation. Despite the condition, ADSCs presented 95%–100% viability and proliferation values, demonstrating the non-toxic effect of the media. Conclusion. This study contributes to the knowledge of differentiation potential of ADSCs in tendon repair. Furthermore, the tendon phenotype generated in the 2D cultures changes when different variables are investigated. Knowing the molecular basis and conformations of the tendon phenotype is key in tendon research. Hence we believe these results can show a new paradigm in tendon repair, making possible to select more suitable treatments depending on the status of the injury on the patients. Acknowledgements. This work was supported by Rosetrees Trust, Arthritis Research UK and the Universityof East Anglia

Aims

Prompt and sufficient broad-spectrum empirical antibiotic treatment is key to preventing infection following open tibial fractures. Succeeding co-administration, we dynamically assessed the time for which vancomycin and meropenem concentrations were above relevant epidemiological cut-off (ECOFF) minimal inhibitory concentrations (T > MIC) in tibial compartments for the bacteria most frequently encountered in open fractures. Low and high MIC targets were applied: 1 and 4 µg/ml for vancomycin, and 0.125 and 2 µg/ml for meropenem.

Aims

In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility.

Aims

The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate.

Stiffness remains one of the most common, and challenging postoperative complications after TKA. Preoperative motion and diagnosis can influence postoperative motion, and careful patient counseling about expectations is important. Postoperative stiffness should be evaluated by ruling out infections, metal allergy, or too aggressive physical therapy. A careful physical and radiographic examination is required. Manipulation under anesthesia (MUA) in selected cases can be helpful. The best timing to perform MUA is between the 6th and 10th week postoperatively. Careful technique is required to minimise the risk of fracture or soft tissue injury. This requires complete paralysis! For more chronic stiffness, revision may be indicated if an etiology can be identified. An excessively thick patellar resurfacing, an overstuffed tibia insert, an oversized femoral component, or gross malrotation should be corrected. During revision, thorough synovectomy, release of contractures, ligamentous balancing and restoration of the joint line is required. Careful attention to component rotation, and sizing is critical. Downsizing components is helpful to place less volume into the joint space. Patients should be counseled that the results of revision for stiffness are mixed and somewhat unpredictable. More frequent postoperative nurturing is helpful to guide rehabilitation progress. Manipulation after revision at 6 weeks is almost expected

Joint assessment through manual physical examination is a fundamental skill that must be acquired by orthopaedic surgeons. These joint assessments allow surgeons to identify soft tissue injuries (e.g. ligament tears) which are critical in identifying appropriate treatment options. The difficulty in communicating the feeling of different joint conditions and the limited opportunities for practice can make these skills challenging to learn, resulting in reduced treatment effectiveness and increased costs. This research seeks to improve the training of joint assessment with the creation of a haptic joint simulator that can train surgeons with increased effectiveness. A first of its kind haptic simulator is presented, which incorporates: a newly defined kinetic knee simulation, a haptic device for user interaction, and a haptic control algorithm. The knee model has been specifically created for this application and allows six degree-of-freedom manipulation of the tibia while considering the effects of ten knee ligament bundles. The model has been mathematically formulated to allow for the high update rates necessary for smooth and stable haptic simulation. Two quantitative assessments were made of the model to confirm its clinical validity. The first was against the widely used OpenSim biomechanical simulation software. Simulations of the model's performance for both anterior-posterior draw tests and varus-valgus rotation tests showed less than 0.7%RMSE for force and 5.5%RMSE for moments. Crucially, the proposed model could generate updated forces in less than 1ms, compared to 188ms for OpenSim. The second validation of the model was against a cadaveric knee that was tested using a validated robotic testing platform. This comparison showed that the model could generate similar force- motion pathways to the cadaveric knee after the model's parameters were scaled to match. Having demonstrated that it is possible to create a computational knee model that has good conformance to gold-standard knee simulations and cadaveric recordings, while updating at less than 1ms, this research has overcome a major hurdle. The next stage of this research will be to incorporate the knee model into a full haptic simulator and perform skill acquisition trials. Given the effectiveness of past haptic training systems in aiding clinical skills acquisition, this research offers a promising way to improve surgeon training, and therefore also patient diagnosis and treatment

INTRODUCTION. The direct anterior approach to THR has become an increasingly popular minimally-invasive technique in an effort to minimize dislocation risk, facility early recovery, and diminish soft tissue injury. However, it has been associated with unique complications including intraoperative femur fracture, cutaneous nerve palsy, stem subsidence, and wound healing complications. These risk of these complications have been documented to be more likely in the surgeon's early experience with the approach. The minimally-invasive Supercapsular Percutaneous-Assisted (SuperPATH) technique was developed to minimize capsular and short-external rotator injury, minimize dislocation risk, and provide an easier transition from the standard posterior approach. METHODS. Fifty (50) consecutive elective total hip replacements in 48 patients were performed using the SuperPATH technique. These also represented the first fifty elective THRs the surgeon performed in practice. Indications were primary or secondary osteoarthritis (92%), avascular necrosis (6%), and impending pathologic fracture (2%). Patients were evaluated retrospectively for dislocation, major, and minor complications. RESULTS. At average follow-up of 10.9 months (Range 1–27 months), there were no dislocation events. There was one periprosthetic fracture identified at 14-day follow-up that required femoral revision surgery in an elderly female patient with osteoporosis. Otherwise, there were no reoperations for any reason. There were no wound complications or deep infections. There was one stem subsidence (2%) of 4 mm. There were no neurovascular injuries. CONCLUSION. The SuperPATH technique can likely be performed at an early experience level with low early complication risk and lower early dislocation risk. This minimally-invasive technique deserves further interest and evaluation as it may present a gentle learning-curve to surgeons

Aims

Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models.

Aims

It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively.

Classification systems for open fractures help the surgeon to follow guidelines for treatment, to predict the prognosis, and to allow comparison of results. The systems of Gustilo and Anderson and of Oestern and Tscherne are most widely used. Although both systems have undergone several revisions, the crucial factors have not changed. They deal with the size of the wound, level of contamination, extent of soft tissue injury, and comminution of bone. In recent years additional classification systems have been created to classify severe open fractures (type III), mainly of the lower extremity. The Mangled Extremity Severity Score (MESS) became the most practicable score for establishing a dividing line between possible functional limb salvage and the need for primary amputation. Management: The principle of surgical debridement of all necrotic tissues has to be followed. Nowadays, soft tissue coverage and restoration of lost bone can be achieved secondarily by different means. However, the method of primary skeletal stabilization has a high impact on the final outcome after open diaphyseal fractures. Upper extremity: Most open fractures of the humerus and forearm can be stabilized sufficiently with plates. Because of the good soft tissue coverage of the humerus and proximal forearm and the good blood supply of this region, coverage of implants can usually be achieved in cases with vast soft tissue destruction and severe bone comminution. External fixation with the option of primary shortening and secondary bone transport is a good alternative in cases of humeral fracture. Indications for intramedullary nailing are limited to minor open fractures that do not require radial nerve exploration. At the distal forearm, the thin soft tissue layer and the necessity of two approaches often make coverage of plates impossible. External fixation is the method of choice in these cases. Lower extremity: Femoral fractures are a domain for intramedullary nailing. The indications for nailing are restricted more by systemic factors rather than by the extent of soft tissue injury. The advantages of intramedullary nailing are based on the closed surgical procedure that leaves the actual fracture site untouched. Static interlocking ensures axial and rotational stability and warrants early functional treatment and weight-bearing mobilisation. External fixation is indicated as emergency treatment, and plating should be restricted to condylar and supracondylar fractures. Tibial fractures leaving 7 cm intact bone proximally and 5 cm distally can be sufficiently stabilized by intramedullary locking nails. In cases of open fractures, small diameter nails can be inserted in the unreamed technique without deterioration of the endosteal vascular supply. This method has better reported results concerning time to union, axial alignment, joint function, and infection rates in comparison with the use of external fixation devices. However, external fixation is an adequate method, especially in cases with extreme proximal and distal fractures. If insufficient stabilization or delayed union with the use of unreamed nails or external fixators occurs, reamed nailing can be performed in a second step with good results. Plating should be restricted to tibial head and pylon fractures

Aims

With the ageing population, fragility fractures have become one of the most common conditions. The objective of this study was to investigate whether microbiological outcomes and fracture-healing in osteoporotic bone is worse than normal bone with fracture-related infection (FRI).

Introduction. Total hip arthroplasty (THA) is a common operation. Different operative approaches have specific benefits and compromises. Soft tissue injury occurs in total hip arthroplasty. This prospective study objectively measured muscle volume changes after direct anterior and posterior approach surgeries. Methods. Patients undergoing Direct Anterior Approach (DAA) and Posterior Approach (PA) THA were prospectively evaluated. 3 orthopaedic surgeons performed all surgeries. Muscle volumes of all major muscles around the hip were objectively measured using preoperative and 2 different postoperative follow-up MRIs. 2 independent measurers performed all radiographic volume measurements. Repeated-measures ANOVA was used to compare mean muscle volume changes over time. Student's t-test was used to compare muscle volumes between groups at specific time intervals. Results. MRIs for 10 DAA and 9 PA patients were analyzed. No significant differences between groups were found in BMI or Age. Pre-operative muscle volume comparisons showed no significant differences. Average postoperative follow-up times were 9.6 and 24.3 weeks. First follow-up showed significant atrophy for the DAA in Gluteus Medius (−7.3%), Gluteus Minimus (−17.5%), and Obturator Internus (−37.3%) muscles. Final follow-up showed significant recovery in Gluteus Medius (+12%) and Minimus (+11.1%) muscles. In the PA, atrophy was significant at first follow-up for Gluteus Minimus (−11.8%), Obturator Internus (−46.8%) and Externus (−16%), Piriformis (−26.5%), and Quadratus Femoris (−30.4%) muscles. Recovery was not seen in any of the significantly atrophied muscles. Muscles with significant quantified fatty atrophy at final follow-up were Obturator Internus [+5.51% (DAA); +7.65% (PA)] and Obturator Externus [+5.55% (PA)]. 3/9 PA patients demonstrated abductor tendinosis, while no DAA patients demonstrated tendinosis. Discussion. Significant atrophy for each group was seen more commonly in the anatomic regions disturbed by each approach respectively. In both approaches, muscles surgically released from their insertion showed greater atrophy, and incomplete recovery

Aims

This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma.

Stiffness remains one of the most common, and challenging post-operative complications after TKA. The exact definition of stiffness varies, and patient expectations of post-operative motion vary as well. Pre-operative motion and diagnosis (such as post-traumatic arthritis) can influence post-operative motion, and careful patient counseling about expectations is important. Post-operative stiffness should be evaluated by ruling out infection, evaluating rehabilitation efforts, and careful physical and radiographic examination. Manipulation under anesthesia (MUA) in selected cases can be helpful. The author generally prefers to perform MUA between the 6- and 8-week mark post-operatively. Careful technique is required to minimised the risk of fracture or soft tissue injury. For more chronic stiffness, revision may be indicated, especially if an etiology is identified pre-operatively (for example, an excessively thick patellar resurfacing, an oversized femoral component, gross malrotation, etc.). CT scanning can be helpful for pre-operative evaluation and planning. During revision, thorough synovectomy and release of contractures and ligamentous balancing is performed as required. Careful attention to gap balancing, component rotation, and sizing is critical. Patients should be counseled that the results of revision for stiffness are mixed and somewhat unpredictable unless a clear etiology was found intra-operatively (for example, a grossly oversized femoral component). More frequent post-operative office visits may be helpful to guide rehabilitation progress in these challenging cases

Introduction. Four parts inter trochanteric fracture of femur are commonest in elderly people. DHS fixation is gold standard treatment of such fractures. Various Complications of DHS implant are reported in the literature. However, Hip Instability: Subluxation and Dislocation is very rare. We report, five cases of Hip instability following DHS fixation surgery. Materials and Methods. This is a retrospective study conducted at ACPM Medical College, Dhule. We found only five cases that developed hip instability after DHS fixation since 1997. Available clinical notes and X-rays of these patients were studied to get the relevant information. Results and Observations. Three patients were male, two female, four had right sided fracture and one had left sided. Three had instability after six weeks and remaining two developed dislocation after eight months which were associated with infection. 1 patient refused further investigations & treatment, 2 other died with due course of time 1 lost to follow-up and one patient with deep infection underwent excision arthroplasty. We could only speculate cause for dislocation / subluxation on the basis of clinical examination, X-ray, Investigations and review of literature. In these cases it appeared that the factors responsible for instability could be mechanical factors and pyogenic infection. Review of literature and possible aetiological factors, investigations and various aspects of management of such cases are discussed. Conclusions. Mechanical factors such as intra-operative femoral head rotation, avulsion of greater trochanter, excessive medialisation, valgus reduction, excessive collapse, soft tissue injury, and infection are contributing factors for hip instability

Background:. Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential. Methods:. Clinical and radiological outcomes in 49 patients with AO type 43B and 43C fractures were evaluated retrospectively. Definitive management depended on patient factors, soft tissue injury and fracture pattern. Results:. The majority of fractures (n=26, 53%) were C3 type. 9 fractures were open (18%), grade 3A or 3B. 34 patients (69%) were definitively managed with open reduction and internal fixation (ORIF) predominantly through an anterior approach. 15 (31%) had mini-open or percutaneous plafond reduction and external fixation. No medial plates were used. There were no deep infections. Complications occurred in 5 (10%) patients, all relating to metaphyseal delayed or non-union. At last review, 18 patients (36%) had radiographic evidence of post-traumatic arthritis. Discussion:. Surgeons treating pilon fractures should be familiar with external and internal fixation techniques in order to minimise surgical complications. An algorithm for treatment planning is suggested. Conclusion:. It is possible to achieve low surgical complication rates through careful management according to the nature of the fracture and patient characteristics. For plating, the antero-lateral distal tibial Peri-Loc plate is an effective and safe implant

Knee laxity following anterior cruciate ligament (ACL) injury is a complex phenomenon influenced by various biomechanical and anatomical factors. The contribution of soft tissue injuries – such as ligaments, menisci, and capsule – has been previously defined, but less is known about the effects of bony morphology. (Tanaka et al, KSSTA 2012) The pivot shift test is frequently employed in the clinical setting to assess the combined rotational and translational laxity of the ACL deficient knee. In order to standardise the maneuver and allow for reproducible interpretation, the quantitative pivot shift test was developed. (Hoshino et al, KSSTA 2013) The aim of this study is to employ the quantitative pivot shift test to determine the effects of bone morphology as determined by magnetic resonance imaging (MRI) on rotatory laxity of the ACL deficient knee. Fifty-three ACL injured patients scheduled for surgical reconstruction (36 males and 17 females; 26±10 years) were prospectively enrolled in the study. Preoperative magnetic resonance imaging (MRI) scans were reviewed by two blinded observers and the following parameters were measured: medial and lateral tibial slope, tibial plateau width, femoral condyle width, bicondylar width, and notch width. (Musahl et al. KSSTA 2012). Preoperatively and under anaesthesia, a quantitative pivot shift test was performed on each patient by a single experienced examiner. An image analysis technique was used to quantify the lateral compartment translation during the maneuver. Subjects were classified as “high laxity” or “low laxity” based upon the median value of lateral compartment translation. (Hoshino et al. KSSTA 2012) Independent t-tests and univariate logistic regression were used to investigate the relationship between the pivot shift grade and various features of bone morphology. Statistical significance was set at p<0.05. A high inter-rater reliability was observed in all MRI measurements of bone morphology (ICC=0.72–0.88). The median lateral compartment translation during quantitative pivot shift testing was 2.8mm. Twenty-nine subjects were classified as “low laxity” (2.8mm). The lateral tibial plateau slope was significantly increased in “high laxity” patients (9.3+/−3.4mm versus 6.1+/−3.7mm; p<0.05). No other significant difference in bone morphology was observed between the groups. This study employed an objective assessment tool – the quantitative pivot shift test – to assess the contribution of various features of bone morphology to rotatory laxity in the ACL deficient knee. Increased lateral tibial plateau slope was shown to be a significant independent predictor of high laxity. These findings could help guide treatment strategies in patients with high grade rotatory laxity. Further research into the role of tibial osteotomies in this sub-group is warranted

Background. Some reports have suggested that debris generated from the head neck taper junction is more destructive than equivalent doses from metal bearing surfaces. Methods. Part 1. We examined the relationship between the source (taper/bearing) and volume of metal debris on Cr and Co concentrations in corresponding blood and hip synovial fluid samples and the observed agglomerated particle sizes in excised tissues using regression analysis of prospectively collected data at a single revision unit. Part 2. We investigated variables most strongly associated with macroscopic soft tissue injury as documented at revision surgery using ordinal logistic regression. Independent variables included source and volume of CoCr exposure, Cr and Co joint fluid concentrations, joint fluid grade, ALVAL (Aseptic Lymphocytic Vasculitis Associated Lesion) grade, presence of vascular hyalinisation, agglomerated particle size, implant type, patient sex and age. Results. A total of 199 explanted MoM hips were analysed. Multiple regression statistical modelling suggested that a greater source contribution of metal debris from the taper junction was associated with smaller aggregated particle sizes in the local tissues and a relative reduction of Cr ion concentrations in the corresponding synovial fluid and blood samples. There was an association between increasing Co concentrations in the joint fluid and an increasing ALVAL score (p<0.001). In contrast, higher Cr concentrations were inversely related to ALVAL (p<0.001). The ALVAL response was itself strongly associated with larger fluid collections (p<0.001). Vascular hyalinisation and larger fluid collections were significantly associated with macroscopic tissue injury (coefficient 2.22, p<0.001 for fluid grade and 4.35, p<0.001 for hyalinisation). Discussion. Metal debris generated from taper junctions appears to be associated with a different biochemical environment than debris generated from bearing surfaces. We believe that this finding may provide some explanation as to the poor performance of MoM THRs compared to the equivalent resurfacing devices and the confusion surrounding the significance of blood metal testing. Conclusion. Chromium does seem to inhibit the development of ALVAL

Pilon fractures are associated to significant soft tissue injury, as well as soft tissue complications. The soft tissue on the medial side of the distal tibia is often involved, likely due to a lack of muscle investment. Medial approaches and medial plate application may well add to the soft tissue trauma. The objective of this study was to examine the relationship between medial plating and soft tissue complications in our center. This is a retrospective study based on a prospective database. Pilon cases treated with plate and screw fixation were identified between 2011 and 2014. Injury characteristics, patient demographics, and soft tissue complications were collected from chart review. Soft tissue complications recorded included any wound or skin problem, as well as patient complaints of hardware irritation leading to hardware removal. Logistic regression was employed. Independent variables for the model included medial plating, the presence of open fracture, smoking status and diagnosis of diabetes. Two models were created, one with the dependent variable as presence of any soft tissue complication, and the second model with the dependent variable as presence of a wound complication, which required surgical intervention. The study included 91 patients, 89 of whom had full data with an average follow up of 11.6 months (1–33 months). The incidence of soft tissue complications, including hardware irritation, was 26% (n=23), and 13% (n=12) required surgical treatment. Smoking status was the only predictor of soft tissue complications with an odds ratio of 3.6 (95%CI 1.2, 10.4; p=0.02), while controlling for other independent variables. The model explained 12% of the variation in soft tissue complications (Cox and Snell 0.119, p=0.028). In the second model, presence of a medial plate predicted soft tissue complications requiring surgical intervention with an odds ratio of 8.8 (95%CI 1.1, 73.7; p=0.045), while controlling for the other independent variables. The model explained 10% of the variation in soft tissue complications requiring surgical intervention (Cox and Snell 0.095, p=0.035). The use of a medial plate does not appear to correlate to general soft tissue complications in pilon fractures. Smoking status increased the odds of a soft tissue complication more than three fold. The use of medial plating did increase the odds of soft tissue complications that required surgical treatment almost nine fold. It appears medial plating is not related to soft tissue complications, however treating soft tissue compilations in the presence of a medial plate may require more invasive methods

The COVID-19 pandemic has led to unprecedented times worldwide. From lockdowns to masks now being part of our everyday routine, to the halting of elective surgeries, the virus has touched everyone and every part of our personal and professional lives. Perhaps, now more than ever, our ability to adapt, change and persevere is critical to our survival. This year's closed meeting of The Knee Society demonstrated exactly those characteristics. When it became evident that an in-person meeting would not be feasible, The Knee Society leadership, under the direction of President John Callaghan, MD and Program Chair Craig Della Valle, MD created a unique and engaging meeting held on September 10–12, 2020. Special recognition should be given to Olga Foley and Cynthia Garcia at The Knee Society for their flexibility and creativeness in putting together a world-class flawless virtual program. The Bone & Joint Journal is very pleased to partner with The Knee Society to once again publish the proceedings of the closed meeting of the Knee Society. The Knee Society is a United States based society of highly selected members who have shown leadership in education and research in knee surgery. It invites up to 15% international members; this includes some of the key opinion leaders in knee surgery from outside the USA. Each year, the top research papers from The Knee Society meeting will be published and made available to the wider orthopaedic community in The Bone & Joint Journal. The first such proceedings were published in BJJ in 2019. International dissemination should help to fulfil the mission and vision of the Knee Society of advancing the care of patients with knee disorders through leadership, education and research. The quality of dissemination that The Bone & Joint Journal provides should enhance the profile of this work and allow a larger body of surgeons, associated healthcare professionals and patients to benefit from the expertise of the members of The Knee Society. The meeting is one of the highlights of the annual academic calendar for knee surgeons. With nearly every member in attendance virtually throughout the 3 days, the top research papers from the membership were presented and discussed in a virtual format that allowed for lively interaction and discussion. There are 75 abstracts presented. More selective proceedings with full papers will be available after a robust peer review process in 2021, both online and in The Bone & Joint Journal. The meeting commenced with the first group of scientific papers focused on Periprosthetic Joint Infection. Dr Berry and colleagues from the Mayo Clinic further help to clarify the issue of serology and aspirate results to diagnose TKA PJI in the acute postoperative setting. 177 TKA's had an aspiration within 12 weeks and 22 were proven to have PJI. Their results demonstrated that acute PJI after TKA should be suspected within 6 weeks if CRP is ≥81 mg/L, synovial WBCs are ≥8500 cells/μL, and/or synovial neutrophils≥86%. Between 6– 12 weeks, concerning thresholds include a CRP ≥ 32 mg/L, synovial WBC ≥7450, and synovial neutrophils ≥ 84%. While historically the results of a DAIR procedure for PJI have been variable, Tom Fehring's study showed promise with the local delivery of vancomycin through the Intraosseous route improved early results. New member Simon Young contrasted the efficacy of the DAIR procedure when comparing early infections to late acute hematogenous PJI. DAIR failed in 63% of late hematogenous PJIs (implant age>1 year) compared to 36% of early (<1year) PJIs. Dr Masri demonstrated in a small group of patients that those with well-functioning articulating spacers can retain their spacers for over 12 months with no difference in infection from those that had a formal two stage exchange. The mental toll of PJI was demonstrated in a longitudinal study by Doug Dennis, where patient being treated with 2 stage exchange had 4x higher rates of depression compared to patient undergoing aseptic revision. The second session focused on both postoperative issues with regards to anticoagulation and manipulation. Steven Haas demonstrated high complication rates with utilization of anticoagulation for treatment of postoperative pulmonary embolism with modern therapeutic anticoagulation (warfarin, enoxaparin, Xa inhibitors) with the Xa inhibitors demonstrating lower complication rates. Two papers focused on the topic of manipulation. Mark Pagnano presented data on timing of manipulation under anesthesia up to even past 12 months. While gains were modest, a subset of patients did achieve substantial gains in ROM > 20degrees even after 3 months post op. Dr Westrich's study demonstrated no difference in MUA outcomes with either IV sedation or neuraxial anesthesia although the length of stay was shorter in the IV sedation group. Several studies in Session II focused on kinematics and femoral component position. Dr Li's in vivo kinematic study during weightbearing flexion and gait demonstrated that several knees rotated with a lateral pivot motion and not all knees can be described with a single motion character. Dr Mayman and his group utilized a computational knee model to demonstrate that additional distal femoral resection results in increasing levels of mid -flexion instability and cautioned against the use of additional bony resection as the first line for flexion contractures. Using computer navigation, Dr Huddleston's study nicely outlined the variability in femoral component rotation to achieve a rectangular flexion gap utilizing a gap balanced method. The third session opened the meeting on Friday morning. The focus was on unicompartmental knee arthroplasty and the increasing utilization of robotic assisted total knee arthroplasty. David Murray showed using registry data that for patient with higher comorbidities (ASA >3), UKA was safer and more cost effective than TKA while Dr Della Valle's group demonstrated overall lower average healthcare costs in UKA patients compared to TKA in the first 10 years after surgery. Dr Geller assessed UKA survivorship among 3 international registries. While survivorship varied by nation and designs, certain designs consistently had better overall performance. Dr Nunley and his group showed robotic navigation UKA significantly reduced outliers in alignment and overhang compared to manual UKA. Dr Catani's data demonstrated that full thickness cartilage loss should still be considered a requirement for UKA success even with robotic assistance. Despite a high dislocation rate of 4%, Mr Dodd demonstrated high survivorship for lateral UKA despite historical contraindications. The growing evidence for robotics TKA was demonstrated in two studies. Professor Haddad showed less soft tissue injury, reduced bone trauma and improved accuracy or rTKA compared to manual TKA while Dr Gustke single surgeon study showed his rTKA had improved forgotten joint scores and less ligament releasing required for balancing. Despite these finding, Dr Lee's study demonstrated that a robotic TKA could not guarantee excellent pain relief and other factors such a patient expectations and psychological factors play a role. Our fourth session was devoted to machine learning and smart tools and modeling. Dr Meneghini used machine learning algorithms to identify optimal alignment outcomes that correlated with patient outcomes. Several parameters such as native tibial slope, femoral sagittal position and coronal limb alignment correlated with outcomes. Along the same lines, Bozic and coauthors demonstrated that using AI algorithms incorporated with PROM's improved levels of shared decision making and patient satisfaction. Dr Lombardi demonstrated that a mobile patient engagement platform that provided smart phone-based exercise and education was comparable to traditional methods. Dr Mahfouz demonstrated the accuracy of using ultrasound to produce 3D models of the bone compared to conventional CT based strategies and Dr Mahoney showed the valued of a preop 3D model in reproducing more normal knee kinematics. The last two talks of the session focused on some of the positives of the COVID-19 pandemic, namely the embracing of telemedicine by patients and surgeons as demonstrated by Dr Slover and the increasing and far reaching educational opportunities made available to residents and fellows during the pandemic. Session five focused on risk stratification and optimization prior to TKA. Dr O'Connor demonstrated that that the implementation of an optimization program preoperatively reduced length of stay and ED visits, and Charles Nelson's study showed that risk stratification tool can lower complication rates in obese patients undergoing TKA comparable to those that are nonobese. Dr Markel's study demonstrated that those who have preoperative depression and anxiety are at higher risk of complications and readmissions after surgery and these issues should be addressed preoperatively. Interestingly, a study by Dr Callaghan demonstrated that care improvement pathways have not lowered the gap in complications for morbidly obese patients undergoing TKA, Dr Barsoum argued that the overall complication rates were low and this patient cohort had significant gains in PROMS after TKA that would not be experienced if arbitrary cutoff for limited surgery were established. The final session on Friday, Session six, had several well done and interesting studies. There continues to be mounting evidence that liposomal bupivacaine has little effect on managing post-operative pain to warrant its increased use. Bill Macaulay and colleagues showed no change in pain scores, opioid consumption and functional scores when liposomal bupivacaine was discontinued at a large academic medical center. Dr Bugbee importantly demonstrated that a supervised ambulation program reduced falls in the early postoperative period. Several paper on healthcare economics were presented. Rich Iorio showed that stratifying complexity of total joint cases between hospitals with a system can be efficient and cost savings while Dr Jiranek demonstrated in his study that complex TKAs can be identified preoperatively and are associated with prolonged operative time and cost of care and consideration should be given in future reimbursement models to a complexity modifier. Dr Springer, in their evaluation of Medicare bundled payment models, demonstrated that providers and hospitals in historical bundled models that became efficient were penalized in the new model, forcing many groups to drop out and return to a fee for service model. Ron Delanois important work showed that social determinants can have a major negative impact on outcomes following TKA. Our final day on Saturday opened with Session seven, and several interesting paper on metal ions/debris in TKA. Dr Whitesides simulator study showed the absence of scratches and material loss in a ceramic TKA compared with Co-Cr TKA and suggested an advantage to this material in patients with metal sensitivity. Conversely, in a histological study of failed TKA, perivascular lymphocytic infiltration was not associated with worse clinical outcomes or differences in revision in a series of 617 aseptic revisions, 19% of which had PVLI found on histology. The Mayo group and Dr Trousdale however, noted that serum metal ion levels can be helpful in identifying implant failure in a group of revision TKAs, especially those with metallic junctions. Dr Dalury demonstrated nicely that use of maximally conforming inserts did not have a negative effect on implant loosening in a series of 76 revision TKA's at an average follow up of 7 years, while Kevin Garvin and his group showed no difference in end of stem pain between cemented and cementless stems in revision TKA. The final two studies in the session by Bolognesi and Peters respectively showed that metaphyseal cones continue to demonstrate excelled survivorship in rTKA setting despite extensive bone loss. Session eight was highlighted by a large series of revision reported by new member Dr Schwarzkopf, who showed that revision TKA done by high volume surgeons demonstrated better outcomes and lower revision rates compared to surgeon who did less than 18 rTKA's per year. Dr Maniar importantly showed that preoperatively, patients with high activity level and low pain and indicated by a high preop forgotten joint score did poorly following TKA while David Ayers nicely demonstrated that KOOS scores that assess specific postoperative outcomes can predict patient dissatisfaction after TKA. The final paper in this session by Max Courtney showed that the majority of surgical cancellations are due to medical issues, yet a minority of these undergo any intervention specifically for that condition, but they resulted in a delay of 5 months. The first two studies of Session nine focused on polyethylene thickness. Dr Backstein demonstrated no difference in KSS scores, change in ROM and aseptic revision rates based on polyethylene thickness in a series of 195 TKA's. An interesting lab study by Dr Tim Wright showed a surprising consistency in liner thickness choice among varying levels of surgeon experience that did not correlate with applied forces or gap stability estimates. Two studies looked specifically at the issue of tibial loosening and implant design. Nam and colleagues were not able to demonstrate concerning findings for increasing tibial loosening in a tibial baseplate with a shortened tibial keel at short term follow up, while Lachiewicz demonstrated a 19% revision or revision pending rate in 223 cemented fixed bearing ATTUNE TKA at a mean of 30 months. Our final session of the meeting, began with encouraging news, that despite only currently capturing about 40% of TJA's done in the US, the American Joint Replacement Registry data is representative of data in other representative US databases. An interesting study presented by Robert Barrack looked at bone remodeling in the proximal tibia after cemented and cementless TKA of two different designs. No significant difference was noted among the groups with the exception of the cemented thicker cobalt chrome tray which demonstrated significantly more bone mineral density loss. Along the same lines, a study out of Dr Bostrom's lab demonstrated treatment of a murine tibial model with iPTH prevents fibrous tissue formation and enhances bone formation in cementless implants. New Member Jamie Howard showed no difference in implant migration and kinematics of a single radius cementless design using either a measured resection or gap balancing technique and Dr Cushner show no difference in blood loss with cemented or cementless TKA with the use of TKA. The final two studies looked at staging and bilateral TKA's. Peter Sharkey showed that simultaneous TKA's were associated with higher complication compared to staged TKA and that staged TKA with less than a 90-day interval was not associated with higher risk. However, Mark Figgie showed that patients undergoing simultaneous TKA compared to staged TKA, missed 17 fewer days of work. In spite of the virtual nature of the meeting, there were some outstanding scientific interactions and the material presented will continue to generate debate and to guide the direction of knee arthroplasty as we move forwards

Purpose of Study. Bicondylar tibial plateau fractures are serious injuries to a major weight bearing joint. These injuries are often associated with severe soft tissue injuries that complicate the surgical management. This retrospective study evaluates the management of these high-energy injuries with the use of limited open reduction and fine wire circular external fixation. Methods. Between July 2008 and June 2012, 54 consecutive patients (19 females and 35 males) with high-energy tibial plateau fractures were treated at our tertiary level government hospital. All patients were treated with limited open reduction, and cannulated screw fixation combined with fine wire circular external fixators as the definitive management. The records of these patients were reviewed. Results. Forty-six patients met the inclusion and exclusion criteria. Thirty-six patients had Schatzker type-VI and ten patients had Schatzker type-V fractures. All fractures united without loss of operative reduction. No wound complications, osteomyelitis or septic arthritis occurred. Average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin tract infection was the most common complication encountered. Conclusion. Fine wire circular external fixation combined with limited open reduction and cannulated screw fixation consistently produced good functional results without serious complications. NO DISCLOSURES

Aims

Recurrent dislocation is both a cause and consequence of glenoid bone loss, and the extent of the bony defect is an indicator guiding operative intervention. Literature suggests that loss greater than 25% requires glenoid reconstruction. Measuring bone loss is controversial; studies use different methods to determine this, with no clear evidence of reproducibility. A systematic review was performed to identify existing CT-based methods of quantifying glenoid bone loss and establish their reliability and reproducibility

Recent evidence suggests that both the accepted mechanism of blast-mediated traumatic amputation (TA) (shockwave then blast wind exposure) and the link with fatal shockwave exposure merit review. Searching UK military prospectively gathered trauma registry data and post mortem CT (PM-CT) records identified casualties from August 2008 to August 2010 with blast-mediated TAs. TA level and associated injuries were recorded. Data on pre-debridement osseous and soft tissue injuries were only consistently available for fatalities through PM-CT imaging. 146 Cases (75 survivors and 71 fatalities) with 271 TAs (130 in survivors and 141 in fatalities) were identified. Through-joint TA rate in fatalities was 34/141 (24.1%). PM-CT analysis demonstrated only 9/34 through joint TAs with contiguous fractures in the immediately proximal long bone/limb girdle. 18/34 had no fracture, and 7/34 had a non-contiguous fracture. The previously reported link between TA and blast lung injury was not present, calling into question the significance of shockwaves in generating blast-mediated TAs. Furthermore, contemporary blast injury theory cannot account for the high prevalence of through joint TAs (previously published rate 1.3%). The proportion of through joint TAs with no associated fracture or a non-contiguous fracture (74%) is supportive of pure flail as a mechanism for blast-mediated TA

Aims

This observational study examines the effect of the COVID-19 pandemic upon the paediatric trauma burden of a district general hospital. We aim to compare the nature and volume of the paediatric trauma during the first 2020 UK lockdown period with the same period in 2019.

Introduction:. The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. Material and methods:. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months. Results:. The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months. Discussion:. The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases

Primary bony tumours of the elbow account for approximately 1% of all osseous tumours. The delayed diagnosis is commonly reported in the literature as a result of lack of clinician familiarity. We present the largest series of primary bone tumours of the elbow in the English literature. We sought to identify characteristics specific to primary elbow tumours and compare these to the current literature. We discuss cases of misdiagnosis and reasons for any delay in diagnosis. The authors also recommend a collaborative protocol for the diagnosis and management of these rare tumours. A prospectively collected national database of all bone tumours is maintained by an independent clerk. The registry and case notes were retrospectively reviewed from January 1954 until June 2013. Eighty cases of primary osseous elbow tumours were studied. Tumours were classified as benign or malignant and then graded according to the Enneking spectrum. There were no benign latent cases in this series. All cases in this series required surgical intervention. These cases presented with persistent rest pain, with or without swelling. The distal humerus was responsible for the majority and most aggressive of cases. The multidisciplinary approach at a specialist centre is integral to management. Misdiagnosis was evident in 12.5 % of all cases. Malignant tumours carried a 5-year mortality of 61%. Benign tumours exhibited a 19% recurrence rate and in particular, giant cell tumour was very aggressive. The evolution in treatment modalities has clearly benefited patients. Clinicians should be aware that elbow tumours can be initially misdiagnosed as soft tissue injuries or cysts. The suspicion of a tumour should be raised in the patient with unremitting, unexplained non-mechanical bony elbow pain. We suggest an investigatory and treatment protocol to avoid a delay to diagnosis. With high rates of local recurrence, we recommend regular postoperative reviews

Mountain biking is increasing in popularity worldwide. The injury patterns associated with elite level and competitive mountain biking are known. This study analysed the incidence, spectrum and risk factors for injuries sustained during recreational mountain biking. The injury rate was 1.54 injuries per 1000 biker exposures. Males were more commonly injured than females, with those aged 30–39 years at highest risk. The commonest types of injury were wounding, skeletal fracture and musculoskeletal soft tissue injury. Joint dislocations occurred more commonly in older mountain bikers. The limbs were more commonly injured than the axial skeleton. The highest hospital admission rates were observed with head, neck and torso injuries. Protective body armour, clip-in pedals and the use of a full-suspension bicycle confer a significant protective effect

Purpose of the study. To assess use of Taylor Spatial Frame to correct posttraumatic equinus contracture of ankle by soft tissue distraction. Description of a successful technique. Methods and end results. We have treated five cases of severe and resistant equinus contracture (20–30 degrees) between 2005 and 2010. All cases resulted from severe soft tissue injury and compartment syndrome of affected limb. They had undergone prolonged treatment for open fracture of tibia prior to referral to our institute and failed to respond to at least six months of aggressive physiotherapy. In all cases fractures did not involve ankle articular surface and all tibial fractures had united. Three out five cases also had associated peroneal nerve palsy. Our procedure included Tendo Achilles Lengthening, ankle and subtalar capsulotomy and application of two-ring Taylor Spatial Frame. We used long bone module to correct the deformity gradually. All deformities were over corrected by 5–10% to prevent recurrence. We successfully corrected equinus deformity in all cases. Follow up ranged from three months to five years and we found no recurrence. Patients with peroneal palsy were provided with Ankle Foot Orthosis (AFO). Conclusion. Taylor Spatial Frame treatment provides a safe, finely controllable, accurate and reproducible method of correcting soft tissue equinus deformity

Traumatic amputations (TAs) are amongst the most significant orthopaedic sequelae following IED strikes. Biomechanically, longer residual limb length confers better function. However, post-trauma definitive through knee amputation (TKA) remains controversial. UK military casualties sustaining ≥1 major TA, 01/08/2008–01/08/2010 were identified using the UK JTTR and post mortem CT databases. All through- and below-knee TAs were termed ‘potential TKAs’ (p-TKAs); hypothetical candidates for definitive TKA. We hypothesised that traumatic TKAs were more common than previously reported (4.5% of lower limb TAs) and a significant cohort of blast injuries exist suitable for definitive TKA. 146 cases (75 survivors, 71 fatalities) sustained 271 TAs (235 lower limb). TKA rate was 34/235 (14.2%). 63/130 survivor TAs and 66/140 fatality TAs merited analysis as p-TKAs. Detailed pathoanatomy was only available for fatality p-TKAs, for whom definitive TKA would have been proximal to the zone of injury (ZOI) in only 3/66 cases. Blast-mediated traumatic TKAs are significantly more common than previously reported (p=0.0118). Most lower limb TAs are skeletally amenable to definitive TKA. Maximising stump length for function incurs the risks of definitive amputation within the original ZOI (including infection and heterotopic ossification) but proximal extent of blast soft tissue injury commonly makes this unavoidable

It is the prime responsibility of the treating surgeon to identify and treat the vascular injury along with the skeletal trauma. Limbs with combined Orthopaedic and Vascular injuries are traditionally admitted as an Orthopaedic emergency. In a 17 year period we treated 67 cases of vascular injuries (including 16 pseudo aneurysms) associated with fractures and dislocations or soft tissue injuries of the limbs. Three cases have been followed up for over 20 years. All patients were operated by Orthopaedic residents on duty with limited resources, without the help of vascular surgeons. We relied on clinical diagnosis and immediate exploration of the blood vessels rather than time consuming procedure of arteriography. Skeletal stabilisation was achieved by internal or external fixation. Vascular reconstruction involved end to end repair or vein grafting. Fasciotomy was performed in selected cases where the injury-revascularisation time was more than 6 hours. Post-operative care involved limb placement at body level, Sympathetic blockade for 48 hours, vasodilators, Lomodex, Mannitol, Aspirin and antibiotic therapy. Urine was monitored for smoky color indicating myoglobinuria. Though only 17 were repaired within six hours, limb viability with good function was obtained in 51 cases. Complications included 7 deaths, 6 amputations, 2 acute renal failures and delayed occlusion in one case

This study concerns an epidemiological analysis of foot and ankle injuries during the Athens Olympic Games 2004. An epidemiological survey was used to analyse injuries in all sport tournaments over the period of the Games. During the Athens Olympic Games 2004 in the period from August 1st to September 1st, 624 patients presented to the Foot and Ankle Department for treatment. The mean age of athletes was 24 years (range 21 to 32). Among the patients there were more males, 358 (58%) than females, 266 (42%). In 525 (84.1%) patients there was only a soft tissue injury and in 99 (15.9%) patients there was bone involvement. Regarding specific diagnoses, tendinitis was the most common reason for a visit, followed by ankle sprains, nail infections/injuries, lesser toes sprains, and stress fractures. Sixty-nine (11%) required emergency transfer to the hospital. Our experience from the Athens Olympic Games will inform the development of public health surveillance systems for future Olympic Games, as well as other similar mass events

High-energy injuries involving the proximal tibia sometimes result in significant soft tissue injuries that may create an incompetent knee extensor mechanism. Reconstruction of the extensor mechanism using the gastrocnemii has been previously described in those patients with tissue loss following either arthroplasty or tumour surgery. In 2009, a single cross-sectional study of eight patients described the technique after trauma, and their outcome at an average of 24 months. Use of a gastrocnemius rotational myoplasty has been described in the literature for six additional cases following trauma. We present our indications, technique and 5-year results of a separate series of four patients in whom the extensor mechanism of the knee was rendered incompetent after direct tissue loss, or subsequent infection, secondary to trauma. In each case, after stabilisation of the periarticular fracture and control of infection, the medial gastrocnemius was employed both to reconstruct the patellar ligament, and to simultaneously restore soft tissue coverage. Three out of 4 patients had excellent outcomes, have returned to their previous occupations and participate in regular sport. The overall mean scores were: Oxford knee Score (38.25), Knee Injury and Osteoarthritis Outcome Score (KOOS) (64.5) and Modified Cincinnati Score (68.25). Mean knee ROM was 5–97 degrees. Video for basic gait analysis was recorded. For those traumatic injuries with the difficult combination of a soft tissue deficit and incompetence of the knee extensor mechanism, we believe the medial gastrocnemius rotational myoplasty provides an excellent reconstructive option to address both of these fundamental problems simultaneously

Extremity injury and complications such as wound infection remain a significant problem for the military. This study investigates the anti-microbial efficacy of four dressings used in militarily relevant complex extremity injury. Under general anaesthesia, the flexor carpi ulnaris of 24 New Zealand White rabbits was exposed to a high-energy impact and then inoculated with 10. 6. colony forming units of Staphylococcus aureus. Dressings: gauze soaked in saline, Chlorhexidine, Betadine or Acticoat¯, were randomised and applied 3 hours post injury, to replicate casualty evacuation. Once recovered, animals were checked at least twice daily and body temperature recorded. Analgesia was administered once a day. At 48hrs animals were culled, the muscle harvested and analyzed by a blinded investigator. Group sizes of 6 were required to detect a statistically significant effect of a mean one log reduction in bacterial counts at 48 hours. No dressing gave a significant reduction in bacterial counts at 48 hours. A paired t-test of contamination versus recovered dose gave p values of 0.903, 0.648, 0.396 and 0.336 for saline, Acticoat¯, chlorhexidine and iodine respectively. Contamination dose between groups compared using ANOVA showed no significant difference (p=0.566). Recovered bacterial loads between groups revealed no significant difference (p=0.280). This study indicates that over a 48 hour period, dressings with reported anti-bacterial properties offer no advantage over saline soaked gauze in reducing the bacterial burden in a contaminated soft tissue injury. Future work will extend the study temporally and introduce multiple contaminants

Estrogen fluctuations have been implicated in the soft tissue injury gender-bias due to the hormones effect on the viscoelastic properties. The isolated effect of estrogen on the mechanical behaviour of human tendon is unknown. The purpose of this study was to elucidate the effect of circulating levels of estrogen on the strain properties of the human Achilles tendon. Twenty females (18–35 years) who were using the pill together with 20 matched, non-pill users, participated in this study. Non-pill users were tested at the time of lowest (menstruation) and highest (ovulation) estrogen whilst pill users, who exhibited constant and attenuated estrogen levels, were tested at menstruation and two weeks later. At each test session, maximal isometric plantarflexion efforts were performed on a calf-raise apparatus whilst synchronous real-time ultrasonography of the triceps surae aponeurosis was recorded. Connective tissue length (Lo) of the triceps surae complex was measured and tendon strain was calculated by dividing aponeurosis displacement during plantarflexion by Lo. Repeated measures ANOVA revealed a significant (p < 0.05) main effect of subject group with significantly higher Achilles strain rates (16.1%) in the non-pill users compared to the pill users. Augmented Achilles tendon strain was associated with higher average estrogen levels in non-pill users. Those results suggest that higher estrogen levels diminish the joint stabilising capacity of the triceps surae musculotendinous unit and may alter the energy storage capacity of the Achilles tendon during stretch-shorten cycle activities. This may result in a higher incidence of injuries during periods of high estrogen concentration

Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries. Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement. The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4. In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management

Aim/Purpose. Review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism. Methods and Results. Retrospective study utilising a prospectively collected combat trauma registry. Records of UK Service Personnel sustaining open pelvic fractures from an explosion from Aug 2008 – Aug 2010 identified. Casualties who survived to be repatriated to the Royal Centre for Defence Medicine, University Hospital Birmingham were selected for further study. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the first 24 hours was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7(24%) had a bowel injury, 11 (38%) had a genital injury and 7(24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required internal fixation. Of those patients who underwent internal fixation, 5 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.5 days, and mean total operative time was 29.6 hours. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability. Conclusion. As a result of the “Global War on Terror” injuries that were previously confined exclusively to conflict areas can now occur anywhere in the form of terrorist attacks. Given the nature of the soft tissue injury, we would advocate an approach of predominantly external fixation in the management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is mandated in all cases