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

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

The December 2023 Trauma Roundup. 360. looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

The December 2022 Trauma Roundup. 360. looks at: Anterior approach for acetabular fractures using anatomical plates; Masquelet–Ilizarov for the management of bone loss post debridement of infected tibial nonunion; Total hip arthroplasty – better results after low-energy displaced femoral neck fracture in young patients; Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial; The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK; Cost-utility analysis of cemented hemiarthroplasty versus hydroxyapatite-coated uncemented hemiarthroplasty; Unstable ankle fractures: fibular nail fixation compared to open reduction and internal fixation; Long-term outcomes of randomized clinical trials: wrist and calcaneus; ‘HeFT’y follow-up of the UK Heel Fracture Trial

The April 2023 Trauma Roundup. 360. looks at: Displaced femoral neck fractures in patients aged 55 to 70 years: internal fixation or total hip arthroplasty?; Tibial plateau fractures: continuous passive motion approves range of motion; Lisfranc fractures: to fuse or not to fuse, that is the question; Is hardware removal after clavicle fracture plate fixation beneficial?; Fixation to coverage in Grade IIIB open fractures – what’s the time window?; Nonoperative versus locking plate fixation in the proximal humerus; Retrograde knee nailing or lateral plate for distal femur fractures?

Aims. Hand trauma accounts for one in five of emergency department attendances, with a UK incidence of over five million injuries/year and 250,000 operations/year. Surgical site infection (SSI) in hand trauma surgery leads to further interventions, poor outcomes, and prolonged recovery, but has been poorly researched. Antimicrobial sutures have been recognized by both the World Health Organization and the National Institute for Clinical Excellence as potentially effective for reducing SSI. They have never been studied in hand trauma surgery: a completely different patient group and clinical pathway to previous randomized clinical trials (RCTs) of these sutures. Antimicrobial sutures are expensive, and further research in hand trauma is warranted before they become standard of care. The aim of this protocol is to conduct a feasibility study of antimicrobial sutures in patients undergoing hand trauma surgery to establish acceptability, compliance, and retention for a definitive trial. Methods. A two-arm, multicentre feasibility RCT of 116 adult participants with hand and wrist injuries, randomized to either antimicrobial sutures or standard sutures. Study participants and outcome assessors will be blinded to treatment allocation. Outcome measures will be recorded at baseline (preoperatively), 30 days, 90 days, and six months, and will include SSI, patient-reported outcome measures, and return to work. Conclusion. This will inform a definitive trial of antimicrobial sutures in the hand and wrist, and will help to inform future upper limb trauma trials. The results of this research will be shared with the medical community through high impact publication and presentation. Cite this article: Bone Jt Open 2022;3(7):529–535

Aims. Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK. Methods. This review summarizes the relevant literature from the last 20 years in the UK. Articles were selected from database searches using MEDLINE, EMBASE, ERIC, Cochrane, and Web of Science. A total of 16 papers met the inclusion criteria. Results. The length of exposure to T&O is declining; the mean total placement duration of two to three weeks is significantly less than the four- to six-week minimum advised by most relevant sources. The main teaching methods described in the literature included didactic lectures, bedside teaching, and small group case-based discussions. Students preferred interactive, blended learning teaching styles over didactic methods. This improvement in satisfaction was reflected in improvements in student assessment scores. However, studies failed to assess competencies in clinical skills and examinations, which is consistent with the opinions of UK foundation year doctors, approximately 40% of whom report a “poor” understanding of orthopaedics. Furthermore, the majority of UK doctors are not exposed to orthopaedics at the postgraduate level, which only serves to amplify the disparity between junior and generalist knowledge, and the standards expected by senior colleagues and professional bodies. Conclusion. There is a deficit in undergraduate orthopaedic training within the UK which has only worsened in the last 20 years, leaving medical students and foundation doctors with a potentially significant lack of orthopaedic knowledge. Cite this article: Bone Jt Open 2022;3(7):549–556

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

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342–345

Aims. The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement. Methods. This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out. Results. A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications. Conclusion. A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families. Cite this article: Bone Jt Open 2023;4(12):970–979

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Aims. Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic. Methods. A vacated private elective surgical centre was repurposed to facilitate a two-site, ‘COVID’ and ‘COVID-free’, hip fracture service. Patients were screened for COVID-19 infection and either kept at our ‘COVID’ site or transferred to our ‘COVID-free’ site. We collected data for 30 days on patient demographics, Clinical Frailty Scale (CFS), Nottingham Hip Fracture Scores (NHFS), time to surgery, COVID-19 status, mortality, and length of stay (LOS). Results. In all, 47 hip fracture patients presented to our service: 12 were admitted to the ‘COVID’ site and 35 to the ‘COVID-free’ site. The ‘COVID’ site cohort were older (mean 86.8 vs 78.5 years, p = 0.0427) and with poorer CFS (p = 0.0147) and NHFS (p = 0.0023) scores. At the ‘COVID-free’ site, mean time to surgery was less (29.8 vs 52.8 hours, p = 0.0146), and mean LOS seemed shorter (8.7 vs 12.6 days, p = 0.0592). No patients tested positive for COVID-19 infection while at the ‘COVID-free’ site. We redirected 74% of our admissions from the base ‘COVID’ site and created 304 inpatient days’ capacity for medical COVID patients. Conclusion. Acquisition of unused elective orthopaedic capacity from the private sector facilitated a two-site trauma service. Patients were treated expeditiously, while successfully achieving strict infection control. We achieved significant gains in medical bed capacity in response to the COVID-19 demand. The authors propose the repurposing of unused elective operating facilities for a two-site ‘COVID’ and ‘COVID-free’ model as a safe and effective way of managing hip fracture patients during the pandemic. Cite this article: Bone Joint Open 2020;1-6:190–197

Aims. Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. Methods. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS. Results. In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias. Conclusion. We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. Cite this article: Bone Joint J 2024;106-B(4):412–418

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables. During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic. COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities. These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention. For any figures or tables, please contact the authors directly

Abstract. Background. Alcohol has been associated with up to 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23. rd. March 2020. Restrictions were most significantly eased on 1. st. June 2020, when shops and schools re-opened. This study aimed to quantify the effect of lockdown on trauma admissions specifically regarding alcohol-related trauma. Methods. All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N=316), and 1. st. April – 31. st. May 2020 (lockdown; N=191) had electronic patient records (EPR) analysed. Patients’ blood alcohol level (BAC) combined with records of intoxication were used to identify alcohol-related trauma. Multiple regression analyses were performed to compare pre- and post-lockdown alcohol-related trauma admissions. Results. Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); Odds Ratio (OR 0.83, 95% CI 0.38 to 1.28, p<0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs pre-lockdown 179/316 (56.7%); OR -0.40, 95% CI -0.79 to -0.02, p=0.041). No significant difference existed between the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p>0.05). Conclusion. UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Furthermore, trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of multiple global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour must be addressed

The Victorian state government introduced a trial electronic scooter sharing scheme on 1. st. February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers

Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Trauma and elective orthopaedic demands in New Zealand are increasing. In this study, prospective and retrospective data has been collected at Nelson Hospital and across New Zealand to identify the percentage of elective theatre time lost due to cancellation for acute patient care. Data has been collected from theatre management systems, hospital data systems and logged against secretarial case bookings, to calculate a percentage of elective theatre time lost to acute operating or insufficient bed capacity. Data was collected over a five-month period at Nelson Hospital, with a total of 215 elective and 226 acute orthopaedic procedures completed. A total of 95 primary hip or knee arthroplasties were completed during this trial while 53 were cancelled. The total number of elective operative sessions (one session is the equivalent of a half day operating theatre time) lost to acute workload was 47.9. Thirty-three percent of allocated elective theatre time was cancelled - an equivalent of approximately one-full day elective operating per week. Over a five-week period data was collected across all provincial hospitals in New Zealand, with an average of 18% of elective operating time per week lost due to acute workload. Elective cancellations were due to acute operating 40% of the time and bed shortages 60% of the time. The worst effected centre was Palmerston North which had an average of 33% of elective operating cancelled per week to accommodate acute surgery or due to bed shortages. New Zealand's provincial orthopaedic surgeons are under immense pressure from acute operating that impedes provision of elective surgery. The New Zealand government definition of an ‘acute case’ does not reflect the nature of today's orthopaedic burden. Increasing and aging populations along with staff and infrastructure shortages have financial and societal impacts beyond medicine and require better definitions, further research, and funding from governance

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort. Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship. The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01). This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future

Hip fractures in elderly patients are managed at both major trauma centers (MTC) and trauma units (TU). Previous evidence has demonstrated the importance of early surgery to reduce the morbidity and mortality related to the injury. The aim of this study is to compare the ‘time to theatre' and ‘30 day mortality' in TUs versus MTC in UK. A retrospective review of prospectively collected data on NHFD was performed. The average ‘time to theatre' in hours and ‘30 day mortality' of all hospitals were analysed between January and December 2018. Further subgroup analysis was done to check for any regional variations; in each instance a Shapiro-Wilk test was used to check for normal distribution, followed by a one-way ANOVA with a Tukey's post hoc test. Data from 158 hospitals in England (ENG), Wales (WAL) and Northern Ireland (NI) were used; 18 of which were MTC. There were 57,936 operative cases in TUs and 8606 in MTC's. The mean time (hours) to surgery from presentation was 32.51 and 32.64 for TUs and MTC respectively (p=0.513). There was no significant difference in ‘30 day mortality' (p=0.635) between TUs (6%) and 5.7% MTC's (5.7%), MTC's and TUs in ENG, WAL and NI (p=0.555), and MTC and WAL, NI and the different regions of ENG (p=0.209). A significant difference was observed, between the regional practice for TUs versus MTC's in ENG, WAL and NI (p=0.001) and between MTC's and TUs in WAL, NI and the different regions of ENG (p=0.001), with patients waiting significantly longer in NI for their procedure (mean=60.25 hours, p=0.001). There was no significant difference in time to surgery or 30 day mortality between TUs and MTC's, demonstrating comparable hip fracture care, despite MTCs need to prioritise more serious injuries

Abstract. Background. University Hospital of Wales (UHW) went live as a Major Trauma Centre (MTC) on the 14th September 2020. New guidelines have been set up by the Wales Trauma Network. Aim. Prospective audit to see how many admissions, correct pathways were followed?. Materials & Methods. Prospective data collection prospective over a period of 3 months: starting from 8.11.2020 to 31.01.2021. Results. Spinal admissions represent around 22% of MTC admissions. The closing loop showed higher amount of admission (45 in comparison with the first audit 28). 42 patients had fractures where three had cord syndromes. 13 patients out of the 45 (29%) were managed operatively. After changing to MTC, more indirect referral from other hospitals representing 64% of total admission with one wrong referral (2.2%) that came to the MTC and could have been managed locally. On the other hand, repatriation rate has improved from 61% to 84%, however, repatriation time was longer than expected with >1 week represents 78%. Conclusions. Changing to MTC had a great impact with increased work load in the trust. Repatriation would be aimed for within 72 hours from treatment either conservative or postoperative. More attention should be paid towards the appropriate referral pathways to avoid wrong referral

The August 2024 Trauma Roundup. 360. looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis

Aims. Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool. Methods. A systematic search screening 3,252 studies identified 45 ML-based prediction models in orthopaedic trauma up to January 2023. The TRIPOD statement assessed transparent reporting and the PROBAST tool the risk of bias. Results. A total of 40 studies reported on training and internal validation; four studies performed both development and external validation, and one study performed only external validation. The most commonly reported outcomes were mortality (33%, 15/45) and length of hospital stay (9%, 4/45), and the majority of prediction models were developed in the hip fracture population (60%, 27/45). The overall median completeness for the TRIPOD statement was 62% (interquartile range 30 to 81%). The overall risk of bias in the PROBAST tool was low in 24% (11/45), high in 69% (31/45), and unclear in 7% (3/45) of the studies. High risk of bias was mainly due to analysis domain concerns including small datasets with low number of outcomes, complete-case analysis in case of missing data, and no reporting of performance measures. Conclusion. The results of this study showed that despite a myriad of potential clinically useful applications, a substantial part of ML studies in orthopaedic trauma lack transparent reporting, and are at high risk of bias. These problems must be resolved by following established guidelines to instil confidence in ML models among patients and clinicians. Otherwise, there will remain a sizeable gap between the development of ML prediction models and their clinical application in our day-to-day orthopaedic trauma practice. Cite this article: Bone Jt Open 2024;5(1):9–19

Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS

Aims. The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery. Methods. Radiation exposure to surgeons during common orthopaedic trauma operations was prospectively assessed using EPDs and thermoluminescent dosimeters (TLDs). Normative data for each operation type were calculated and compared to recommended guidelines. Results. Current PPE appears to mitigate more than 90% of ionizing radiation in orthopaedic fluoroscopic procedures. There is a higher exposure to the inner thigh during seated procedures. EPDs provided results for individual procedures. Conclusion. PPE currently used by surgeons in orthopaedic trauma theatre adequately reduces radiation exposure to below recommended levels. Normative data per trauma case show specific anatomical areas of higher exposure, which may benefit from enhanced radiation protection. EPDs can be used to assess real-time radiation exposure in orthopaedic surgery. There may be a role in future medical wearables for orthopaedic surgeons. Cite this article: Bone Jt Open 2022;3(11):907–912

Aims. Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. Methods. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Results. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). Conclusion. The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries. Cite this article: Bone Jt Open 2022;3(8):623–627

Queensland is in the phase to develop a comprehensive, integrated state wide Trauma System with support from the Queensland Health and Emergency Services. A strategic step in this circumstance is benchmarking the current trauma system with other established trauma systems, to compare performance and indicators of trauma care. Queensland’s first recognized Adult Major Trauma Service, the Princess Alexandra Hospital (PAH) in Brisbane, was compared with the results of the established Trauma Registry of the German Trauma Society (DGU). This study analysed the whole range of trauma care, from the scene of the accident to discharge from the hospital. Methodology: The study populations were retrospectively identified and extracted from the Queensland Trauma Registry and the DGU Trauma Registry. Both databases contain all primary and secondary admitted trauma patients of all ages, with an Injury Severity Score (ISS) > 15, for the year 2005. The collected patient data included demographics, mechanism of injury, details on pre-hospital phase, injury, treatment, complications and outcome. Results: At the PAH 309 patients with an ISS > 15 were treated, compared to 2537 in the DGU Registry. The demographics (age and gender) and trauma mechanisms (blunt vs penetrating injuries) were comparable, even the average ISS scores were higher in the DGU registry (29) than at PAH (25). The primary referrals from the accident scene to the PA Hospital were significantly lower (52%) than to the German Trauma centres (82%). The secondary referrals arrived at PA Hospital on average 13.5 hrs post accident compared to 3.4 hrs in the DGU registry. PAH patients less often needed surgery (61% versus 78%), ICU-admission (49% versus 88%) and mechanical ventilation (44% versus 72%). The average time of the patients in ED was significantly higher with almost 4 hrs compared to 1 hrs in the German trauma centres. Nevertheless the overall mortality was lower at PA Hospital: 10% versus 18%, with an equal time to death, age and injury severity of deaths. Conclusions: Queensland’s enormous size entails significant implications for trauma care. The results of the benchmarking study may reflect an suboptimal care in the first crucial hours after the accident leading to a higher secondary referral rate and a lower ISS score of the arriving patients to PA Hospital. The relatively low number of in-hospital deaths was presumably due to a higher number of prehospital deaths, although we are unable to quantify this at present. The in hospital clinical course was elongated in the ED at PA Hospital, and several reasons can be discussed for this. This benchmarking study helps to reflect the current trauma care coming to PA Hospital, even many issues remain unanswered in a retrospective study. This presentation will review the integrated approach of Queensland to streamline the trauma care and highlights the first steps taken to improve the efficiency of the system

The February 2024 Trauma Roundup. 360. looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years

The June 2023 Trauma Roundup. 360. looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures

Trauma, across the United Kingdom, is managed using several software, paper based lists on Microsoft Word/Excel or Teams. There is usually poor handover or no handover in a standard format- during the on call, in the trauma meetings or in the wards. The software in the market for trauma management are not cost friendly or adaptable to local demands. The alternatives like Microsoft WORD based lists are fraught with their own problems. We endeavoured to make our trauma management effective. A Quality Improvement Project was done. The goals to achieve at end of a year were:. Daily Trauma Handover in standardised format >90%. Ward Handover in standardised format >90%. Availability of outcomes of patients in clinic >80%. Reduction of paper usage >90% at the end of six months. Availability of updated “outliers” information >90% at the weekend ward round. Documentation from the Trauma Meeting > 90%. On-Call documentation in standardised format >90%. Doctor Satisfaction >75% in terms of: ease of us;, searchability of patient; ward round experience; morning trauma meeting experience; handover experience; inter-specialty communication; reliability; daily time saving; on-call time saving; patient care/safety; overall satisfaction. We used Microsoft Sharepoint List to manage our trauma workload and have named the tool as “The List”. The List has achieved all objectives as above in one year's time, except Outlier information which was at 67% in a recent PDSA (Plan-Do-Study-Act) cycle. The survey showed excellent doctor satisfaction and 90% respondents felt that The List saved an hour or more during the on-call and also during the ward rounds. We conclude that The List is a very powerful tool making trauma meetings efficient and handover effective. It is indigenous, adaptable, safe, sustainable, cost neutral and easy to use

The February 2023 Trauma Roundup. 360. looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures

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

Abstract. Introduction. Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives. To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods. Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P<0.05. Results. There was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P<0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P<0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P<0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P<0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P<0.001). Conclusion. Skeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients. A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted. Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively. In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics

First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of this study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rate and identify other commonly associated injuries. This study examined patients who presented to the Rockhampton Hospital with a traumatic FRF between the dates of July 2015 to June 2020. Patient demographics, mortality rate and additional injuries sustained by the patients were collected. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs, mortality rate and other injuries sustained at the time of rib fracture. In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and other associated injuries, such as chest wall fractures and thoracic injuries, when treating a patient with a fracture of their first rib

Aims. This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements. Methods. Data capture was by collaborative approach. Patients undergoing procedures from 22 August 2022 and operated on before 31 October 2022 were included. Arm one captured weekly caseload and theatre capacity. Arm two concerned patient and injury demographics, and time to surgery for specific injury groups. Results. Data was available from 90 hospitals across 86 data access groups (70 in England, two in Wales, ten in Scotland, and four in Northern Ireland). After exclusions, 709 weeks' of data on theatre capacity and 23,138 operations were analyzed. The average number of cases per operating session was 1.73. Only 5.8% of all theatre sessions were dedicated day surgery sessions, despite 29% of general trauma patients being eligible for such pathways. In addition, 12.3% of patients experienced at least one cancellation. Delays to surgery were longest in Northern Ireland and shortest in England and Scotland. There was marked variance across all fracture types. Open fractures and fragility hip fractures, influenced by guidelines and performance renumeration, had short waits, and varied least. In all, nine hospitals had 40 or more patients waiting for surgery every week, while seven had less than five. Conclusion. There is great variability in operative demand and list provision seen in this study of 90 UK hospitals. There is marked variation in nearly all injuries apart from those associated with performance monitoring. There is no evidence of local network level coordination of care for orthopaedic trauma patients. Day case operating and pathways of care are underused and are an important area for service improvement. Cite this article: Bone Jt Open 2023;4(6):463–471

Introduction. Current undergraduate trauma and life-support training inadequately equips medical students with the knowledge, practical skills and confidence to manage trauma patients. Often first to the scene of medical emergencies, it is imperative junior doctors feel confident and competent from day one. No UK university currently includes advanced trauma and life support (ATLS) in their curriculum. This study piloted an ATLS course for Cardiff final-year medical students to improve confidence and knowledge in management of the trauma patient. Aim. To assess the immediate effect of a one-day undergraduate ATLS course on medical student's confidence in management of the trauma patients. Methods. Twelve final-year students attended a one-day, practical-skills based and interactive course led by trauma surgeons. Students' confidence managing a trauma patient were assessed pre and post-course using a six-item-MCQ with a 5-point Likert scale. Paired t-tests were carried out on SPSS for comparison pre and post-course across the six items. Qualitative feedback was also collected. Results. The students' confidence in managing a trauma patient's ‘airway and breathing’, ‘circulation’ and ‘C-spine’ all significantly improved after attending the course (p=0.023, p=0.045 and p=000 respectively). Students felt significantly more confident completing practical skills related to trauma (p= 0.001) and their confidence in managing trauma patients overall at the level expected of a Foundation doctor increased significantly (p= 0.003). Qualitative feedback demonstrated high faculty-to-student ratio, practical and interactive teaching methods were particularly helpful. Conclusion. The content and delivery of this course proved beneficial for final-year medical students imminently becoming Foundation doctors, evidencing the requirement for increased trauma training. We advocate the expansion and continuation of this novel student course to continue improving the trauma training within the undergraduate curriculum

Aims. This study reviews the past 30 years of research from the Canadian Orthopedic Trauma Society (COTS), to identify predictive factors that delay or accelerate the course of randomized controlled trials in orthopaedic trauma. Methods. We conducted a methodological review of all papers published through the Canadian Orthopaedic Trauma Society or its affiliates. Data abstracted included: year of publication; journal of publication; study type; number of study sites; sample size; and achievement of sample size goals. Information about the study timelines was also collected, including: the date of study proposal to COTS; date recruitment began; date recruitment ended; and date of publication. Results. In total, 22 studies have been published through the COTS working group, 13 of which are randomized controlled trials (RCTs). In total, 1,423 individual patients have been involved in COTS studies, a mean of 110 patients per trial (22 to 424). Each study was conducted across a mean of approximately six centres (1 to 11) and took nearly ten years (mean 119.9 months (59 to 188)) from presentation of concept to publication. The mean length of enrolment was 63 months (26 to 113) and the mean time from cessation of enrolment to publication 51 months (19 to 78). Regardless of sample size, the only factor associated with a decreased length of enrolment was a higher number of clinical sites (p = 0.041). Neither study sample size nor length of enrolment were associated with total time to publication. Conclusion. Over the last three decades, COTS has developed a multinational strategy to produce high-quality evidence in the field of orthopaedic trauma through 13 multicentre RCTs. Future efficiencies can be realized by recruitment of more clinical sites, improving connectivity between the sites, and the promotion of national streamlined ethics processes. Cite this article: Bone Joint J 2021;103-B(5):898–901

Introduction. Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address. Materials and Methods. Retrospective analysis of a prospectively collected database of all traumatic lower limb amputations secondary to trauma from a regional multidisciplinary amputee service at Queen Mary's Hospital. Electronic patient records and paper notes were consulted for evidence of re-operation, infection (superficial or deep), phantom limb pain and neuroma. 222 patients were screened and 108 included in the data analysis. Results. Records identified 108 lower limb amputations secondary to trauma in 99 patients with a mean age of 34 years (at time of amputation). Average follow-up was 225 months. 33.6% of patients underwent re-operation, 25.2% had at least one episode of infection. Of those who underwent re-operation, 47.2% had evidence of infection. 42% and 3.7% of patients described phantom limb pain and neuroma respectively. Conclusions. Lower limb amputations secondary to trauma exhibit higher rates of re-operation and infection compared to vascular or diabetic amputees. This first study to provide high quality data describing the incidence of complications such as re-operation, infection, phantom limb pain and neuroma in lower limb amputations secondary to trauma

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were

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. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Since the emergence of the COVID-19 pandemic, the NHS has been under unprecedentedpressure. Elective surgery had ceased, and trauma surgery has decreased dramatically. Surgical training is multi-faceted and requires a specialist trainee to have a timetable which includes regular elective non-emergency operating, trauma operating and training in outpatient clinics. Consequently, training in theatre and the achievement of operative numbers and index procedures had not been possible for Trauma and Orthopaedic (T&O) specialist trainees. The Joint Committee on Surgical Training (JCST) has clear training index requirements for all T&O specialist trainees. In this study, we surveyed specialist trainees in the North West London deanery against the annual requirements set by the JCST guidelines. In addition, we retrospectively assessed the total number of trauma referrals and operations scheduled in our unit during the COVID-19 outbreak compared to that one year previously. The aim of this study is to objectively assess the effect the pandemic has on T&O specialist training. A total of 24 responses were collected from specialist trainees. The results of the survey showed 87% of trainees believed that their training had been affected. 75% of trainees felt they were not on track to meet operative numbers for the year, and 71% felt index number achievement had been affected. Trauma case numbers dropped by 20% compared to that one year previously. We recommend timely, planned and conscientious remediation for specialist trainees’ educational requirements. Specialist trainees must take responsibility for their training and use of additional educational opportunities. Clinical supervisors and training programme directors must provide additional support and guidance to achieve ARCP outcomes however in some scenarios extension of training may be necessary

Fracture risks are the most common argument against the use of Ceramic on ceramic (CoC) hip implants. Question: is ceramic material at risk in case of severe local trauma?. Over a long period, we tried to identify patients with a CoC prosthesis (Ceraver Osteal°)who did sustain a trauma. This was conducted in three different institutions. Eleven patients were found: 9 males and 2 females aged 17 to 70 years at time of index surgery. Accident occurred 6 months to 15 years after index: one car accident, five motorcycle accident, five significant trauma after a fall, including one ski board accident. Consequences of these trauma were: six fractures of the acetabulum with socket loosening in 4 that needed revision, two femoral shaft fracture, one orifed and one stem exchanged, one traumatic hip dislocation associated to loosening of the socket revised at 10 years, and one traumatic loosening of the socket. Ten had no consequence on ceramic integrity. One experienced a fracture of the patella from a dashboard trauma, a liner shipping was discovered during socket revision 2 years later. This is the only case of possible relation between trauma and ceramic fracture. In a more recent longitudinal study on 1856 CoC prosthesis performed from 2010 to 2021, 29 severe traumas were identified with no consequence on Ceramic material. From this limited case study, it can be assumed that Pure Alumina Ceramic well designed and manufactured, will not break after a significant trauma

Abstract. Hospitals during Covid 19 were faced with extreme pressures notably on Emergency Departments. This led to delays in treatment for patients in Trauma and Orthopeadics. In order to support Emergency Departments and improve the service provided, this District General Hospital introduced a Specialty Doctor and Consultant led walk in trauma clinic running on weekdays from 9am-5pm. This abstract focusses on three factors. Firstly the time spent in A&E, secondly the time taken for patients to receive basic radiographic imaging and finally availability of the next fracture clinic appointment. A random sample of 100 patients were selected over a 4 week period prior to introduction of this service and compared with 100 patients since this service began. The average time spent in A&E before this service was 197 minutes which was reduced by 86% by to 27 minutes. The average time taken to receive basic imaging reduced by 18.5% from 81 minutes to 66 minutes. Finally prior to the introduction of these clinics the waiting time of the next fracture clinic varied from 3 to 17 days where as now the patient can be seen by a Consultant in a fracture clinic the next working day. Our findings show the walk in Trauma clinic service has proven to be an invaluable service to this DGH and the NHS. As a result of this service patients are receiving a higher quality of care sooner and a case can be made for the introduction of these clinics throughout the country

It has been established that a dedicated orthopaedic trauma room (DOTR) provides significant clinical and organizational benefits to the management of trauma patients. After-hours care is associated with surgeon fatigue, a high risk of patient complications, and increased costs related to staffing. However, hesitation due to concerns of the associated opportunity cost at the hospital leadership level is a major barrier to wide-spread adoption. The primary aim of this study is to determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency. Secondly, we sought to evaluate the associated financial impact of the DOTR, with respect to both after-hours care costs as well as the opportunity cost of displaced elective cases. This was a retrospective cost-analysis study performed at a single academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a four-year period from 2016-2019 were included. Patient data acquired for two-years prior and two-years after the implementation of a DOTR were compared, adjusting for the number of cases performed. Surgical duration and number of day-time and after-hours cases was recorded pre- and post-implementation. Cost savings of performing trauma cases during daytime and the opportunity cost of displacing elective cases by performing cases during the day was calculated. A sensitivity analysis accounting for varying overtime costs and hospital elective case profit was also performed. 1960 orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR. After accounting for the total number of each procedure performed, the mean weighted reduction was 31.4% and the mean time saved was 29.6 minutes per surgery. The number of daytime surgical hours increased 21%, while nighttime hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2,476. Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Through the regular scheduling of a DOTR at a single hospital in Canada, the number of surgeries occurring during daytime hours increased while the number of after-hours cases decreased. The same surgeries were also completed nearly one-third faster (30 minutes per case) on average. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Notably, the savings partially stem from decreased OR time as well as decreased nurse overtime. Widespread implementation can improve patient care while still remaining financially favourable

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases

BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement

This brief annotation summarises the particular contributions made by the annual Edinburgh International Trauma Symposium in various areas of research into aspects of orthopaedic trauma and the management of acutely injured patients, during the 25 years since its establishment

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Following the establishment of regional Major Trauma Networks in England in 2012, there were concerns that pressures regarding resource allocation in Major Trauma Centres (MTCs) may have a detrimental impact on the care of patients with hip fractures in these hospitals. This study aimed to compare outcomes in hip fracture care between MTCs and trauma units (TUs). National Hip Fracture Database data was extracted from 01/01/2015 to 31/12/2022 for all hospitals in England. Outcome measures included perioperative medical and physiotherapy assessments, time to surgery, consultant supervision in theatre, Best Practice Tariff (BPT) compliance, discharge to original residence, and mortality. Data was pooled and weighted for MTCs and remaining hospitals (TUs). A total of 487,089 patients with hip fractures were included from 167 hospitals (23 MTCs and 144 TUs). MTCs achieved marginally higher rates of orthogeriatrician assessment within 72 hours of admission (91.1% vs 90.4%, p<0.001) and mobilisation out of bed by first postoperative day (81.9% vs 79.7%, p<0.001). A lower proportion of patients underwent surgery by the day after admission in MTCs (65.2% vs 69.7%, p<0.001). However, there was significantly higher consultant surgeon and anaesthetist supervision rates during surgery in MTCs (71.8% vs 61.6%, p<0.001). There was poorer compliance with BPT criteria in MTCs (57.3% vs 60.4%, p<0.001), and proportionately fewer MTC patients were discharged to their original residence (63.5% vs 60.4%, p<0.001). There was no difference between MTCs and TUs in 30-day mortality (6.8% vs 6.8%, p=0.825). This study demonstrates that MTCs have greater difficulty in providing prompt surgery to hip fracture patients. However, their marginally superior perioperative care outcomes appear to compensate for this, as their mortality rates are similar to TUs. These findings suggest that the regionalisation of major trauma in England has not significantly compromised the overall care of hip fracture patients

Aims. The aim of this study was to determine the fracture haematoma (fxH) proteome after multiple trauma using label-free proteomics, comparing two different fracture treatment strategies. Methods. A porcine multiple trauma model was used in which two fracture treatment strategies were compared: early total care (ETC) and damage control orthopaedics (DCO). fxH was harvested and analyzed using liquid chromatography-tandem mass spectrometry. Per group, discriminating proteins were identified and protein interaction analyses were performed to further elucidate key biomolecular pathways in the early fracture healing phase. Results. The early fxH proteome was characterized by immunomodulatory and osteogenic proteins, and proteins involved in the coagulation cascade. Treatment-specific proteome alterations were observed. The fxH proteome of the ETC group showed increased expression of pro-inflammatory proteins related to, among others, activation of the complement system, neutrophil functioning, and macrophage activation, while showing decreased expression of proteins related to osteogenesis and tissue remodelling. Conversely, the fxH proteome of the DCO group contained various upregulated or exclusively detected proteins related to tissue regeneration and remodelling, and proteins related to anti-inflammatory and osteogenic processes. Conclusion. The early fxH proteome of the ETC group was characterized by the expression of immunomodulatory, mainly pro-inflammatory, proteins, whereas the early fxH proteome of the DCO group was more regenerative and osteogenic in nature. These findings match clinical observations, in which enhanced surgical trauma after multiple trauma causes dysbalanced inflammation, potentially leading to reduced tissue regeneration, and gained insights into regulatory mechanisms of fracture healing after severe trauma. Cite this article: Bone Joint Res 2024;13(5):214–225

The prevalence of alcohol and opioids in severely injured patients has been widely reported from 30-80%. However, despite the increasing global misuse of stimulant drugs, there is a paucity of literature regarding the presence of stimulant drugs in trauma patients. The primary aim of this study was to define the prevalence of stimulant drugs that were detected in patients who presented to Level One Trauma Centers throughout North America, and their effect on length of stay and mortality. Our triage criteria for admittance to the regional trauma centre are based on the recommendations by the American College of Surgeons Committee on Trauma, who now recommend toxicology screening on every patient. This was a retrospective analysis of data from the Trauma Quality Improvement Program, including all patients presenting emergently to participating Level 1 Trauma Centers from January 2017 to December 2018. A stimulant drug was defined as the detection of cocaine, amphetamine, or methamphetamine. Adults aged 18-64 years were included. Patient risk factors were included adjusted for in the analysis: age, sex, body mass index (BMI), alcohol screening results and smoking status. Univariate analysis was performed for all variables. Multivariable logistic regression and liner regression were used for mortality and length of stay, respectively. Of a total of 110,561 patients included in the study, 15,958 patients (14.4%) had positive screens for stimulants. The average age in the stimulants cohort was 40.8 years, with a 77.6% male preponderance, BMI of 26.9, blood alcohol content of 0.07, and ISS of 11.3. The control cohort was comparable, though 71.1% male (p<0.001) Patients who tested positive for stimulants had 1.79 times (95% CI, 1.09-2.93) the odds of dying in the emergency department as the control group (p=0.02). Following transfer from the emergency department, the odds ratio for deaths in hospital (OR=1.02, 95% CI 0.90-1.15) was comparable to the control group (p=0.78). The mean length of stay was significantly higher in the stimulant group (2.84 days) compared to the control group (1.79 days) (p<.001). In the Intensive Care Unit, length of stay was 0.64 days in the stimulant group versus 1.65 in the control (p=0.48). Stimulant misuse is a relevant issue in the trauma population, associated with a longer hospital stay and higher mortality in the emergency department. The continued routine drug screening of trauma patients may be beneficial in trauma centers, to implement preventative measures and optimise resource allocation

Pain and disability following wrist trauma are highly prevalent, however the mechanisms underlying painare highly unknown. Recent studies in the knee have demonstrated that altered joint contact may induce changes to the subchondral bone density and associated pain following trauma, due to the vascularity of the subchondral bone. In order to examine these changes, a depth-specific imaging technique using quantitative computed tomography (QCT) has been used. We've demonstrated the utility of QCT in measuring vBMD according to static jointcontact and found differences invBMD between healthy and previously injured wrists. However, analyzing a static joint in a neutral position is not necessarily indicative of higher or lower vBMD. Therefore, the purposeof this study is to explore the relationship between subchondral vBMDand kinematic joint contact using the same imaging technique. To demonstrate the relationship between kinematic joint contact and subchondral vBMDusing QCT, we analyzed the wrists of n = 10 participants (n = 5 healthy and n = 5 with previous wrist trauma). Participantsunderwent 4DCT scans while performing flexion to extension to estimate radiocarpal (specifically the radiolunate (RL) and radioscaphoid (RS)) joint contact area (JCa) between the articulating surfaces. The participantsalso underwent a static CT scan accompanied by a calibration phantom with known material densities that was used to estimate subchondral vBMDof the distal radius. Joint contact is measured by calculatinginter-bone distances (mm2) using a previously validated algorithm. Subchondral vBMD is presented using mean vBMD (mg/K2HPO4) at three normalized depths from the subchondral surface (0 to 2.5, 2.5 to 5 and 5 to 7.5 mm) of the distal radius. The participants in the healthy cohort demonstrated a larger JCa in the RS joint during both extension and flexion, while the trauma cohort demonstrated a larger JCa in the RL during extension and flexion. With regards to vBMD, the healthy cohort demonstrated a higher vBMD for all three normalized depths from the subchondral surface when compared to the trauma cohort. Results from our preliminary analysis demonstrate that in the RL joint specifically, a larger JCa throughout flexion and extension was associated with an overall lower vBMD across all three normalized layers. Potential reasoning behind this association could be that following wrist trauma, altered joint contact mechanics due to pathological changes (for example, musculoskeletal trauma), has led to overloading in the RL region. The overloading on this specific region may have led to a decrease in the underlying vBMD when compared to a healthy wrist. However, we are unable to conclude if this is a momentary decrease in vBMD that could be associated with the acute healing phase following trauma given that our analysis is cross-sectional. Therefore, future work should aim to analyze kinematic JCa and vBMD longitudinally to better understand how changes in kinematic JCa over time, and how the healing process following wrist trauma, impacts the underlying subchondral bone in the acute and longitudinal phases of recovery

Excessive resident duty hours (RDH) are a recognized issue with implications for physician well-being and patient safety. A major component of the RDH concern is on-call duty. While considerable work has been done to reduce resident call workload, there is a paucity of research in optimizing resident call scheduling. Call coverage is scheduled manually rather than demand-based, which generally leads to over-scheduling to prevent a service gap. Machine learning (ML) has been widely applied in other industries to prevent such issues of a supply-demand mismatch. However, the healthcare field has been slow to adopt these innovations. As such, the aim of this study was to use ML models to 1) predict demand on orthopaedic surgery residents at a level I trauma centre and 2) identify variables key to demand prediction. Daily surgical handover emails over an eight year (2012-2019) period at a level I trauma centre were collected. The following data was used to calculate demand: spine call coverage, date, and number of operating rooms (ORs), traumas, admissions and consults completed. Various ML models (linear, tree-based and neural networks) were trained to predict the workload, with their results compared to the current scheduling approach. Quality of models was determined by using the area under the receiver operator curve (AUC) and accuracy of the predictions. The top ten most important variables were extracted from the most successful model. During training, the model with the highest AUC and accuracy was the multivariate adaptive regression splines (MARS) model, with an AUC of 0.78±0.03 and accuracy of 71.7%±3.1%. During testing, the model with the highest AUC and accuracy was the neural network model, with an AUC of 0.81 and accuracy of 73.7%. All models were better than the current approach, which had an AUC of 0.50 and accuracy of 50.1%. Key variables used by the neural network model were (descending order): spine call duty, year, weekday/weekend, month, and day of the week. This was the first study attempting to use ML to predict the service demand on orthopaedic surgery residents at a major level I trauma centre. Multiple ML models were shown to be more appropriate and accurate at predicting the demand on surgical residents as compared to the current scheduling approach. Future work should look to incorporate predictive models with optimization strategies to match scheduling with demand in order to improve resident well being and patient care

The purpose of this study was (1) to evaluate the adequacy of informed consent documentation in the trauma setting for distal radius fracture surgery compared with the elective setting for total knee arthroplasty (TKA) at a large public hospital and (2) to explore the relevant guidelines in New Zealand relating to consent documentation. Consecutive adult patients (≥16 years) undergoing operations for distal radius fractures and elective TKA over a 12-month period in a single-centre were retrospectively identified. All medical records were reviewed for the risks and complications recorded. The consent form was analysed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) index readability scores. A total of 133 patients undergoing 134 operations for 135 distal radius fractures and 239 patients undergoing 247 TKA were included. Specific risks of surgery were recorded significantly less frequently for distal radius fractures than TKA (43.3% versus 78.5%, P < 0.001). Significantly fewer risks were recorded in the trauma setting compared to the elective (2.35 ± 2.98 versus 4.95 ± 3.33, P < 0.001). The readability of the consent form was 40.5 using the FRES and 10.9 using the SMOG index, indicating a university undergraduate level of reading. This study has shown poor compliance in documenting risks of surgery during the informed consent process in an acute trauma setting compared to elective arthroplasty. Institutions must prioritise improving documentation of informed consent for orthopaedic trauma patients to ensure a patient-centred approach to healthcare

Aims. The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. Methods. Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification. Results. Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396). Conclusion. Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives. Cite this article: Bone Joint J 2022;104-B(3):408–412

Tibial plateau fractures classically present in a bimodal distribution associated with high energy mechanisms in the younger population and fragility fractures in the elderly populations as a result they are well suited for looking at the effect major trauma centre status. Military trauma surgeons in training should be exposed to as much young high-energy trauma as possible to equip them for operations. Retrospective review of all tibial plateaus presenting to RVI 20 months before MTC status and 20 months following this. 61 patients pre, 66 post. Schatzker grade 1–4 were similar pre and post change. Post change there was an increase in Schatzker 5 (62%) and 6 (27%). High energy injuries were most common in younger males, cause was falls followed by RTAs. MTC status has meant an increase in high energy tibial plateaus (Schatzker 5–6) These were predominantly seen in younger males with high-energy mechanisms. As this is likely to be replicated across all injuries, we would recommend military trauma surgeons have a significant period of time training in major trauma centres to ensure adequate exposure to young high energy trauma

This study examined spinal fractures in patients admitted to a Major Trauma Centre via two independent pathways, a major trauma (MT) pathway and a standard unscheduled non-major trauma (NMT) pathway. A total of 134 patients were admitted with a spinal fracture over a period of two years; 50% of patients were MT and the remainder NMT. MT patients were predominantly male, had a mean age of 48.8 years (13 to 95), commonly underwent surgery (62.7%), characteristically had fractures in the cervico-thoracic and thoracic regions and 50% had fractures of more than one vertebrae, which were radiologically unstable in 70%. By contrast, NMT patients showed an equal gender distribution, were older (mean 58.1 years; 12 to 94), required fewer operations (56.7%), characteristically had fractures in the lumbar region and had fewer multiple and unstable fractures. This level of complexity was reflected in the length of stay in hospital; MT patients receiving surgery were in hospital for a mean of three to four days longer than NMT patients. These results show that MT patients differ from their NMT counterparts and have an increasing complexity of spinal injury. Cite this article: Bone Joint J 2015;97-B:235–9

Introduction. We used patient reported outcome measures (PROMS) to evaluate qualitative and societal outcomes of trauma. Methods. We collected PROMs data between Sept 2013 and March 2015 for 92 patients with injury severity score (ISS) greater than 9. We enquired regarding return to work, income and socioeconomic status, dignity and satisfaction and the EQ-5D questionnaire. Results. Return to work. Of patients working at admission 15/58(26%) anticipated returning to work within 14 days of discharge. Work plans at discharge did not correlate with ISS scores overall (r=−0.05, ns), or when stratified by working group. Increased physicality of work showed a trend towards poorer return to work outcomes (not significant in Spearman's rank analysis: r= 0.14, p= 0.32). Income and socioeconomic status: No significant difference was demonstrated between the comparative incomes of patients with the best and worst return to work outcomes (ANOVA n=61, t=0.63, ns). Lowest quartile earners (n=19) were more likely to complete the open questions (79%) than higher income patients (62%). Dignity and satisfaction: Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. %). Patients ‘mostly’ or ‘always’ satisfied with their care did not have significantly different incomes (ANOVA, t=0.13, ns). EQ-5D: Self-rated health status correlated with perceived likelihood of return to work (r=0.25, p=0.0395). Correlation was demonstrated between EQ-5D scores and perceived dignity preservation (r=0.38, p=0.0004), and overall satisfaction (r=0.46, p< 0.0001). There was no correlation between EQ-5D and ISS score. Conclusion. EQ5D correlated with work plans, dignity, and satisfaction. Planned return to work did not correlate with ISS score or socioeconomic status. Unlike previous studies we demonstrated that lower socioeconomic groups have best engagement with PROMS. This study highlighted the value of qualitative PROMS analysis in leading patient-driven improvements in trauma care

Aims. The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods. Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results. There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion. The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention

Aims. Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients. Methods. This randomized controlled feasibility trial was conducted at two teaching hospitals within the South Eastern Sydney Local Health District. Adult patients (age ≥ 18 years) pending orthopaedic trauma surgery between March 2021 and September 2021 were recruited and randomized to detailed or standard methods of informed consent using a random sequence concealed in sealed, opaque envelopes. The detailed group received procedure-specific written information in addition to the standard verbal consent. The primary outcome was total recall, using a seven-point interview-administered recall questionnaire at 72 hours postoperatively. Points were awarded if the participant correctly recalled details of potential complications (maximum three points), implants used (maximum three points), and postoperative instructions (maximum one point). Secondary outcomes included the anxiety subscale of the Hospital and Anxiety Depression Scale (HADS-A) and visual analogue scale (VAS) for pain collected at 24 hours preoperatively and 72 hours postoperatively. Additionally, the Patient Satisfaction Questionnaire Short Form (PSQ-18) measured satisfaction at 72 hours postoperatively. Results. A total of 60 patients were randomized, 32 to the standard group and 28 to the detailed group. Patients in the detailed group had significantly higher total recall score compared to the standard group (mean difference 1.29 points (95% confidence interval (CI) 0.51 to 2.08); p = 0.002). There were no differences in HADS-A (mean difference 0.39 (95% CI -2.11 to 2.88); p = 0.757), VAS pain (mean difference 5.71 (95% CI -22.25 to 11.11); p = 0.499), or PSQ-18 (mean difference 0.499; 95% CI -1.6 to 3.42; p = 0.392). Conclusion. Detailed written tools are useful in improving postoperative recall in adult orthopaedic trauma patients. Cite this article: Bone Jt Open 2023;4(2):104–109

Aim: To compare and assess the quality of nursing care provided to acute trauma patients that have been admitted to trauma wards and non-trauma outlying wards. Design: Multi-centre comparison, questionnaire study undertaken in three large hospitals in South Wales. The study compares the knowledge of qualified trauma nurses, based on trauma wards and non-trauma nurses, based on outlying wards. Method: 100 qualified trauma nurses and 170 qualified non-trauma nurses were asked to independently complete a questionnaire. The questions included the nursing management of common fractures and post operative conditions. The completed questionnaires were marked and the results analysed. Results: 100% of the questionnaires were completed and returned. The trauma nurses conveyed the importance of ice (85%) and elevation (97%) in the initial management of limb fractures. This compares with ice (10%) and elevation (50%) on the outlying wards. Trauma nurses correctly monitor for potentially devastating post operative complications and compartment syndrome 87% of the time compared with 42% on outlying wards. Spinal injuries are managed appropriately 88% of the time on trauma wards compared with 36% on outlying wards. Conclusion: Trauma patients receive optimum nursing care when admitted to a trauma ward and are nursed by trauma nurses. They probably have a shorter hospital stay. Many of the out-lying wards provide sub-optimal trauma nursing care and a few are positively dangerous. Recommendations: We believe that hospital trusts should train nurses to confidently and competently be able to nurse outlying patients. Until that time, we recommend that trauma patients should not be nursed by non-trauma nurses

The aim was to investigate the outcomes of patients admitted with orthopaedic injuries to adult Level 1 trauma centres. All patients admitted to the two Level 1 adult trauma centres in Victoria, Australia were registered by the Victorian Orthopaedic Trauma Outcome Registry (VOTOR). Baseline data collected included age, gender and injury cause, diagnosis and management. Patients were contacted 6 months after their trauma. Pain, disability, health related quality of life and work status were determined using visual analogues scales, global disability scales, SF12 and the work subscale of the Sickness Impact Profile. Patients were categorized into 3 groups: isolated orthopaedic injury alone, multiple orthopaedic injuries alone and orthopaedic injuries and other injuries. Non-parametric tests were used to compare outcomes across these groups. Six month outcomes were determined in 75.6% of 1181 eligible patients. The patients lost to follow-up were more likely to be male, younger and have isolated injuries than those who were available for follow-up. Patients reported ongoing pain (moderate-severe pain 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in those who had other injuries than those with isolated or multiple orthopaedic injuries alone. A large proportion of patients presenting to adult Level 1 trauma centres have ongoing pain and disability and a reduced capacity to work 6 months after orthopaedic injuries. Further research into the long-term outcomes of these patients is required to identify patient sub-groups and specific injuries and treatments that result in high morbidity

Introduction: Trauma constitutes a substantial portion of the workload of any Trauma and Orthopaedic department and any attempt for improvement in service is warranted. Aim of this study was to compare a New with an Old Trauma Service Protocol, by means of quality of Clinical service, junior doctors training and financial impact. Methods: Search was performed through the HISS archives and the theatre registry. Quantitative and qualitative parameters were assessed. Wait till surgery, length of patient hospitalisation, out of hours surgery, case cancellations, complications and number of procedures performed by junior doctors were all compared. Medical and nursing staff members were interviewed regarding their subjective opinion for the two protocols. Results: Length of wait to surgery was substantially decreased for most of the fracture groups. Out of hours surgery were almost eliminated and there were hardly any cancellations for reasons other than medical. The number of trauma cases performed by junior doctors was increased and there was always performed under supervision. The total length of stay for all the trauma patients was substantially decreased in the second year. All health professionals quoted improvement of their working-lives with less stress and better organization. The financial impact was less than we thought. Discussion: Within a patient focused NHS all patients deserve the best of care that could be provided; implementing proper resources for Trauma service should be one of our first priorities in the Bone and Joint Decade

In 2019, the incidence of fractures were 178 million globally, South Africa accounting for close to 600 000 of these fractures, an 18.53% increase since 1990. South Africa does not have the public infrastructure to adequately facilitate the optimal surgical management of this burden. This forces intensive labour practices among orthopaedic surgeons, often performing complex surgeries throughout the night. There is a direct correlation between “after-hour”operations and the increase in morbidities. A retrospective review of the orthopaedic surgical cases and orthopaedic surgical emergencies done at a tertiary institution in Johannesburg between 8th of August 2021 to 12th December 2022. The nature of the orthopaedic interventions, the date of booking of the surgical procedures, date of surgical procedures, as well as start and end time of the orthopaedic interventions were analysed. “After-Hours” orthopaedic interventions were defined as interventions done between 16:00 and 07:00. Orthopaedic emergencies were defined as: Open fracture debridements, external Fixator insertion, arthrotomies, fasciotomies and the insertion of steinmann pins. 1483 (27.92%) of 5310 operative cases done on the emergency board were orthopaedic cases. 1098 (74.04%) hardware-related cases and 535 (36.08%) orthopaedic emergencies were done. 854 (57.58%) cases were done “After-Hours” of which 433 (29.20%) cases were done during “Dead-Hours” (23:00–07:00). Of these 433 cases, only 173 (39.95%) were true orthopaedic emergencies. Although the proportion of emergencies done after hours were greater than during working hours, there is still a large proportion of intricate orthopaedic cases done between 16:00– 07:00 that should not be prioritized, due to an associated higher morbidity. Enhanced strategic planning is advisable in future in order to prioritize complex hardware cases during working hours, and due to the burden, prioritize minor relooks and simple skin- grafts for the latter aspects of the night. A dedicated Orthopaedic Trauma theatre is recommended

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Aims. Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. Methods. All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. Results. The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). Conclusion. Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures. Cite this article: Bone Jt Open 2022;3(7):582–588

Orthopaedic injuries in the knee are often associated with vascular injury. When these vascular injuries are missed devastating there are devastating outcomes like limb ablation. Pulse examination in these patients is not sensitive to exclude vascular injuries. That often lead to clinicians opting for Computed Tomography Angiogram (CTA) to exclude vascular. this usually leads to a burden in Radiology Department. This study aimed to evaluate the prevalence of vascular injury in patient with orthopaedic injury in the knee. The computed tomography (CT) done in patients with distal femur fracture, knee dislocation and proximal tibia fractures were retrieved from the picture archiving and comunication system (PACS). The CTs were done between June 2017 and June 2022. The computed tomography angiogram (CTA) reports were reviewed to determine cases that vascular injury. A sample size of 511 cases was collected. 386 cases were done CTA and 125 cases were not done CTA. There were 218 tibial plateau fractures, 79 knee dislocations, 72 distal metaphyseal femur fractures, 61 floating knees, 55 distal femure intraarticular and 26 proximal metaphyseal tibia fractures. The mechanisms of injury in these were gunshot, fall from standing height, fall from height, MVA, MBA, PVA and sports. Prevalance was 9.17% (47) of the total injuries in the knee. Prevalance in patients who were sent for CTA was 12.08%. Routine CTA in patients with injuries in the knee is not recomended. The use of ankle brachial index may decrease the number of CTA done

Aims. COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development. Methods. A split-site service was introduced, with a COVID-19 free site treating the majority of trauma patients. Polytrauma, spinal, and paediatric trauma patients, plus COVID-19 confirmed or suspicious cases, were managed at another site. Prospective data on all trauma patients undergoing surgery at either site between 16 March 2020 and 31 May 2020 was collated and compared with retrospective review of the same period in 2019. Patient demographics, injury, surgical details, length of stay (LOS), COVID-19 status, and outcome were compared. Results. There were 1,004 urgent orthopaedic trauma patients (604 in 2019; 400 in 2020). Significant reductions in time to theatre and LOS stay were observed. COVID-19 positive status was confirmed in 4.5% (n = 18). The COVID-19 mortality rate was 1.8% (n = 7). Day-case surgery comprised 47.8% (n = 191), none testing positive for COVID-19 or developing clinically significant COVID-19 symptoms requiring readmission, at a minimum of 17 days follow-up. Conclusion. The novel split-site service, segregating suspected or confirmed COVID-19 cases, minimized onward transmission and demonstrated improved outcomes regarding time to surgery and LOS, despite altered working patterns and additional constraints. Day-surgery pathways appear safe regarding COVID-19 transmission. Lessons learned require dissemination and should be sustained in preparation for a potential second wave or, the return of a “normal” non-COVID workload. Cite this article: Bone Joint Open 2020;1-9:568–575

Background. The decision to attempt limb salvage vs to amputate in a significant traumatic limb injury is based on patient´s best predicted outcome. When amputation cannot be avoided the aim is to provide a pain free limb whilst preserving the soft tissue and limb length. Methods. Retrospective study covering 5 years (2011–2016), all the trauma patients requiring lower limb amputation (LLA) included. Demographics, mechanism, type of injury, amputation type, cause and level, theatre trips for stump management were analysed. Results. 19 patients aged 27–93 included. RTC was the leading cause (47%) of LLA. Amputation type: traumatic, caused by the injury itself (31.5%) acute surgical, amputation performed in a limb threatening injury (37%); 72% of them had vascular compromise delayed amputations after failure of limb salvage surgery (31.5%); failed soft tissue coverage and poorly functioning limb were the lead cause (33% each) Type of injury: open fractures (89%), isolated to a limb segment (53%). One level/extended level=9/10 patients. More than 50% of initial amputations were extended with multiple subsequent theatre trips (33/10 patients) for stump management. Conclusions. It was difficult to predict the patients needing an extended amputation. Early MDT and prosthetic rehab service involvement is crucial in LLA decision. When consenting patients for LLA consider a 50% change to extend the initial level of amputation with subsequent theatre trips

Abstract. Background. This study aims to estimate the risk of acquiring a medical complication or death from COVID-19 infection in patients who were admitted for orthopaedic trauma surgery during the peak and plateau of pandemic. Unlike other recently published studies, where patient-cohort includes a more morbid group and cancer surgeries, we report on a group more akin to those having routine elective orthopaedic surgery. Methods. The study included 214 patients who underwent orthopaedic trauma surgeries in the hospital between 12th March and 12th May 2020 when the COVID-19 pandemic was on the rise in the United Kingdom. Data was collected on demographic profile including comorbidities, ASA grade, COVID-19 test results, type of procedures and any readmissions, complications or mortality due to COVID-19. Results. There were 7.9% readmissions and 52.9% of it was for respiratory complications. Only one patient had positive COVID-19 test during readmission. 30-day mortality for trauma surgeries was 0% if hip fractures were excluded and 2.8% in all patients. All the mortalities were for neck of femur fracture surgeries and between ASA Grade 3 and 4 or in patients above the age of 70 years. Conclusion. This study suggests that presence of COVID-19 virus in the community and hospital did not adversely affect the outcome of orthopaedic trauma surgeries or lead to excess mortality or readmissions in patients undergoing limb trauma surgery. The findings also support resumption of elective orthopaedic surgeries with appropriate risk stratification, patient optimization and with adequate infrastructural support amidst the recovery phase of the pandemic

Introduction. Despite the established guidelines on lower extremity free flap reconstruction by the British Orthopaedic Association Standard for Trauma (BOAST-4) the post-operative care has yet to be standardised. There is currently no coherent evidence in the literature regarding clinical monitoring, warming, dangling and compression; the optimal regimes and their respective physiological benefits. The aim of this study is to survey all UK Major Trauma Centres (MTCs) with regards to the post-operative care of lower extremity free flaps and elucidate the current protocols for clinical monitoring, warming, dangling and compression. Materials & Methods. All UK-based adult MTCs were surveyed. We formulated a detailed questionnaire to enquire about the post-operative care of lower extremity free flap reconstructions; the number of free flap reconstructions per month and take backs per month and for which post-operative methods a protocol is used in each MTC. We asked specific questions concerning: clinical monitoring, warming, dangling and compression. This questionnaire was distributed to consultant leads in the form of multiple choice questions, with an option of free-text box for further comments, using JISC online surveys. Results were analysed in Excel and presented in percentages. Results. The 28 adult MTCs were contacted. The results showed a lack of formal regional protocols with great variability, suggesting there is no general consensus on post-operative care of lower extremity free flap reconstructions with regards to clinical monitoring, warming, dangling and compression. Conclusions. This survey of UK MTCs on the post-operative protocols for lower extremity free flap reconstruction demonstrated lack of evidence, consensus and large variability in common practice which requires standardisation

Since the advent of the COVID-19 pandemic, there has been a technologically based progression to almost every sector of society. This has led to an influx of e-hailing motorcycle drivers (online based consumable transportation platforms) and thus an increase in road traffic accidents. This group experiences an abundance of Orthopaedic related trauma with a considerable economic burden. Therefore, the study aimed to determine the incidence of this study group as well as quantify the severity and cost implications thereof for the sake of public health and epidemiology. This was an observational study whereby a prospective cohort analysis was respectively conducted at a single centre to determine the incidence, of the study group, over a seven-month period. The study included any e-hailing motorcycle driver who sustained Orthopaedic related trauma, whilst on duty, within the catchment area whereas all other patients were excluded and used as a comparator. A descriptive statistical analysis was done to further delineate the severity of injury by comparing the type of injury, anatomical location injured, and management plan incurred. A total of 5096 individuals experienced Orthopaedic related trauma with 60 individuals (1.18%) being e-hailing motorcyclists who sustained injury whilst on duty. The incidence being 118 per 10000 patients. Further analysis revealed that 78.33% of the population experienced fractures or dislocations with 52.31% of these injuries requiring surgical intervention. The Upper limb (53.85%) and Lower limb (43.08%) were the most affected anatomical locations. The Orthopaedic care for this population group places a meaningful burden on the South African Health sector. These drivers work in unsafe environments and sustain high energy impacts, yet very little oversight exists. Therefore, continued research with new regulations needs to be drafted, looking into vehicle safety, working conditions, operative hours, and the need for public awareness

Aims. The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. Methods. A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy. Results. A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001). Conclusion. SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729–735

Abstract. Introduction. The risk of Covid-19 community and hospital acquired infection (HAI) on patient outcomes in trauma is still relevant. Patient's should be routinely consented for this risk to ensure informed consent for perioperative contraction. Method. A prospective audit was completed from December-March 2022 examining a consecutive series of patient admissions with capacity to consent. The standards for compliance was RCOS Toolkit 5#3 stating the importance of enhanced consent for risk of contraction, in operating and changes to care pathways. The target was 95% compliance. 2/2 contingency tables were generated to determine odds ratio for compliance versus Covid+ rate. Results. This audit generated 80 consecutive patients from which 28 were excluded as non-operative or lacking capacity. It was found that 25% (13/52) had been specifically consented for risks of Covid-19. The rate of PCR-positive results was 15% (8/52) with a mortality of 25%. Approximately 2% of patients in this series were informed of the risk and had a positive Covid-PCR. An odds ratio of 0.38 indicates that being informed of the risk is not associated with rate of infection e.g by adopting enhanced personal protective measures. Conclusions. The pandemic recovery has not removed this substantial community and nosocomial risk. Our results demonstrate poor compliance with RCS guidance despite ongoing relevance to care. Consent includes the counselling of a patient to specific Covid-related risks including thrombosis & death. Dissemination of these results will be followed by completion of the audit cycle to look for improvements in compliance

Aims. To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes. Methods. The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and EuroQol five-dimension questionnaire (EQ-5D) health-related quality of life in the year after injury, and with deep infection at 30 days, according to the Centers for Disease Control and Prevention definition of a deep surgical site infection. Results. A total of 748 participants were included in the analysis. Of these, 288 (38.5%) had a simple open fracture and 460 (61.5%) had a complex fracture as defined by the new classification system. At 12 months, the mean DRI in the simple fracture group was 32.5 (SD 26.8) versus 43.9 (SD 26.1) in the complex fracture group (odds ratio (OR) 8.19; 95% confidence interval (CI) 3.69 to 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple fracture group was 0.59 (SD 0.29) versus 0.56 (SD 0.32) in the complex fracture group (OR -0.03; 95% CI -0.09 to 0.02). The differences in the rate of deep infection at 30 days was not statistically significant. Conclusion. The Orthopaedic Trauma Society open fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of open fractures of the lower limb. Cite this article: Bone Joint J 2020;102-B(11):1469–1474

Evidence suggests that there 17% rise in cycling related injuries in the last year. The objective of the study is to analyze the pattern of injuries in cyclists who were treated as a MTC. This is a retrospective study performed at a Tertiary Trauma Centre in central London. All cyclists who were admitted as MTC to hospital between January 2011 and August 2013 were included. Overall there were 518 patients who were treated as vehicle- related Major Trauma Cases, out of which 118 (23%) were cyclists. Of the 118 cyclists, 98 (83%) were male and 20 (17%) female. The mean Injury Severity Score was 19.2 ±11.1 (mean/SD). There were 58 (49%) patients who required ITU support. Major proportion of patients (68 patients – 61%) sustained neurological injuries. There were 2 (1.7%) deaths, both due to neurological injuries. In comparison to other group of vehicles there is less number of bicycles on the roads. Our results show that the proportion of cyclists involved in road traffic incidents is higher (23%) than other vehicles. Our results show that large proportions (61%) of cyclists sustain neurological injuries, reinforcing the previous evidence that safe protective head gear is vital for cyclists

Introduction. Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction. Materials & Methods. A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management. Results. A total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts. Conclusions. The diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction

Introduction and Objective. Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental knee arthritis after extra-articular injury must rationally be attributed to malalignment. Materials and Methods. The picture archiving system was searched to identify all 1160 long leg x ray films available at a major metropolitan trauma center over a 12-year period. Images were screened for inclusion and exclusion criteria, namely patients >10 years after traumatic long bone fracture without contralateral injury or arthroplasty to give 39 cases. Alignment was measured according to established surgical standards on long leg films by 3 independent reviewers, and arthritis scores Osteoarthritis Research Society International (OARSI) and Kellegren-Lawrence (KL) were recorded independently for each compartment of both knees. Malalignment was defined conservatively as mechanical axis deviation outside of 0–20 mm medial from centre of the knee, to give 27 patients. Comparison of mean compartmental arthritis score was performed for patients with varus and valgus malalignment, using Analysis of Variance and linear regression. Results. In knees with varus malalignment there was a greater mean arthritis score in the medial compartment compared to the contralateral knee, with OARSI scores 5.69 vs 3.86 (0.32, 3.35 95% CI; p<0.05) and KL 2.92 vs 1.92 (0.38, 1.62; p<0.005). There was a similar trend in valgus knees for the lateral compartment OARSI 2.98 vs 1.84 (CI −0.16, 2.42; p=0.1) and KL 1.76 vs 1.31 (CI −0.12, 1.01; p=0.17), but the evidence was not conclusive. OARSI arthritis score was significantly associated with absolute MAD (0.7/10mm MAD, p<0.0005) and Time (0.6/decade, p=0.01) in a linear regression model. Conclusions. Malalignment in the coronal plane is correlated with worsened arthritis scores in the medial compartment for varus deformity and may similarly result in worsened lateral compartment arthritis in valgus knees. These findings support the mechanical hypothesis that arthritis may be related to altered stress distribution at the knee, larger studies may provide further conclusive evidence

Aims. Europe has found itself at the epicentre of the COVID-19 pandemic. Naturally, this has placed added strain onto healthcare systems internationally. It was feared that the impact of the COVID-19 pandemic could overrun the Irish healthcare system. As such, the Irish government opted to introduce a national lockdown on the 27 March 2020 in an attempt to stem the flow of admissions to hospitals. Similar lockdowns in the UK and New Zealand have resulted in reduced emergency department presentations and trauma admissions. The aim of this study is to assess the effect of the national lockdown on trauma presentations to a model-3 hospital in Dublin, Ireland. Methods. A retrospective study was conducted. All emergency department presentations between 27 March 2019 to 27 April 2020 and 27 March 2020 to 27 April 2020 were cross-referenced against the National Integrated Medical Imaging System-Picture Archiving Communication System (NIMIS-PACS) radiology system to identify those with radiologically proven skeletal trauma. These patients were grouped according to sex, age, discharge outcome, mechanism of injury, and injury location. Results. A 21% decrease in radiologically proven trauma was observed on comparison with the same time-period last year. Additionally, a 40% reduction in trauma admissions was observed during the COVID-19 lockdown. A 60% reduction in sports-related injuries and road traffic accident-related injuries was noted during the national lockdown. However, a 17% increase was observed in patients sustaining trauma because of domestic accidents. Conclusion. Variation was observed in both the volume and nature of trauma presentations during the COVID-19 lockdown. As would be expected, a reduction was seen in the number of injuries resulting from outdoor activities. Interestingly, increased rates of domestic injuries were seen during this period which could represent an unintended consequence of the prolonged period of lockdown. Cite this article: Bone Joint Open 2020;1-6:261–266

Aims. The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA). Methods. Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used. Results. A total of 19 studies met the inclusion criteria, investigating 28 possible prognostic factors. Most QUIPS domains (84%) were rated as moderate to high risk of bias. The quality of the evidence was low or very low for all prognostic factors. In low-quality evidence, prognostic factors with consistent associations with failure of TEA in more than one study were: the sequelae of trauma leading to TEA, either independently or combined with acute trauma, and male sex. Several other studies investigating sex reported no association. The evidence for other factors was of very low quality and mostly involved exploratory studies. Conclusion. The current evidence investigating the prognostic factors associated with failure of TEA is of low or very low quality, and studies generally have a moderate to high risk of bias. Prognostic factors are subject to uncertainty, should be interpreted with caution, and are of little clinical value. Higher-quality evidence is required to determine robust prognostic factors for failure of TEA. Cite this article: Bone Joint Res 2024;13(5):201–213

Introduction. In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated. Methods. All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge. Results. Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households. Conclusion. Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process. Cite this article: Bone Joint Open 2020;1-6:287–292

There is increasing popularity in the use of artificial intelligence and machine-learning techniques to provide diagnostic and prognostic models for various aspects of Trauma & Orthopaedic surgery. However, correct interpretation of these models is difficult for those without specific knowledge of computing or health data science methodology. Lack of current reporting standards leads to the potential for significant heterogeneity in the design and quality of published studies. We provide an overview of machine-learning techniques for the lay individual, including key terminology and best practice reporting guidelines. Cite this article: Bone Joint J 2021;103-B(12):1754–1758

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48-hours. We identified all patients treated at our trauma centre following this protocol between 1 January 2014 and 31 December 2019. All patients were clinically reviewed at least 12 months following surgery and assessed using the Brief Michigan Hand Outcomes Questionnaire (bMHQ), the Boston Carpal Tunnel Questionnaire (BCTQ) and sensory assessment with Semmes-Weinstein monofilament testing. The study group was made up of 35 patients. Thirty-three patients were treated within 36-hours. Patients treated with our unit protocol for early surgery comprising nerve decompression and bony stabilization within 36-hours, report excellent outcomes at medium term follow up. We propose that nerve decompression and bony surgical stabilization should be undertaken as soon as practically possible once the diagnosis is made. This is emergent treatment to protect and preserve nerve function. In our experience, the vast majority of patients were treated within 24-hours

Aims. Several studies have reported that patients presenting during the evening or weekend have poorer quality healthcare. Our objective was to examine how timely surgery for patients with severe open tibial fracture varies by day and time of presentation and by type of hospital. This cohort study included patients with severe open tibial fractures from the Trauma Audit and Research Network (TARN). Methods. Provision of prompt surgery (debridement within 12 hours and soft-tissue coverage in 72 hours) was examined, using multivariate logistic regression to derive adjusted risk ratios (RRs). Time was categorized into three eight-hour intervals for each day of the week. The models were adjusted for treatment in a major trauma centre (MTC), sex, age, year of presentation, injury severity score, injury mechanism, and number of operations each patient received. Results. We studied 8,258 patients from 175 hospitals. Patients presenting during the day (08:00 to 15:59; risk ratio (RR) 1.11, 95% confidence interval (CI) 1.02 to 1.20) were more likely to receive debridement within 12 hours, and patients presenting at night (16:00 to 23:59; RR 0.56, 95% CI 0.51 to 0.62) were less likely to achieve the target; triage to a MTC had no effect. Day of presentation was associated with soft-tissue coverage within 72 hours; patients presenting on a Thursday or Friday being less likely to receive this surgery within 72 hours (Thursday RR 0.88, 95% CI 0.81 to 0.97; Friday RR 0.89, 95% CI 0.81 to 0.98), and the standard less likely to be achieved for those treated in ‘non-MTC’ hospitals (RR 0.76, 95% CI 0.70 to 0.82). Conclusion. Variations in care were observed for timely surgery for severe open tibial fractures with debridement surgery affected by time of presentation and soft-tissue coverage affected by day of presentation and type of hospital. The variation is unwarranted and highlights that there are opportunities to substantially improve the delivery and quality of care for patients with severe open tibial fracture. Cite this article: Bone Jt Open 2022;3(12):941–952

Abstract. Objectives. Our objective was to determine the incidence of post-operative COVID-19 infection within the first two weeks following treatment at the COVID-free site. During the COVID-19 pandemic our hospital saw one of the highest rates of COVID-19 infection in the United Kingdom. As a result, our trauma services were relocated to a vacant private elective hospital to provide a ‘COVID-free’ setting for trauma patients. Patients admitted to the COVID-free site were screened for coronavirus infection and only treated at that site if asymptomatic. Those with symptoms were treated at the ‘COVID’ site. Method. We collected data at the COVID-free site during the first seven weeks of its’ establishment. Inclusion criteria were all patients presenting for operative management of limb trauma; however, fragility hip fractures were excluded. All patients were screened for symptoms of COVID-19 infection at their 2-week follow-up appointment. Results. 72 patients presented to our service during the study period. The mean age was 34.9 years (21 to 89). 62 patients had general anaesthesia (86%), 7 patients had regional anaesthesia (10%) and 3 patients had local anaesthesia (4%). One asymptotic patient who was swabbed for COVID-19 on admission returned a positive result. This patient had contracted the infection before surgery and was excluded from further analysis. 71 patients (100%) remained asymptomatic at follow-up and none had required medical attention for suspected COVID-19 infection. Conclusion. A ‘COVID-free’ trauma service was established in a private elective hospital during the pandemic. None of the patients undergoing urgent trauma surgery in this setting developed COVID-19 symptoms as a result of their hospital admission. Establishing a separate site with screening to avoid admission of patients with COVID-19 infection can allow safe emergency surgery. This data can support informed consent and reassure patients of their risks when we resume day case and elective surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. This study aimed to identify patients receiving total hip arthroplasty (THA) for trauma during the peak of the COVID-19 pandemic in the UK and quantify the risks of contracting SARS-CoV-2 virus, the proportion of patients requiring treatment in an intensive care unit (ICU), and rate of complications including mortality. Methods. All patients receiving a primary THA for trauma in four regional hospitals were identified for analysis during the period 1 March to 1 June 2020, which covered the current peak of the COVID-19 pandemic in the UK. Results. Overall, one of 48 patients (2%) contracted COVID-19 during their admission. Although they required a protracted stay in hospital, they did not require ICU treatment. Two patients did require ICU support for medical problems but not relating to COVID-19. Complications were no greater than expected given the short follow-up. There were no mortalities. Conclusion. There is a paucity of evidence to guide restarting elective joint arthroplasties following the COVID-19 pandemic. Although THAs for trauma are by no means a perfect surrogate, the results of this study show a low incidence of contracting COVID-19 virus during admission and no significant sequalae during this period. Cite this article: Bone Joint Open 2020;1-7:438–442

Optimal utilisation of operating theatres has a significant impact on the ability of an institution to deliver productive, value for money surgical services. With the recent introduction of the national ‘Productive Theatres’ programme and in the current economic climate it is receiving increasing attention. In addition, it improves patient satisfaction and outcomes, reduces adverse events and has positive influences on staff morale. The aim of this study was to highlight factors influencing trauma theatre utilisation in general, whilst also addressing any problems identified with a view to improving trauma services locally. We conducted a prospective analysis of activity in the trauma theatre at our institution over 1 month. Direct observation was performed by a single independent observer. In the absence of any published guidelines, all theatre lists were assessed against pre-determined standards for each component of the theatre pathway. Overall end utilisation (combined time utilised for anaesthesia and surgery) was found to be low at 65%. A number of factors were found to contribute to inefficiencies including delay in sending for patients (mean 42mins, range 0-105), prolonged patient transit times to theatre (mean 22% of all sessions), late starts to lists (mean 43 mins, range 15-105 mins) waiting for x-ray availability (mean 21mins, range 10-45) and knock on delay from previous lists. Surgeons and anaesthetists were found to be, overall, arriving on time or early for all lists. Strategies for maximising trauma theatre productivity are essential. This study has identified common issues, of potential benefit to numerous institutions when planning trauma services