Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective.

Cite this article: Bone Jt Open 2021;2-10:893–899.

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Introduction

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and major amputation. The treatment of these patients is controversial. Internal stabilization and/or external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective major amputation. However, we report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

Objectives

to evaluate effect of a dedicated ward for patients with fractured neck of femur on length of acute bed stay and 30 days mortality rate.

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration.

All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction.

Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases.

Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy.

In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration.

Massive segmental bone defects in long bones remain a considerable clinical challenge and are a source for significant morbidity and prolonged dysfunction for the patient. We demonstrate the successful use of resorbable polylactide membranes as a scaffold for autologous bone graft in the treatment of a 10cm traumatic femoral bone defect.

A 28-year-old male was involved in a motorcycle accident vs. tree at 140k/hr. He sustained a Gustillo grade 3b intercondylar fracture of his right femur, and a 10cm piece of his femoral bone found at the scene was brought to Emergency in a sterile container. He was taken to theatre for debridement and ORIF of the intercondylar fracture, with vacuum dressing cover. Day 5 post injury the patient returned to theatre and the LISS plate was revised to correct the rotation and 3cm shortening. The 10cm cortical defect now present was filled with antibiotic cement (Palacos) and delayed primary closure was performed.

Day 21 post injury the cement spacer was removed and replaced with two polylactide membrane tubes, one within the medullary canal and the other around the outside of the bone. The “neocortical” space thus produced was grafted with cancellous autograft mixed with bone morphogenic protein (OP1, Stryker). The remainder of the post-operative course was uncomplicated and the patient was discharged home 5 days later.

The patient was reviewed at the 6 week and 3 month mark post injury. The femoral defect demonstrated both radiological and clinical union at the 3 month mark and full weight bearing was permitted. His range of motion at that stage was 5 to 95 degrees with no sign of infection.

The use of polylactide membranes as a scaffold in the treatment of segmental long bone defects is an excellent and relatively straightforward technique. Forming a space between the 2 tubes controls cancellous graft to the site of the cortical area where it is required and the polylactide membrane then resorbs over years producing CO2 and water. This case demonstrates that the use of polylactide membranes is safe and effective in the management of segmental long bone defects.

We compared the early complication rates of total hip (THA) and total knee (TKA) arthroplasty carried out at a regional orthopaedic hospital (AOC) and two Independent Sector Treatment Units (ISTUs) (WGH and CNH). After THA, reoperation rates were higher at CNH (9%) than AOC (0.6%) or WGH (1.4%). After TKA, reoperation rates at CNH were (8%) higher than AOC (1%) and WGH (1.9%).

5% of patients undergoing TKR at CNH underwent 2 stage revision for deep infection.

After THA, dislocation rates at CNH (6%) were higher than AOC and WGH (1.8%). Readmission from CNH (13%) was higher than AOC (1.2%) and WGH (0.6%).

Major wound problems at CNH (20%) were higher than WGH (3.8%) and AOC (0.4%).

After TKA, major wound problems were higher at CNH (19%) compared to WGH (1.9%) and AOC (1.1%). Readmission rates not requiring surgery from CNH (13%) were higher than AOC. (1.1%) and WGH (1%). AOC and WGH audited their outcomes. None were available from CNH. WGH initially missed many of their complications because they presented at base hospitals elsewhere.

ISTUs performed approximately 2/3rds of procedures for which patients had been referred from base hospitals.

At CNH, 23% were rejected on grounds of potential co-morbidity. Audit from ISTUs is inferior to NHS hospitals and the results in one of those audited significantly worse.

Patients offered surgery at ISTUs should be told that the audited outcome of the surgeon who will be treating them is not known and that, in some, results are inferior to surgery in the NHS.