Introduction: The Plastic Surgery challenge in groin sarcoma is often twofold involving restoration of integrity to the lower abdominal wall and provision of durable soft tissue cover for the groin and perineum. Methods: This is a retrospective review of consecutive patients undergoing groin sarcoma excision with plastic surgery involvement over the last 7 years. The referral patterns of these patients, histological types, margins and details of reconstructions performed were analysed. Information was also gathered regarding adjuvant therapy, recurrences and survival. Results: Thirteen patients were included in this review. In twelve out of the thirteen patients initial biopsies/explorations were performed by either General Surgeons or Urologists. Ten of these biopsies were incompletely excised. On average 4.4 months elapsed between initial biopsy and referral to the Regional Sarcoma Service. The most frequently performed reconstruction was a rectus abdominis musculo-cutaneous flap. Six patients developed post operative complications. Complete/adequate surgical margins were achieved in seven patients. A further five patients had margins designated as “narrow” or “marginal”. Six patients received post operative radiotherapy based on the multidisciplinary clinic review. Three patients were referred for radiotherapy but did not receive treatment. Five patients developed recurrences and four of these patients died. Discussion: Groin sarcomas represent a surgical and logistical challenge. The anatomical topography makes complete surgical excision difficult without available reconstructive techniques and complication rates can be high. Referral of these patients to the regional sarcoma service is often delayed whilst exploration or biopsy is performed. This delay can persist even after a diagnosis of sarcoma has been made. Communication with colleagues in other centres may be the key to improving this side of management

The aims of this study were to review the management of open tibial fractures in our specialist ortho-plastic centre and to assess whether our practice concurred with the BAO/BAPS guidelines. A retrospective note review of patients with open tibial fractures was undertaken. Data was collected on time to referral to the plastic surgery unit and time to definitive soft tissue cover. Return of limb function was assessed using the Enneking score. Forty five consecutive patients (27M vs. 18F), with an age range of 11–86 yrs (median age of 42 years), were treated using strict protocols. Seventeen cases were referred by the on-site orthopaedic unit, and 28 patients were from 7 neighbouring units. Time from injury to initial plastic surgery assessment ranged from 0 to 19 days, with a median of 4 days. Time from injury to definitive soft tissue cover ranged from 0 to 21, with a median of 5 days. 41/45 cases had definitive surgery within 5 days of initial plastics assessment. 5 patients with definitive treatment at days 4, 4, 7, 7, 12 developed superficial wound infection. Patients referred from neighbouring units underwent on average 1 extra operation. We failed to detect any significant difference in return of function between the 2 groups indicating that referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment. Open tibial fractures should be managed in a specialist centre, manned with dedicated lower limb plastic and orthopaedic reconstructive surgeons and followed up in a combined ortho-plastic clinic. However, more emphasis should be put on improved communication between referring units and the specialist centre

Introduction: The centre provides hand services to remote hospitals which require patients to travel long distances at odd hours for assessment and consenting to their operation only to be done at a later date in day surgery unit unless otherwise indicated. Aims: Compare video conferencing to patient and surgeon ‘face to face’ consultation in counselling of patients prior to surgery. Methods: Four injuries (Nail bed, extensor tendon, nerve repair, wrist laceration) were identified for which operative management was clear. 10 plastic surgery SHOs were shown photographs of the patients injury and asked to ‘counsel’ the ‘patient’(played by consultant plastic surgeon) with regards to the intended benefits, risks and complications of surgery. The assessment was done for all four scenarios both in person and over a video conference link (AHMS). The order of each case was varied to minimise ‘rehearsal’ of the consent. The consent process was scored on a number of points followed by rating. SHOs acted as their own controls removing bias of differing levels of knowledge. Results: The mean counselling time was 6 minutes/session. Equipments functioned reliably with audio and speed rated as excellent. Quality of councelling sessions using telemedicine was considered by consultants as good (32/40) to satisfactory (8/40) and was found comparable to in person councelling in obtaining consent. Conclusion: Telemedicine is as effective as specialist-on site counselling for non-controversial hand injuries and thereby reduces the movement of patients from remote A& E departments to plastic surgery units for consent and booking of their surgery

The authors felt that it would be an interesting and worthwhile exercise to examine the process and management of open long-bone fractures referred to East Grinstead as we felt that we were not achieving the timeframe, as advised by the BOA/BAPS guidelines.

Methods The notes of patients who were referred East Grinstead for soft tissue management of long-bone fractures were examined over a 1 year period and analysed. After the results were seen to be poor in terms of management, practices were changed and the following year’s patients’ management underwent the same analysis prospectively.

Results The first years audit revealed average day of referral of 6.1, day of transfer was 13.2 days and time to soft tissue coverage was 18.3 days. 8% of patients achieved the BOA/BAPS guidelines of coverage by day 5. The second cohort of patients showed little improvement in their process of care.

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

Aims. Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. Methods. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. Results. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. Conclusion. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations. Cite this article: Bone Joint J 2023;105-B(1):21–28

Aims. Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Methods. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. Results. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. Conclusion. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160–1167

Introduction. The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology. Materials & Methods. Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap. Results. Union rate of 100% (11/11) was noted with periosteal flap osteotomies, versus those without flaps at 28.6% (2/7) (p = 0.0025). Time to union was also reduced in the periosteal flaps at 8.5 months versus 16.75 months in the control group (p = 0.023). Survival curves with a hazard ratio of 4.1, equating to a 4 times higher chance of union with periosteal flaps (log-rank p = 0.0016) was observed. Conclusions. The chimeric fibula-periosteal flap provides an option for atrophic recalcitrant non-unions where use of vascularised fibula graft alone may not provide an adequate biological environment for consolidation

Introduction. Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC). Materials & Methods. This cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed. Weightbearing status over the treatment course was monitored. Patient frailty was measured using the clinical frailty score (CFS). Results. There were 35 patients, mean age 77 years (range 65–97 years), 86% female. Mean length of admission in the MTC was 26.4 days (range 3–78). Most (94%) had a low-energy mechanism of injury. Only 57% of patients underwent one-stage surgery (ORIF n=15, hindfoot nail n=1, external frame n=4) with 45% being permitted to fully weightbear (FWB). Eleven (31.4%) underwent two-stage surgery (external fixator; ORIF), with 18% permitted to FWB. Of those patients with pre-injury mobility, 12 (66%) patients were able to FWB following definitive fixation. Delay in weightbearing ranged from 2–8weeks post-operatively. Seven patients (20%) underwent an initial Orthoplastic wound debridement. Ten patients (28.6%) required plastic surgery input (split-skin grafts n=9, local or free flaps n=3), whereby four patients (40%) underwent one stage Orthoplastic surgery. Eighteen (51.4%) patients had a CFS ≥5. Patients with a CFS of ≥7 had 60% 90-day mortality. Only 17% patients had orthogeriatrician input during admission. Conclusions. These patients have high frailty scores, utilise a relatively large portion of resources with multiple theatre attendances and protracted ward occupancy in an MTC. Early FWB status needs to be the goal of treatment, ideally in a single-staged procedure. Poor access to orthogeriatric care for these frail patients may represent healthcare inequality

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

Materials & Methods. Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures. Results. We reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year. 60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation. Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation. Conclusions. Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires early referral to a specialist Orthoplastic unit. Less than half of organisms cultured pre-operatively reflect the causative organisms cultured intra-operatively with 52% of these infections being polymicrobial. After initial treatment, 8% of patients will require a further combination of extended antibiotic therapy and surgery to eradicate infection

Introduction. Open fractures are fortunately rare but pose an even greater challenge due to poor soft tissues, in addition to poor bone quality. Co-morbidities and pre-existing medical conditions, in particular, peripheral vascular diseases make them often unsuitable for free flaps. We present our experience in treating severe open fractures of tibia with Acute Intentional Deformation (AID) to close the soft tissues followed by gradual correction of deformity to achieve anatomical alignment of the tibia and fracture healing with Taylor Spatial Frame. Materials and Methods. We treated 4 geriatric (3 female and 1 male) patients with Gustillo-Anderson III B fractures of the tibia between 2017–18. All were unfit to undergo orthoplastic procedures (free flap or local flaps). The age range is 69 yrs to 92 years. Co-morbidities included severe rheumatoid arthritis, multiple sclerosis and heart failure. The procedure involved wound debridement, application of two ring Taylor Spatial Frame, acute deformation of the limb on the table to achieve soft-tissue closure/approximation. Regular neurovascular assessments were performed in the immediate post-operative period to monitor for compartment syndrome and nerve compression symptoms. After 7–10 days of latent period, the frame was gradually manipulated, according to a method we had previously published, to achieve anatomical alignment. The frame was removed in clinic after fracture healing. Results. Time in frame ranged from 1.5 months to 7 months. In one patient (92 yr old with an open fracture of the ankle) hindfoot nail was inserted after soft-tissue closure was achieved at 1.5 months, and frame removed. We achieved complete healing of soft tissue wounds without any input from plastic surgeons in all patients. All fractures healed in anatomical alignment. 3 patients had one episode of superficial pin infection each requiring 5 days of oral antibiotics. None of the patients developed a deep infection. Conclusions. Acute intentional deformation (AID) with Taylor Spatial Frame achieves good closure of soft tissues in physiologically compromised geriatric patients who were deemed unfit for plastic surgery. We also achieved fracture healing in all four cases without any major complications

Aims. Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. Patients and Methods. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. Results. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. . Conclusion. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53

Purpose of the study. To use a simple way of manipulating Taylor Spatial Frame to achieve soft tissue closure by acute intentional deformation and then gradually achieving anatomical alignment of the fracture without complex deformity and frame parameters. Methods and end results. 10 consecutive cases of Gustillo III B open fractures of tibia and of soft tissue defect due to infected implant were treated with a new technique of acute intentional deformation using Taylor Spatial frame to successfully close the soft tissue defect without plastic surgery. We describe a new simple technique of achieving anatomical alignment of the fracture after creating complex deformity to close the soft tissue defect. We achieved complete full thickness cover of the exposed bone in all cases without plastic surgery and restored the bone to anatomical alignment. Only one patient needed additional Taylor Spatial Frame total residual prescription to correct minor residual deformity. Conclusion. We describe a simple way of using Taylor Spatial Frame (TSF) for acute deformation of Gustilo IIIB tibial fractures and other tibial defects in order to close soft tissue defects and gradual correction to the anatomical alignment. We have used the Direct Scheduler Utility module of the web-based software for Taylor Spatial Frames (TSF) to successfully restore the anatomical alignment

Purpose of the study. To use a simple way of manipulating Taylor Spatial Frame to achieve soft tissue closure by acute intentional deformation and then gradually achieving anatomical alignment of the fracture without complex deformity and frame parameters. Methods and end results. 10 consecutive cases of Gustillo III B open fractures of tibia and of soft tissue defect due to infected implant were treated with a new technique of acute intentional deformation using Taylor Spatial frame to successfully close the soft tissue defect without plastic surgery. We describe a new simple technique of achieving anatomical alignment of the fracture after creating complex deformity to close the soft tissue defect. We achieved complete full thickness cover of the exposed bone in all cases without plastic surgery and restored the bone to anatomical alignment. Only one patient needed additional Taylor Spatial Frame total residual prescription to correct minor residual deformity. Conclusion. We describe a simple way of using Taylor Spatial Frame (TSF) for acute deformation of Gustillo IIIB tibial fractures and other tibial defects in order to close soft tissue defects and gradual correction to the anatomical alignment. We have used the Direct Scheduler Utility module of the web-based software for Taylor Spatial Frames (TSF) to successfully restore the anatomical alignment

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Initially, all surgeons in Australia were generalists and those with an interest in the anatomy of the hand performed hand surgery. Early hand surgeons, such as Benjamin Rank, excelled and Rank and Wakefield's Textbook of Hand Surgery was widely used throughout the world. Eventually, groups of like-minded surgeons formed the Australian Hand Club in 1972, which subsequently became formalised as The Australian Hand Surgery Society (AHSS), in 2001. A very high standard of hand surgery has been achieved in Australia, with most hand surgeons having trained in either plastic surgery or orthopaedic surgery, and then further trained in Fellowships in Europe or North America. Bernard O'Brien and John Hueston achieved international recognition in the field of microsurgery and Dupuytren's surgery. Wayne Morrison has been responsible for pioneering work in toe–to–hand transfer and basic research. Tim Herbert changed the way fractures of the scaphoid are managed throughout the world. In 2007 the AHSS commenced a Travelling Fellowship Programme to facilitate an increased involvement in Australia in academic hand surgery and to foster contacts between hand surgeons of the future. At the present time, the AHSS is concentrating on education and training in order to raise the overall standard of management of hand surgery, particularly in relation to after hours' trauma. This is particularly necessary in rural and regional areas where hand surgery has traditionally been treated by occasional practitioners. There is a risk that hand surgery falls between the two stools of plastic surgery and orthopaedic surgery and the AHSS wishes to further formalise training and education within the Royal Australasian College of Surgeons (RACS) as a single training stream in the future. There are potential threats both within and without, with safe working hours a particular threat in relation to reducing both the quantity and quality of training. The future will almost certainly involve greater emphasis on biomaterials and prosthetic compounds, but trying to ensure a uniformly high standard of hand surgery management throughout the country will remain as a primary focus

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

Objective. Ankle fractures are frequent and seem to be easy to handle in most cases. Of course, also these easy fractures can cause infections that must be carefully managed. What risk factors do we find? What options do we have in treating these complications? What are the consequences and what will the result for the patient be like, compared to non-infected cases?. In a retrospective study we included 82 patients treated with an osteosynthesis in ankle fractures (AO 44 B or C fractures). Average age was 52.4 years (range 20–84 years, median 51.0). Results. In 9 (10.9%) patients there were septic complications. Concerning risk factors, we found 4 (44.4%) patients with nicotine abuse, 2 (22.2%) with additional alcohol abuse. Average stay in hospital was 39.6 days (range 9–95 days). In 4 (44.4%) cases local infection was treated with antibiotics and rest alone. 5 (55.5%) of the patients had additional operations due to infection, in average 5.4 per patient (range 1–10). Early implant removal was done in 3 (33.3%) cases, in average after 3 months. We found 2 (22.2%) infections due to Staphylococcus aureus, 1 (11.1%) due to MRSA and one infection with MRSA and Proteus mirabilis. In one case vacuum dressing had been applied for 44 days. In another case infection could only be healed with an intramedullary vancomycin augmented spacer and finally a screw arthodesis of the ankle, this was a patient with proven arteriosclerosis of the lower extremities. All other fractures finally showed bony healing in xrays. No plastic surgery (e.g. flaps) was needed to close a wound definitely. In follow up (in average after 33 months, range 17–42), the average AOFAS of these patients was 76.5 (range 35–100, median 81.5), compared to an average AOFAS of 89.4 (range 35–100, median 98.0) of all patients. No patient developed a septic syndrom, no ICU stay occurred because of the infection. Conclusions. In spite of most cases of ankle fractures having good outcomes without complications, once infected an ankle osteosynthesis can be a serious problem for both surgeon and patient. Consequent surgical therapy at the right time including early hardware removal, spacers or vacuum dressing if necessary as well as an antibiotic regime addressing problematic pathogens like MRSA are needed to control infections. Problems remaining are functional outcome and wound closure in this sensitive area. Plastic surgery might be needed

Aim. A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI. Method. We performed a retrospective review of all patients undergoing gastrocnemius muscle transfer with split thickness skin grafting as part of their treatment for knee PJI at a tertiary referral centre between 1994 and 2015. Data recorded included patient characteristics, orthopaedic procedure, microbiology result and antimicrobial management. Outcome measures included flap failure, infection recurrence, amputation, functional outcome (Oxford knee score; OKS) and mortality. Results. In total, 115 consecutive patients (39% female) with a mean age of 74.4 years (range 44–100) were followed up for an average of 5.5 years (range 119 days – 19.7 years). There were no reported cases of flap failure. Gastrocnemius flaps were most commonly performed at the time of the first stage of a two-stage revision (41%), or during debridement and implant retention (DAIR) (27%). 10% were performed at the second stage of a two-stage procedure and 4% were performed during a single stage revision. Of 96 positive deep specimen cultures, 43 (45%) showed mixed growth and 47 (49%) grew coagulase-negative staphylococcus (with or without other microorganisms). The infection recurrence rate was 32%. Limb salvage was achieved in 88% of cases. 12% of patients required life-long suppressive antibiotic therapy. 55 knees were followed up for five years or more, with a survival (not deceased, not amputated) of 64%. 37 knees were followed up for 10 years or more, with a survival of 32%. In living patients who did not have an amputation, the mean OKS was 25.8 (n=36; range 7–47). Conclusion. This study represents the largest series to date of infected knee prostheses treated with gastrocnemius flap coverage. A multidisciplinary approach to complex PJI surgery is recommended, involving infectious disease physicians and the orthoplastic team. We also recommend a low threshold for requesting plastic surgery input. In our experience, this technique is safe, with no flap failure, and has enabled limb salvage for the majority (88%) of patients with infected knee prostheses and insufficient soft tissue envelope

Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. We reviewed the cases undertaken in our department, complications, which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12 years period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range [18 to 66]). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. In conclusion this study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although, the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed

Ligamentoplasty resorting to autogenous bone-tendon-bone grafts represents an effective long-lasting remedy to the anterior instability of the knee. If this indication has proved effective regarding the stability, the sampling of a piece of the extensor system often brings about a certain morbidity. Various approaches have been advocated concerning the tendinous site: some leave it open, others suture one of the peripheral thirds of the remaining tendon to the other. These various technical choices are likely to alter the morbidity and the patellar level, together with the tissue nature of the site of sampling. The purpose of this study was to assess the effect of the suture of the site of sampling on the patellar level, after a ligament plastic surgery resorting to a bone-tendon-bone graft. To this end, a group of 40 patients whose tendinous site of sampling had been left open was compared to another group of patients whose peripheral thirds of the remaining patellar tendon had been sutured one to the other. The patellar level was assessed with Caton’s, Black-burne’s and Insall and Salvati’s methods on x-rays first taken before and then 6 months after the operation. To analyse the results, we resorted to the reduced gap method and the Student-Fisher one for the comparison between quantitative and qualitative variables, and to the correlation coefficient method for the comparison between quantitative variables. The post-operative values of Caton’s, Blackburne’s and Insall and Salvati’s indexes were respectively 1.002, 0.844, and 1.188 for patients whose patellar tendon had been left open, and 1.023, 0.882, and 1.184 for patients whose tendinous edges had been sutured up. The discrepancy between those values had no statistical significance. Suturing the site of sampling in a bone-tendon-bone ligament plastic surgery has no effect on the patellar level

Background Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. Method We reviewed the cases undertaken in our department, complications which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12-year period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range 18–66). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. Results There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. Conclusion This study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms. All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams. 36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality. Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes

Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use

Aim. To evaluate the clinical outcome of a new absorbable, gentamycin loaded calcium sulfate/hydroxyapatite biocomposite (CERAMENT. ™. /G) as cavity filler after debridement and removal of infected metalwork in chronic osteomyelitis. Methods. We report the retrospective study of prospectively collected data from 36 patients with chronic osteomyelitis from implant infection. Treatment included a single stage protocol with removal of the metalwork, debridement augmented with application of CERAMENT. ™. /G, stabilization, culture-specific antibiotics and primary skin closure or flap. The biocomposite was used for dead space filling after resection of Cierny-Mader (C-M) stage III and IV chronic osteomyelitis. Data were collected on patient age, comorbidities, operation details, microbiology, postoperative complications and type of fixation or plastic surgery. Primary measure of outcome was recurrence rate. Results. According to the C-M classification 22 patients (63%) were defined as Type III and 13 (37%) as Type IV. A total of 26 (72%) patients were Class B hosts. In 9 cases (25%), there was an infected non-union and 1 patient had septic arthritis. Mean age was 52 years (range 22 to 81). Patients were followed for a mean of 20 months (range 6 to 36). Infection was eradicated in 32 patients. There were three (8.3%) recurrences (two cases of osteomyelitis and one of soft tissue/flap infection). Two of them were successfully managed with repeat surgery (one Class B and one Class A host) and one (Class B host) with suppressive antibiotic therapy as per patient's choice. In one infected nonunion the infection was eradicated but the nonunion persisted. Thirteen patients (36.6%) had a local or free fascio-cutaneus flap. Staphylococci (50%) and Enterococci (15%) were the most common microorganisms. Pseudomonas aeruginosa was more common in polymicrobial infection usually with Staphylococcus aureus. Conclusions. A multidisciplicary approach including augmented debridement with CERAMENT. ™. /G is effective for treatment of chronic osteomyelitis with infected metalwork

Aims

Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK.

The June 2023 Wrist & Hand Roundup³⁶⁰ looks at: Residual flexion deformity after scaphoid nonunion surgery: a seven-year follow-up study; The effectiveness of cognitive behavioural therapy for patients with concurrent hand and psychological disorders; Bite injuries to the hand and forearm: analysis of hospital stay, treatment, and costs; Outcomes of acute perilunate injuries - a systematic review; Abnormal MRI signal intensity of the triangular fibrocartilage complex in asymptomatic wrists; Patient comprehension of operative instructions with a paper handout versus a video: a prospective, randomized controlled trial; Can common hand surgeries be undertaken in the office setting?; The effect of corticosteroid injections on postoperative infections in trigger finger release.

Aims

Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes.

Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation. A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input. 56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks. The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients

Background. With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre. Methods. Patients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes. Results. Between April 2013 and January 2016, 97 patients aged over 65 were admitted with open fractures, 38 of these were open tibial fractures. 10 patients required soft tissue reconstruction for Gustillo and Anderson IIIB tibial fractures (age range 67–95). In this group there were 4 midshaft (AO 42), 1 proximal (AO 41) and 5 distal (AO 43) fractures. Five patients were treated with internal fixation and 5 with circular frames. The median length of hospital stay was 33 days (range 16–113 days), 50% longer than comparable patients under 65. Four patients received pedicled local flaps and six underwent free tissue transfer. Of the 6 patients treated with free tissue transfer, one required pre-operative femoral angioplasty. There were no flap losses. Two patients had fasciocutaneous flaps, one an EDB flap and one gastrocnemius flap. All patients went on to unite and return to their pre-morbid weight-bearing status (2 using frames, 3 using sticks, 5 independent). Discussion. Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and post-operatively. These challenges are reflected in the significantly longer length of stay in comparably injured patients under the age of 65

The February 2023 Oncology Roundup³⁶⁰ looks at: Is the number of national database research studies in musculoskeletal sarcoma increasing, and are these studies reliable?; Re-excision after unplanned excision of soft-tissue sarcoma is associated with high morbidity; Adjuvant radiation in atypical lipomatous tumours; The oncological outcomes of isolated limb perfusion and neoadjuvant radiotherapy in soft-tissue sarcoma patients - a nationwide multicentre study; Can low-grade chondrosarcoma be treated with intralesional curettage and cryotherapy?; Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis; Doxorubicin-polymeric meshes prevent local recurrence after sarcoma resection while avoiding cardiotoxicity; How important are skip lesions in Ewing’s sarcoma?; Improving outcomes for amputees: the health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees.

Improve the quality of care mine-explosive wounds and preventing infection in mine blast injury. We have treated 19 patients affected by MEI during Anti-Terrorist Operation (ATO) in Ukraine. The patients had been received by our department within 5–28 days after the injury. All patients were comprehensively examined (general surgeon, neurosurgeon, thoracic surgeon, CT, X-ray, ultrasound, lab tests). 14/19 patients had an open fractures (10 of those 14 had a soft tissue defects). All patients with open fractures underwent secondary surgical treatment (radical debridement, irrigation, ultrasonic cavitation, fracture stabilization by external fixation). The patients with soft tissue defects underwent variety of plastic surgery. After soft tissues healing a plate or IM nail was installed. Evaluation of results was based on X-ray monitoring and the lower limb function assessment. 16 patients had full fracture consolidation and good function, 3 patients had slow consolidation and limitation of movement. Analysis of treatment showed that adherence to radical debridement and thorough soft tissue management led to significant reducing of the incidence of infectious complications in combat related fractures

Aims

The risk of postoperative complications after resection of soft-tissue sarcoma in the medial thigh is higher than in other locations. This study investigated whether a vessel sealing system (VSS) could help reduce the risk of postoperative complications after wide resection of soft-tissue sarcoma in the medial thigh.

Introduction. Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation. Methods. Between September 2012 and January 2016, more than 120 patients with open tibial fractures were admitted to our unit. Patients were identified through prospective databases. Data collected included patient demographics, injury details, orthopaedic and plastic surgery procedures. Major complications were recorded. Paediatric cases were excluded and one patient was lost to follow up. Results. Fifty-seven patients (median age 41 years (range 16–95)) were identified with open tibial fractures classified grade IIIB or IIIC requiring soft tissue coverage. Of these 57 patients, 39 were treated by initial temporary external fixation, soft tissue cover, and circular frame and 18 by initial temporary external fixation, soft tissue cover and internal fixation (ORIF). Of the 57 patients, 51 were acutely managed by Leeds MTC, and 6 were tertiary referrals primarily managed elsewhere. Soft tissue cover constituted free tissue transfer in 43 patients (19 gracilis, 15 ALT, 6 LD, 2 radial forearm and 1 groin flap), pedicled flap in 12 patients (6 gastroc, 4 fasciocutaneous, 1 soleus, 1 EDB), and skin graft in 2 patients. Complications included flap failure (n=3), return to theatre (n=1). Long term soft tissue cover was definitely achieved in 100% of cases. Chronic deep infection was reported in 1 acutely managed case. There were no cases of soft tissue failure after delayed circular frame fixation following soft tissue reconstruction. Conclusions. Evolution of orthopaedic techniques has meant that the management of these complex fractures using delayed definitive fixation with a circular frame is increasingly commonplace. This case series demonstrates that a joint orthoplastic approach, with circular frame application undertaken a short time after soft tissue reconstruction (including free flap surgery) is safe and can be undertaken without risk to the soft tissue coverage

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons

Aims

Revision total knee arthroplasty (rTKA) is a technically challenging and costly procedure. It is well-documented that primary TKA (pTKA) have better survivorship than rTKA; however, we were unable to identify any studies explicitly investigating previous rTKA as a risk factor for failure following rTKA. The purpose of this study is to compare the outcomes following rTKA between patients undergoing index rTKA and those who had been previously revised.

Aims

This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated.

Aims

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England.