Background. The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital. Patients and methods. Our protocol (1999-2002) uses flexible intramedullary nails for children older than five, early hip spica (within one week of injury) for the under five year olds, and external fixation for polytrauma (Early Active Group[EAG], n = 25). Prior to this (1999-2002), treatment consisted of late application of a hip spica (3-4 weeks following injury) or inpatient traction (Traditional Group [TG], n = 41). Outcome measures were length of hospital stay, degree of malunion, knee and hip movements, and leg length discrepancy. The financial burden to the family including waged and non-waged time lost, transport, childminder, and other extra costs were estimated. Hospital costs including inpatient stay, theatre, and implant costs were analysed. Results. A 40% reduction in the incidence of femoral fractures over the six-year period was noted. Mean hospital stay was 29 and 10 nights (p<0.001); family costs were £1,243 and £968; and hospital costs were £10,831 and £4,291 per patient (p<0.005) in the TG and the EAG respectively. Parents in both groups preferred early discharge (86%-94%). In the EAG, 10 patients were short at 3 months (0.5 - 3 cm). None was short at 2 years. Eight children were long at 2 years. At 2 years, all had good clinical and functional results. There was no significant difference in the mal-union rate between the two groups. All the fractures united by three months. Five out of nine complications occurred in the EAG. Conclusion. The use of our early active treatment protocol has resulted in a significant reduction in hospital stay, costs to the families and the hospital

The requirement for the peer support groups were born out of concern for the psychological wellbeing of the paediatric patients and to assess if this would improve their wellbeing during their treatment. Groupwork is a method of Social Work which is recognised as a powerful tool to allow people meet their need for belonging while also creating the forum for group members to empower one another. Social Work meet with all paediatric patients attending the limb reconstruction service in the hospital. The focus of the Medical Social Worker (MSW) is to provide practical and emotional support to the patient and their parent/guardian regarding coping with the frame. Some of the challenges identified through this direct work include patient's struggling with the appearance of the frame and allowing peers to see the frame. The peer support group aims to offer its attendees the opportunities to engage with fellow paediatric patients in the same position. It allowed them to visually identify with one another. We wanted to create a safe space to discuss the emotional impact of treatment and the frames. It normalises the common problems paediatric patients face during treatment. We assisted our participants to identify new coping techniques and actions they can take to make their journey through limb reconstruction treatment more manageable. Finally, we aimed to offer the parents space to similarly seek peer support with regard to caring for a child in treatment. All paediatric patients were under the care of the Paediatric Orthopaedic Consultant and were actively engaging with the limb reconstruction multi-disciplinary team (MDT). The patient selection was completed by the MDT; based on age, required to be in active treatment, or their frames were removed within one month prior to the group's commencement. Qualitative data was collected through written questionnaires and reflection from participants in MSW sessions. We also used observational data from direct verbal feedback from the MDT. In the first group, parents gave feedback due to participants age and completed written feedback forms. For our second group, initial feedback was collated from the participants after the first session to get an understanding of group expectations. Upon completion, we collected data from both the participants and the parents. Qualitative and scaling questions gathered feedback on their experience of participating in the group. We held two peer support groups in 2022:One group for patients aged between 3–6 years in January 2022 across two sessions, which was attended by four patients. The second group for young teenage patients aged between 11–15 years in April 2022 across four sessions, which was attended by five patients. The written feedback received from group one focused on eliciting the participant's experience of the groupwork. 100% of participants identified the shared experience as the main benefit of the groupwork. 100% of participants agreed they would attend a peer support group again, and no participant had suggestions for improvement to the group. Feedback did indicate that group work at the beginning of treatment could be more beneficial. In relation to the second group, 60% of the paediatric patients and their parents returned the questionnaires. All of the parent's feedback identified that it was beneficial for their child to meet peers in a similar situation. They agreed that it was beneficial to meet other parents, so they could get support and advice from one another. On a scale between 1 and 5, 5 being the highest score, the participants scored high on the group work meeting their expectations, enjoyment of the sessions, and the group work was a beneficial aspect of their treatment. All respondents would strongly recommend groupwork to other paediatric patients attending for limb reconstruction treatment. Overall, the MDT limb reconstruction team, found the peer support group work of great benefit to the participants and their parents. The MSW team identified that during a period on the limb reconstruction team, when a high number of patients were in active treatment, the workload of the MSW also increased reflecting this activity. Common issues and concerns were raised directly to MSW (particularly from group two) regarding numerous difficulties they experienced trying to cope with the frame. The group work facilitators created a space where the participants could get peer support, share issues caused by the frame, hear directly from others, and that they too experience similar feelings or issues. Collectively, they identified ways of coping and promoting their own wellbeing while in treatment. The participants in group two, subsequently created a group on social media, to be able to continue their newly formed friendships and to continue to update one another on their treatment journeys. The participants self-requested another group in the future. This was facilitated in November 2023, the facilitators sought more feedback from all participants and their parents after this session. These findings will contribute towards the analysis for the presentation. Peer support groupwork was presented at the hospital's foundation day and has been well received by senior management in the hospital, as a positive addition to the limb reconstruction service. The focus of the MDT in 2024, is to further develop and facilitate more peer support groups for our paediatric patients

Hypothesis. Pre-specified pooling of data from the four phase III RECORD studies was conducted to determine whether rivaroxaban significantly reduced the less-frequent clinical endpoint of symptomatic venous thromboembolism (VTE) and all-cause mortality after total hip or knee arthroplasty (THA or TKA, respectively), compared with standard North American and European enoxaparin regimens. Methods and analysis. Patients (n=12,729) received rivaroxaban 10 mg once daily or enoxaparin 40 mg once daily (RECORD1-3) or 30 mg 12-hourly (RECORD4). Thromboprophylaxis was administered for 31-39 days (RECORD1; THA) or 10-14 days (RECORD3 and 4; TKA). RECORD2 (THA) compared 31-39 days' rivaroxaban with 10-14 days' enoxaparin followed by placebo. The pre-specified primary efficacy endpoint in the pooled analysis (composite of symptomatic VTE and all-cause mortality) and adjudicated bleeding events were analysed in the day 12±2 active treatment pool, when all patients had received active drug, and total treatment duration pool, where subgroup analyses were performed. Results. In the day 12±2 active treatment pool, the primary efficacy endpoint occurred in 0.5% of patients receiving rivaroxaban versus 1.0% of patients receiving enoxaparin (p=0.001). Major bleeding occurred in 0.3% versus 0.2% patients respectively (p=0.18) and major plus clinically relevant non-major bleeding occurred in 2.9% versus 2.5% patients respectively (p=0.19). In the total treatment duration pool, rivaroxaban significantly reduced the primary efficacy endpoint compared with enoxaparin regimens 0.6% versus 1.3% patients (p< 0.001) with similar rates of major bleeding. Over the total treatment period, rivaroxaban consistently reduced the primary efficacy endpoint across the pre-specified subgroups (age, gender, body weight, creatinine clearance). Conclusion. Rivaroxaban significantly reduced the composite of clinically important symptomatic VTE and all-cause mortality after THA or TKA compared with subcutaneous enoxaparin regimens in the direct comparison day 12±2 active treatment pool, with no significant differences in bleeding events. These results suggest a positive benefit-risk profile for oral, once-daily rivaroxaban

Introduction. Total joint arthroplasty is associated with substantial blood loss as well as changes in basic metabolic labs. Routinely patients receive multiple post-operative blood draws for measuring hematocrit, hemoglobin (H&H), and basic metabolic panels (BMP). Based on a multimodal approach to blood conservation and pre-operative optimization, we questioned the need to check daily labs on our inpatient primary total hip and knee patients. The purpose of this study was to identify risk factors for transfusion and metabolic abnormalities requiring treatment in an attempt to reduce the number of post-operative blood draws and labs. Methods. We retrospectively reviewed all 1134 patients who underwent primary total hip (THA) or total knee arthroplasty (TKA) from July 2016 to March 2017 in our inpatient hospital setting. There were 733 TKA and 401 THA. Pre- and post-operative lab values were reviewed and correlated with transfusion and medical treatments. Results. Twelve patients received a post-operative transfusion (1.1%). In TKA patients 2 of 733 (0.2%) were transfused while in THA patients 10 of 401 (2.4%) were transfused. Of the 12 patients receiving transfusions 11 were females, and in all 12 the pre-operative hemoglobin was less than 13. For the overall series of 1134 patients, 176 (15.5%) required potassium chloride supplementation based on BMP. Only patients with pre-existing renal disease or diuretic treatment received potassium chloride supplementation. Conclusions. Based on our findings, only patients with pre-operative hemoglobin less than 13 require post-operative H&H. Additionally, only patients with low pre-operative potassium, history of renal disease, or active treatment with a diuretic require post-operative BMP

Diabetic foot syndrome with osteomyelitis of metatarsal head show frequent recurrence and need a very long antibiotic treatment, often only to see the inflammation flare up once antibiotic are dismissed. We present our initial experience about 3 patients presenting a clinical and radiologically confirmed osteomyelitis of the metatarsal head. We treated them with limited resection of metatarsal head, microbiologic sample and filling of the remaining metatarsal canal by means of an absorbable antibiotic loaded bone graft substitute, packing an absorbable antibiotic sponge (Gentamycin) in place of the metatarsal head and direct skin closure. All patients had an orthesis avoiding fore-foot weight bearing during the first month, but allowing them to walk normally. Follow up took place on a weekly rhythm during the first month, every fortnight during the 2° month and after this once a month. Actually the follow up period extends from 4 – 7 months. None of the treated 3 patients did need any second look operation nor did they present any local complications. Due to the type of resorbable implant used, some oozing of transparent liquid during the first 4 weeks may present and is to be considered normal. This new method presents a valid alternative to the more classic “two step cement nail” procedure of active osteomyelitis treatment. We consider planing long term study and a multicenter randomized trial

Greater trochanteric pain syndrome (GTPS) is common, yet the impact on function and quality of life has not been measured. The aim of this study was to quantify the impact on function and quality of life, comparing the results to people with severe hip osteoarthritis and an asymptomatic control group. Forty two people with GTPS – including 11 not actively seeking treatment and 11 seeking surgical treatment, 20 with severe hip osteoarthritis (OA), and 23 age and sex matched asymptomatic participants (ASC) where recruited from public and private hospitals, and the community. Upon confirming meeting inclusion and exclusion criteria participants were interviewed. Exclusion criteria included lumbar nerve root signs; inflammatory, neoplastic and metabolic disorders. Measured used were the Harris hip score (HHS); the Oswestry disability index (ODI); the Australian quality of life instrument (AQoL); the Functional co-morbidity index (FCI); and fulltime work assessments. No difference was found between the GTPS and the OA group on the HHS, ODI, AQoL or the FCI measures. Both symptomatic groups were significantly more disabled than the ASC group on the HHS and ODI (p<0.001). The GTPS and OA groups had lower AQoL than the ASC group (p<0.001); and higher FCI results than the ASC group (GTPS vs ASC, p=0.005; OA vs ASC, p=0.019). GTPS participants were least likely to be in full time work; full time work participation probability (95% C.I.): GTPS Prob=0.288 (0.160 to 0.463), OA Prob= 0.518 (0.273 to 0.753); ASC group of Prob=0.676 (0.439 to 0.847). People with GTPS have similar levels of pain, disability and quality of life, but are less likely to be in full time employment than people with severe hip OA which puts them at risk of economic hardship. Research on conservative and surgical treatments should measure pain, disability and work participation