Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

Background. Severe infantile Blount's disease can result in a multiplanar deformity of the proximal tibia with both intra-articular and metaphyseal components. Correction can represent a significant surgical challenge. We describe our results using the Taylor spatial frame for acute tibial hemiplateau elevation combined with gradual metaphyseal correction in patients with severe infantile blounts with an associated physeal bony bar. Methods. Eight patients (10 knees) underwent tibial hemiplateau elevation and metaphyseal correction with use of the Taylor Spatial Frame between 2012–2016. We undertook a retrospective case note and radiographic review of all patients to assess clinical and radiographic outcomes. Mean age at the time of surgery of was 11.7 years and mean length of follow up was 16.8 months. Results. At time of latest follow up all patients reported no hip, knee or ankle pain. All knees were clinically stable without lateral thrust during gait. Improvement in radiographic parameters was seen in all patients. The mean tibiofemoral angle improved from −28.3 to 5.9 degrees post operatively. The angle between femoral condyles and the tibial shaft improved from a mean of 56.3 degrees to 90.3 degrees. The joint depression angle was also seen to improve from mean 47.4 degrees to 9.8 degrees. No significant complications were seen. Conclusion. This technique has been shown to be an effective method of correction of the complex deformity encountered in severe infantile Blount's disease. Use of the Taylor spatial frame may provide certain advantages in comparison to previously described approaches. Level of Evidence: Level IV (Case Series)

Aims. The aim of this study was to evaluate the clinical and radiological outcomes of locking plate fixation, with and without an associated fibular strut allograft, for the treatment of displaced proximal humeral fractures in elderly osteoporotic patients. Patients and Methods. We undertook a retrospective comparison of two methods of fixation, using a locking plate without an associated fibular strut allograft (LP group) and with a fibular allograft (FA group) for the treatment of these fractures. The outcome was assessed for 52 patients in the LP group and 45 in the FA group, with a mean age of 74.3 years (52 to 89), at a mean follow-up of 14.2 months (12 to 19). The clinical results were evaluated using a visual analogue scale (VAS) score for pain, the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, and the range of movement. Radiological results were evaluated using the neck-shaft angle (NSA) and humeral head height (HHH). Results. The mean forward elevation in the LP and FA groups was 125.3° (. sd. 21.4) and 148.9° (. sd. 19.8), respectively (p = 0.042), while other clinical factors showed no statistically significant differences between the groups. The changes in NSA and HHH immediately after the operation and at final follow-up were significantly better in the FA group than in the LP group (p = 0.015 and p = 0.021, respectively). Conclusion. For comminuted proximal humeral fractures in osteoporotic patients, locking plate fixation with a fibular strut allograft shows satisfactory short-term results with respect to humeral head support and maintenance of reduction, and may reduce the incidence of complications associated with fixation using a locking plate alone. Cite this article: Bone Joint J 2019;101-B:260–265

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

Aims

There is increasing evidence to support the use of topical antibiotics to prevent surgical site infections. Although previous research suggests a minimal nephrotoxic risk with a single dose of vancomycin powder, fracture patients often require multiple procedures and receive additional doses of topical antibiotics. We aimed to determine if cumulative doses of intrawound vancomycin or tobramycin powder for infection prophylaxis increased the risk of drug-induced acute kidney injury (AKI) among fracture patients.

Aims

We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements. Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients. Cite this article: Bone Joint J 2013;95-B:230–8

A 7-day randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercially available dressings. The Flexor Carpi Ulnaris of anaesthetised rabbits was exposed to high-energy trauma using a computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. Quantitative microbiological assessment demonstrated reduced bacterial counts in INADINE (Iodine) and ACTICOAT (Nanocrystalline Silver) groups and an increase in ACTIVON TULLE (Manuka Honey) group (2-way ANOVA p<0.05). Clinical observations were made throughout the study. Haematology and plasma cytokines were analysed at intervals. Post-mortem histopathology included subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy (SEM). There were no bacteraemias, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. There were no significant differences in animal behaviour, weight change, maximum body temperature or white blood cell count elevation nor in pathology severity in muscle or lymph nodes (Kruskal-Wallis). There was no evidence of bacterial penetration or biofilm formation on SEM. Interleukin-4 and Tumour Necrosis Factor α levels were significantly higher in the ACTIVON TULLE group (1-way ANOVA p<0.05). This time-limited study demonstrated a statistically significant reduction in Staphylococcus aureus counts in wounds dressed with INADINE and ACTICOAT and an increase in wounds dressed with ACTIVON TULLE. There was no evidence that any of these dressings cause harm but nor have we established any definite clinical advantage associated with the use of the dressings tested in this study

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up. For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period. The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome

Introduction. Monomicrobian necrotizing cellulitis affects the skin and subcutaneous tissue as starting point the deepest level of the superficial fascia. The pathogen inoculation is by skin disruption, abrasions, burns, injections or bites. The free base cocaine is used with homemade pipes that generate pulps fingers skin microabrasions. We present 3 patients (one bilateral) with cellulitis necrotizing of the thumb caused by pricking and dermoabrasive trauma secondary to different manipulation methods for drogue use. Material and Method. Experience in 3 patients free base cocaine addicts treated in our Hospital. Medical examination shows febrile syndrome (corporal temperature over 38C), and elevation of heart rate. They present cellulitis in thumb's first and second phalanx, with thenar swelling and digital necrosis with abundant purulent discharged. All of them had a pricking trauma 36 to 48 hours before. They were under surgical intervention, by surgical cleaning with necrotic and devitalized tissue's debridement. In 3 of the 4 patients amputation of the distal phalanx was mandatory. Tissue and bone culture was made in all patients. Intravenous antibiotic was performed. Two patients miss total antibiotic treatment by early no medical discharged. Results. Due necrotizing cellulitis is an acute and aggressive pathology, that compromised general condition and the 3 patients had important and advanced lesions was mandatory to made 3 thumb amputations with 1 aggressive debridement. The specific antibiotic postoperative treatment was ciprofloxacin + clindamicin because the isolated pathogen in all the samples was Stafilococo Aureus Meticilin Resistent from the community. Conclusion. The high consume of drugs in young people and the unprotective features (social, cultural and economics) of this group, is increasing the incidence of this pathology. Due to his fast and hiperacute evolution plus the delay in consultation, a radical treatment (amputation) is require. That's why we think the prevention of this illness could avoid ending in an important disability

Aim. The aim of this prospective comparative study was to evaluate the serum levels of different cytokines in patients underwent total knee replacement (TKR) and received allogeneic blood transfusion, post-operative auto-transfusion or not transfused. Material and Methods. This was a prospective non-randomized comparative study in 248 patients underwent TKR. Patient's demographic and clinical data including age, gender, body mass index (BMI), preoperative Hb value, complications were documented. The serum levels of IL-1b, IL-6, IL-8, IL-10, and TNF were measure pre-operatively, the 1st, 2nd, 3rd and 5th post-operative day. Patients were categorized in three groups; in Group 0 patients received no blood transfusion, in Group 1 patients received post-operative auto-transfusion and in Group 2 allogeneic blood transfusion was applied. Statistical analysis of the results was performed using repeated measures ANOVA. Results. Significant changes were observed in cytokines levels in Groups 1 and 2. In Group 1 (auto-transfusion) the levels of all cytokines significantly increased the 1st postoperative day, remaining above the pre-operative levels even the 5th post-operative day. In Group 2 (allogenic transfusion), although the levels of IL-6, IL-8 and IL-10 were also significantly increased the 1st postoperative day, they gradually returned to the per-operative levels by the 5th post-operative day. In Group 0 (no transfusion) the only significant increase was observed in IL-6 between pre-operative and 1st and 3rd day values. Furthermore, the area under the curve (AUC) of IL-1b, IL-6, IL-8 and IL-10 levels in Group 1 and AUC of IL-6, IL-8 and IL-10 levels in Group 2, were significantly higher compared to Group 0. There was no significant difference in post-operative patient's complications. Conclusion. According to the results of this study significant elevation of cytokine values were observed during the first five post-operative days in patients received blood transfusion after TKR. These changes were more pronounced in the auto-transfusion group

Background. In elderly patients with complex proximal humerus fractures and osteoporotic bone reconstruction is not always possible. Although hemiarthroplasty is an alternative, non-union or tuberosity migration can lead to inferior functional results. Implantation of a Reverse Total Shoulder Arthroplasty (RTSA) seems to be an interesting alternative. In the present study we retrospectively analyzed the short-term results of RTSA for complex proximal humerus fractures in the elderly. Methods. From 31.10.2005 to 20.07.2010 RTSA was performed in 29 patients (average age 80 years [67;90], 25 women, 4 man) with subcapital, three- or four-part fracture of the proximal humerus as a primary treatment. All procedures were performed using the Anatomical Inverse Shoulder (Zimmer) with fracture stem. A deltopectoral approach was used in every case with reattachment of the tuberosities. Pain, range of motion, subjected shoulder value (SSV) as well as the Constant score (CS) were used to evaluate shoulder function. Implant positioning and signs of loosening were analyzed on standard x-rays. Results. Included were 23 patients with a minimal follow-up of 12 month. The average follow-up was 17 month (12 month to 5 years). The mean SSV was 81% [40;100]. The absolute CS averaged 67 points [34;84] and the relative CS 97% [52;139]. The mean pain score (VAS) was 13.7 of 15, the mean activity score 18.4 of 20, the mean mobility score 28.6 of 40 and the mean strength score 5.1 of 25. The mean active anterior elevation was 130° [80;160], the mean active abduction 128° [80;170] and the mean active external rotation in 0° abduction 21° [-30;70]. All patients reached the same activity level as before surgery and could return to independent living. The results after 12 month were already comparable to those after 24 month (10 patients). Radiographically no signs of loosening were detected. There was a total of 3 complications and reoperations, two due to a hematoma and one because of a periprosthetic fracture. Conclusions. In elderly patients with complex proximal humerus fractures and osteoporotic bone RTSA seems to be a very satisfactory procedure. The short-term clinical results are excellent and predictable with a rapid postoperative recovery of daily comfort. The complication rate is low and acceptable

We evaluated the results of Cementless Surface Replacement Arthroplasty (CSRA) of the shoulder in 67 patients with advanced glenohumeral destruction who have an intact rotator cuff. Between november 2002 and december 2008, 70 CSRA (32 Copeland/ Biomet and 38 SMRR/ Lima) were implanted in 67 patients. A deltopectoral approach was used in 34 cases and an anterosuperior approach in 36 cases. Patients were assessed using Constant score, a patient satisfaction score and a detailed radiographic analysis. The mean follow up was 3.4 years (range 1 to 7.5 years). The mean Constant score improved preoperatively from 17.6 points (range 2–55) to an average postoperative score of 66.1 (range 13–91). The pain score improved from 1.13 points (range 0–6) to 12.3 points (range 3–15). The forward flexion and external rotation improved from 71° (range 20 to 140) and 0° (range −40 to +45) to 143° (range 60 to180) and 34.4° (range −20 to +60) respectively. Complications included: 1 subscapularis detachment, 5 secondary rotator cuff tear, 1sepsis, 3 patients with shoulder stiffness. No shift in implant position was observed. 11 humeral components developed radiolucencies at the prosthesis-bone interface. The radiographic analysis involved a system of dividing the prosthesis/bone interface into 5 zones. The best clinical results were significantly achieved in patients with necrosis compared with osteoarthritis (Constant Score, ant. elevation, ext. Rotation). Using regression analysis we found that changes in the head-shaft angle position of the implant (valgus/varus placement of the CSRA) significantly predicted the age and sex adjusted Constant score. When the inclination angle of the humeral head decreases, the adjusted Constant score increases. In the same model, we also found that the lateral offset of the humerus significantly predicted the adjusted Constant score. When the lateral offset of the humerus decreases, the adjusted Constant score increases. The medialization of the glenoid significantly and negatively predicted the Constant score. Conclusion. CSRA of the shoulder outcomes have been comparable with those of stemmed arthroplasties. Radiolucent lines occur with follow up and most of the time located in the S1 area. Glenoid wear and humeral head lateralization negatively impact the clinical score. Cementless Shoulder resurfacing is a viable alternative to conventional shoulder arthroplasty

Introduction. Latissimus dorsi transfer is a procedure used in massive irreparable posterosuperior rotator cuff tears, in young patient with severe pain and significant functional impairment. The purpose of this retrospective study was to evaluate its clinical, radiological and electromyographic results. Methods. Forteen massive irreparable posterosuperior rotator cuff tears were performed with latissimus dorsi transfer between 2000 and 2008, and were reviewed at an average follow-up of 56 months and minimum of 19 months. Five transfers were primary reconstructions, and nine were revision surgeries. Patients’ mean age was 52.7 years. Clinical outcomes were measured by the Constant score, pain level, active range of motion, and strength. Osteoarthritis and acromiohumeral distance were measured on standardized radiographs. Ultrasound examination evaluate the integrity of the tendon. Axial images in CT-scan looked for muscle atrophy of latissimus dorsi in comparison with the controlateral. Electromyographic activity was measured during active flexion, abduction, adduction and rotations. Results. Twelve patients were satisfied. At the last follow-up, the average pain level according to a 100 mm visual analog scale was 31. The mean age and gender-matched Constant and Murley score improved from 34 to 60 % (p=0.003), forward elevation from 89° to 132° (p=0.006), abduction from 92° to 104°, external rotation from 12° to 24° (p=0.015). Mean abduction and external rotation strength were measured at 2.5 kg. Osteoarthritis progressed, and mean acromio-humeral distance has a significant decrease from 7.5 mm to 4.4 mm (p=0.003). Ultrasound examination showed twelve transferred tendons healed to the greater tuberosity. CT-scan showed a small atrophy of the transferred muscle, with a measurement of the cross-sectional area of the muscle belly at the inferior angle of the scapula at 1405 mm2, versus 1644 mm2 for the controlateral (p=0.06). Electromyographic analysis demonstrated a significant higher electric activity on the operative side during abduction and external rotation, and significant lower activity during adduction and internal rotation in comparison with the nonoperative side. Conclusions. Latissimus dorsi transfer allows for significant pain relief and function improvement in irreparable posterosuperior rotator cuff tears at young patients. Its electric activity increase in abduction and external rotation shows that the transferred muscle can integrate a new function and act like an active muscle transfer, in addition to an interposition or tenodesis effect. However we didn't find any depression of the humeral head or strength improvement

We have carried out a prospective, randomised trial to measure the rise of temperature during reaming of the tibia before intramedullary nailing. We studied 34 patients with a mean age of 35.1 years (18 to 63) and mean injury severity score of 10 (9 to 13). The patients were randomised into two groups: group 1 included 18 patients whose procedure was undertaken without a tourniquet and group 2, 16 patients in whom a tourniquet was used. The temperature in the bone was measured directly by two thermocouples inserted into the cortical bone near the isthmus of the tibial diaphysis. Reaming was carried out to at least 1.5 mm above the required diameter of the nail. Blood loss was assessed by recording the preoperative and postoperative haemoglobin (Hb) level. The minimum clinical follow-up was six months. In group 1 (no tourniquet), the mean Hb dropped 2.8 g/dl from 14.3 ± 1.02 g/dl to 11.5 ± 1.04 g/dl (p = 0.0001), whereas with the tourniquet, the mean decrease was 1.3 g/dl from 14 ± 1 g/dl to 12.7 ± 1.3 g/dl (p = 0.007). This difference was not statistically significant. The mean initial tibial temperature was 35.6°C (. sd. 0.6) and rose with reaming to levels between 36.3°C and 51.6°C. The highest temperatures were obtained with the largest reamers (11 and 12 mm, p = 0.0001) and the most rapid rise with the smallest diameters of medullary canal (8 or 9 mm). The rise of temperature was transient (20s). We were unable to identify any effect of the use of a tourniquet on the temperature achieved. Reamed intramedullary tibial nailing induces a transient elevation of temperature which is directly related to the amount of reaming

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).

Aims

Compartment syndrome results from increased intra-compartmental pressure (ICP) causing local tissue ischaemia and cell death, but the systemic effects are not well described. We hypothesised that compartment syndrome would have a profound effect not only on the affected limb, but also on remote organs.