Introduction. Unstable dorsal fracture/dislocation of PIP joint is a complex injury and difficult to treat. Different treatment methods have been described with varying results. We describe a novel technique to combine fracture fixation with volar plate repair using micro anchor suture. Material and methods. Between July and December 2005, 11 consecutive patients with unstable dorsal PIP joint dislocations underwent open reduction and volar plate repair using our technique. Nine patients had dorsal fracture dislocations and two had open dislocations. All patients were males and their average age was 26 years. All patients were reviewed with the minimum follow up of 12 months. The pain score, range of movements and grip strength were recorded and compared to the normal side. Operative Technique. Volar approach was made using a semi Brunar incision. One or two micro bioabsorbable anchors (Mitek, Ethicon Ltd, UK) were used to stabilise the joint and repair the volar plate. Additional anchor was used to repair the collateral ligament when indicated. Post-operatively the hand was rested in Edinburgh functional splint for 10 days followed by active and assisted range of movements under hand physiotherapist supervision. Results. 10 out 11 patients had excellent pain relief. The average range of movement of the PIP joint was 100 degrees. One patient with neglected PIP joint fracture dislocation for 10 weeks had mild residual pain and stiffness. The mean grip strength was 87% of that of contralateral normal side. All patients returned to their same work as before. 8 out of 9 patients returned to play their regular sports at the same level. All patients were satisfied with the functional outcome. Conclusion. Combined fracture fixation and volar plate repair through anterior approach using micro bioabsorbable anchors appears to be very effective way of treating this otherwise complex unstable fracture/dislocation of PIP joint

Crescent fractures are represented by a spectrum of morphological fracture patterns, sharing a common mechanism of injury. We propose three distinct types according to the extent of Sacroiliac (SI) joint involvement and the size of the crescent fragment, which enables a pragmatic choice of surgical approach and stabilisation technique. Crescent fractures are fracture dislocations of the SI joint in which there is variable amount of disruption of the SI ligaments extending proximally as a fracture of the posterior iliac wing. We identified three groups of Crescent fractures according to the extent of SI joint involvement, relationship of the fracture line to the S1 and S2 nerve root foramina on anteroposterior and outlet plain radiograph views, and CT films. Type I involves the less than inferior third of the SI joint with a large posterior iliac fragment left attached to the sacrum. This is best approached anteriorly for stabilisation. Type II has between one-third to two-thirds involvement of the SI joint and is treated according to Helfet's technique. Type III has a very small crescent fragment left attached to the sacrum and the inferior two-thirds of the SI joint is disrupted. This is treated with percutaneous SI screws, but will need anterior open reduction in delayed presentations. Based on this, we treated sixteen patients and followed them for at least two years. There were four Type I, four Type II and eight Type III fractures. Fifteen had anatomical reduction and stabilisation of the SI joint with good functional results. Delayed referral, the presence of significant soft tissue injury posteriorly and infected external fixator pins. From our experience we would like to propose this functional classification of crescent fractures which we find useful in making a choice of surgical approach and stabilisation technique to achieve satisfactory reduction and stabilisation of sacroiliac joint

Background. Evidence concerning the management of dorsal fracture dislocation (DFD) of the proximal interphalangeal joint (PIPJ) in the hand has been limited by small sample size and case heterogeneity within studies. This retrospective case control study examined clinical outcome of this specific subgroup managed by three different methods. Methods. Patients undergoing fixation of unstable DFD of the PIPJ between March 2005 and August 2011 were identified from theatre records. A retrospective review of case-notes and radiographs was undertaken to determine fracture characteristics, fixation methods and clinical outcomes. Results. 21 patients with DFD of the PIPJ were identified with a mean age of 40 years (range 22–65). The majority of patients were male (17/21, 81%) and the mean percentage articular surface involvement of fractures was 41% (Std. Dev. 11.3%). PIPJ DFD's were managed by reduction of the PIPJ and temporary transarticular K-wire fixation (12/21, 57%), hemi-hamate arthroplasty (7/21, 33%), or by open reduction and internal fixation (2/21,10%). PIPJ ROM following hemi-hamate arthroplasty was 65° (range 34–108°) and was greater than K-Wire fixation at 56. o. (range 9–85. o. ) (p = 0.82). Hemi-hamate arthroplasty and K-wire fixation resulted in fixed flexion deformity of 20° (range −12–52°) and 15° (range −6–50°) respectively (p = 0.61). Hand therapy data was available for one case undergoing ORIF with a post-operative ROM of 60° and 30° of fixed flexion. There was poor correlation between articular surface involvement and post-operative range of movement at the PIPJ (Co-efficient −0.16, p = 0.55). Conclusion. We present a relatively large series of outcomes following DFD of the PIPJ. We were unable to demonstrate any difference in post operative clinical outcomes between the fixation methods examined

Australian Football (AF) is a popular sport in Australia, with females now representing one-third of participants. Despite this, the injury profiles of females versus males in largely unknown. The current study investigated fractures, dislocations and tendon ruptures in females versus males presenting to emergency departments (ED) with an AF injury. All patients, regardless of age, presenting to one of 10 EDs in Victoria, Australia, with an AF injury were included. Data were prospectively collected over a 10-month period, coinciding with a complete AF season. Data were extracted from patient medical records regarding injury-type, body-part injured and treatments required. Female and male data were compared with chi-squared tests. Of the 1635 patients presenting with an AF injury, 595 (36.0%) had a fracture, dislocation or tendon rupture, of whom 85 (14.3%) were female and the average age was 20.5 years (SD 8.0). Fractures accounted for most injuries (n=478, 80.3% of patients had a fracture), followed by dislocations (n=118, 19.8%) and tendon ruptures (n=14, 2.4%). Upper limb fractures were more common than lower limb fractures (71.1% v 11.5% of fractures). Females were more likely to fracture their hands or fingers than males (45.7% v 34.3%). Males were more likely to fracture ribs (5.4% v 0%). Most fractures (91.2%) were managed in the ED, with the remainder being admitted for surgery (GAMP/ORIF). Males were more likely to be admitted for surgery than females (11.2% v 5.9%). Regarding dislocations (n=118), females were more likely to dislocate the patella (36.8% v 8.1% of dislocations). Only males sustained a tendon rupture (n=14): finger extensor or flexor (57.1%), achilles tendon (28.6%) and patella tendon (14.3%). Orthopaedic AF injuries are common presentations to EDs in Victoria, though few require specialist orthopaedic intervention. Injury profiles differed between genders suggesting that gender specific injury prevention and management might be required

Proximal humerus fracture dislocations are amongst the most severe proximal humerus injuries, presenting a challenging management problem. The aim of this study was to report on the long-term outcomes of the management of proximal humerus fracture dislocations. Patients with a proximal humerus fracture dislocation managed at a Level 1 trauma centre from January 2010 to December 2018 were included. Patients with an isolated tuberosity fracture dislocation or a pathological fracture were excluded. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, non-union/malunion, and avascular necrosis. A total of 69 patients were included with a proximal humerus fracture dislocation in the study period; 48 underwent surgical management and 21 were managed with closed reduction alone. The mean (SD) age of the cohort was 59.7 (±20.4), and 54% were male. Overall patients reported a mean OSS of 39.8 (±10.3), a mean EQ-5D utility score of 0.73 (±0.20), and 78% were able to return to work at a median of 1.2 months. There was a high prevalence of complications in both patients managed operatively or with closed reduction (25% and 38% respectively). In patients undergoing surgical management, 21% required subsequent surgery. Patient reported outcome measures post proximal humerus fracture dislocations do not return to normal population levels. These injuries are associated with a high prevalence of complications regardless of management. Appropriate patient counselling should be undertaken before embarking on definitive management

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Abstract. Introduction. There is little literature exploring clinical outcomes of secondarily displaced proximal humerus fractures. The aim of this study was to assess the rate of secondary displacement in undisplaced proximal humeral fractures (PHF) and their clinical outcomes. Methods. This was a retrospective cohort study of undisplaced PHFs at Royal Derby Hospital, UK, between January 2018-December 2019. Radiographs were reviewed for displacement and classified according to Neer's classification. Displacement was defined as translation of fracture fragments by greater than 1cm or 20° of angulation. Patients with pathological, periprosthetic, bilateral, fracture dislocations and head-split fractures were excluded along with those without adequate radiological follow-up. Results. In total, 681 patients were treated with PHFs within the study period and out of those 155 were excluded as above. There were 385 undisplaced PHFs with mean age 70 years (range, 21–97years) and female to male ratio of 3.3:1. There were 88 isolated greater tuberosity fractures, 182 comminuted PHFs and 115 surgical neck fractures. Secondary displacement occurred in 33 patients (8.6%). Mean time to displacement was 14.8 days (range, 5–45days) with surgical intervention required in only 5 patients. In those managed nonoperatively, three had malunion and one had nonunion. No significant differences were noted in ROM between undisplaced and secondarily displaced PHFs. Conclusion. Undisplaced fractures are the most common type of PHF. Rate of secondary displacement is low at 8.6% and can occur up to 7 weeks after injury. Displacement can lead to surgery, but those managed conservatively maintain their ROM at final follow up

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

The Lisfranc fracture dislocation of the tarsometatarsal joint (TMTJ) is a complex injury with a reported incidence of 9.2 to 14/100,000 person-years. Lisfranc fixation involves dorsal bridge plating, transarticular screws, combination or primary arthrodesis. We aimed to identify predictors of poor patient reported outcome measures at long term follow up after operative intervention. 127 patients underwent Lisfranc fixation at our Level One Trauma Centre between November 2007 and July 2013. At mean follow-up of 10.7 years (8.0-13.9), 85 patients (66.92%) were successfully contacted. Epidemiological data including age, gender and mechanism of injury and fracture characteristics such as number of columns injured, direction of subluxation/dislocation and classification based on those proposed by Hardcastle and Lau were recorded. Descriptive analysis was performed to compare our primary outcomes (AOFAS and FFI scores). Univariate analysis and multivariate regression analysis was done adjusted for age and sex to compare the entirety of our data set. P<0.05 was considered significant. The primary outcomes were the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI). The number of columns involved in the injury best predicts functional outcomes (FFI, P <0.05, AOFAS, P<0.05) with more columns involved resulting in poorer outcomes. Functional outcomes were not significantly associated with any of the fixation groups (FFI, P = 0.21, AOFAS, P = 0.14). Injury type by Myerson classification systems (FFI, P = 0.17, AOFAS, P = 0.58) or open versus closed status (FFI, P = 0.29, AOFAS, P = 0.20) was also not significantly associated with any fixation group. We concluded that 10 years post-surgery, patients generally had a good functional outcome with minimal complications. Prognosis of functional outcomes is based on number of columns involved and injured. Sagittal plane disruption, mechanism and fracture type does not seem to make a difference in outcomes

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs. Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures. We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0 .004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0 .004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons). We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries

‘Getting It Right First Time’ guidance recommends the universal use of cemented prostheses in patients aged over 65 within the UK. This cut off has since been raised to 70. The report claims that the increased cost of uncemented technology is not justifiable in terms of patient outcomes. Our aim was to evaluate any disparity between patients across these age thresholds, in terms of functional outcomes, complication and costs following elective uncemented THR. We utilised a single surgeon prospectively updated database, to compare functional outcome of patients aged over and under 65 and again at 70 following elective uncemented THR. We measured functional outcome using Oxford Hip Score (OHS). Patients were followed routinely for up to 2 years and subsequently up to 6 years. Patient ages ranged from 23–89. Over 97% of patients reported an improvement in hip function, with an average increase of 24.1 in OHS. There was no statistical significance between patient age and functional hip outcome, p=0.108 with a cut off at 65 and p=0229 at 70. 1.1% of under 65s required revision surgery, compared to 2.3% of over 65s. 1.4% of patients under 70 required revision surgery, compared to 2.5% in those above. The most common reason for revision surgery was debridement, antibiotics and implant retention. Patients under 65 had a 1.4% chance of experiencing a fracture or dislocation, compared to 2.5% of patients over 65. 2.0% of patients under 70 experienced a fracture or dislocation, in comparison to 2.2% in those over 70. There was 1 recorded mortality, a patient aged over 70. Cost analysis is challenging accounting for all variables between techniques. Cementing invariably requires additional operating time and diminished theatre efficiency, with direct cost estimated at £364 in theatre running fees per case. Within the series, uncemented THRs was found to be a safe and efficacious procedure irrespective of age. Functional hip outcome was not correlated to patient age, conflicting with GIRFT recommendations. The extra duration of cemented surgery may equilibrate the financial disparity of uncemented practice

Abstract. Background. Fracture dislocation of the knee involves disruption of two or more knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee(IKDC) score and Knee Injury & Osteoarthritis Outcome Score(KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements & complications. Results. 23 patients were presented with the mean age was 37 years(17–74). 14% of patients sustained vascular injury & 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within 3 weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 & KOOS was 73. The mean postoperative Tegner Activity Scale was 3.6 with mean flexion of 115(90–130). We observed some patterns of tibial plateau fractures are associated with similar patterns of ligamentous injuries. The anterio-medial rim fractures (52%) were associated with PCL, ACL & avulsion injuries of posterio-lateral corner structures. Most of the neurovascular injuries happened in this group. The other recognisable pattern was posterio-medial fractures, which were associated with ACL avulsion injury. Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

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

Background. In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless. Aim. To assess differences in patient reported outcomes in uncemented THAs based on patient demographics in order to decide when cementless THA can be done safely. Method. Prospective data collection of consecutive 1079 uncemented THAs performed for 954 patients in single trust between 2010 and 2020. Oxford Hip Score (OHS) and complications were analysed against demographic variables (age, sex, BMI, ASA) and prosthesis features (femoral and acetabular size, offset and acetabular screws). Results. The mean pre-operative OHS was 14.6 which improved to 39.0 at 1 year follow up (P Value=0.000). There was no statistically significant difference between OHS outcome in patients aged over 70 versus younger groups. With a small number of revisable complications increase with age from 50s upwards. Male patients’ OHS score was on average 2.4 points higher than women. Men, however were 2.9 times more likely to experience fractures and high offset hips were 2.5 times more likely to experience dislocations. DAIR, intraoperative calcar fractures, post-operative fractures and dislocations were not associated with worse OHS. Patients with increased BMI had worse pre and post-operative hip functions yet, there was a significant multivariate association between increased BMI and increased improvement in OHS from pre-op to 1 year in women aged 55–80 and men under the age of 60. Femoral stem size increases with age but decreases in male patients over 80. There was no difference found in OHS between bilateral hip replacements and unilateral, nor was there any change found with laterality side of the replacement. Conclusions. This study suggests that ageing >70 is not associated with poorer outcomes despite small number of revisable complication rates that increase with age from 50 upwards. Men had marginally higher average OHS than women At 1 year. Higher BMI or ASA scores are associated with worse pre-operative hips and worse final outcome score. Despite this, the Delta OHS increases with increased BMI shown in the 55–80 year old female patients and male patients under 60. Key Words: THR, Uncemented, Oxford hip score, outcome

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated. During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient. Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Background. We identified several opportunities to significantly reduce cost for hip and knee arthroplasty procedures:. Customized instruments: by identifying the essential instruments for arthroplasty cases, we managed to have one universal tray for each case, and 3 specific trays from the implant manufacturing company. Customized wrap-free, color-coded, stackable trays: by using a wrap-free trays, preparation time in central sterile, opening tray time in OR and turn-over time were reduced. Also, stackable trays were organized based on side and size, therefore only 2 trays needed to be used in each case. Discounted implants: negotiated through optional case coverage with revision system and reps available as backup. Optional rep coverage protocols: designed through process management of the operating room surgical staff and central sterile. Aim of the study was to measure the cost savings, efficacy, and outcomes associated with primary total hip and knee arthroplasty by implementing these protocol. Methods. This is a prospective study from January to October 2016 for selected primary total hip and knee arthroplasties were performed with the above protocols by 2 experienced arthroplasty trained surgeons, were followed for minimum 3 months. Initiating the cost saving protocols were achieved by re-engineering customized trays, discounted implants through optional case coverage (Sourced Based Selection of a Cooperating Manufacturer, MTD), and focused on process management of the staff training. Staff responsibilities were divided into 2 categories:. Familiarity of the instruments, implant, and techniques; trays set up and assurance of availability of the implants. These responsibilities were covered by a trained OR technician and the surgeon. Final verification of the accurate implants prior to opening the packaging. This was achieved by a trained OR nurse and the surgeon. Results. We did not have any intra-operative complications. We also did not encounter any issued with the trays or errors in opening of the implants. There were no re-admissions, fracture, dislocation, or infection. The mean length of stay was 2.2 ± 0.5 days (range 1–3 days) with 68% home discharges. The cost of the implant was reduced from $4,800 to $1,895 with $2,905 cost saving per case and total savings of $58,100. The projected savings only for uncomplicated primary total hip arthroplasty (minimum 120 cases/year between 2 surgeons) is $384,600. Further cost saving from the process management changes were seen in central sterile processing time. Prior to the one tray system, the hospital had 3 in-house trays and there were 4 device company trays. We also noticed an approximate 27% improvement in turnover time. Conclusion. Repless model has significant cost saving potential. Preparation for the transition, proper patient selection, standardization of the trays and implants, and distribution of the responsibilities between OR nurses, technicians and the surgeon are essential

Background. Failed ingrowth and subsequent separation of revision acetabular components from the inferior hemi-pelvis constitutes a primary mode of failure in revision total hip arthroplasty (THA). Few studies have highlighted other techniques than multiple screws and an ischial flange or hook of cages to reinforce the ischiopubic fixation of the acetabular components, nor did any authors report the use of porous metal augments in the ischium and/or pubis to reinforce ischiopubic fixation of the acetabular cup. The aims of this study were to introduce the concept of extended ischiopubic fixation into the ischium and/or pubis during revision total hip arthroplasty [Fig. 2], and to determine the early clinical outcomes and the radiographic outcomes of hips revised with inferior extended fixation. Methods. Patients who underwent revision THA utilizing the surgical technique of extended ischiopubic fixation with porous metal augments secured in the ischium and/or pubis in a single institution from 2014 to 2016 were reviewed. 16 patients were included based on the criteria of minimum 24 months clinical and radiographic follow-up. No patients were lost to follow-up. The median duration of follow-up for the overall population was 37.43 months. The patients' clinical results were assessed using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and Short form (SF)-12 score and satisfaction level based on a scale with five levels at each office visit. All inpatient and outpatient records were examined for complications, including infection, intraoperative fracture, dislocation, postoperative nerve palsy, hematoma, wound complication and/or any subsequent reoperation(s). The vertical and horizontal distances of the center of rotation to the anatomic femoral head and the inclination and anteversion angle of the cup were measured on the preoperative and postoperative radiographs. All the postoperative plain radiographs were reviewed to assess the stability of the components. Results. At the most recent follow-up, 11 (68.8%) patients rated their satisfaction level as “very satisfied” and 4 (25.0%) were “satisfied.” The median HHS improved significantly and the WOMAC global score decreased significantly at the latest follow-up (? 0.001). No intraoperative or postoperative complications were identified. All constructs were considered to have obtained bone ingrowth fixation. The median vertical distance between the latest postoperative center of rotation to the anatomic center of the femoral head improved from 14.7±10.05 mm preoperatively to 6.77±9.14 mm at final follow-up (p=0.002). The median horizontal distance between the latest postoperative center of rotation to the anatomic center of femoral head improved from 6.3±12.07 mm laterally preoperatively to 2.18±6.98 mm medially at the most recent follow-up (p=0.013) postoperatively. The median acetabular cup abduction angle improved from 55.04°±10.11° preoperatively to 44.43°± 5.73° at the most recent follow-up postoperatively (p=0.001). However, there was no difference in the median cup anteversion angles preoperatively (9.15°±5.36°) to postoperatively (9.66°±3.97°) (P=0.535). Conclusions. Early follow-up of patients reconstructed with the technique of extended ischiopubic fixation with porous metal augments demonstrated satisfactory clinical outcomes, restoration of the center of rotation and adequate biological fixation. For any figures or tables, please contact the authors directly

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Patella fracture after total knee arthroplasty has a variety of etiologies and has been reported to occur with an incidence ranging from 3% to 21%. Heavy patients with full flexion are at greatest risk for sustaining patella fracture. Overstuffing the patellofemoral joint with an oversized femoral component, an anteriorised femoral component or a femoral component placed in excessive extension can also overload the underlying patella. A similar phenomenon may be seen with underrsection of the patella or use of a thick button. Excessive patellar resection can predispose to patellar fracture as well. It has been demonstrated that a residual patella thickness of less than 15 mm can substantially increase anterior patellar strain. Asymmetric patellar resection can also critically alter the mechanical strength of the patella making it vulnerable to failure. Elevation of the tibiofemoral joint line, from excessive femoral resection and hastened by posterior cruciate ligament release, will result in a relative patella baja. This can cause early patellofemoral articulation, which may result in patellar impingement on the tibial insert in late flexion and ultimately predispose the patella to fracture. Surgical approach and soft tissue dissection should be as atraumatic to the patellar blood supply as possible to preserve the superolateral geniculate artery when performing a lateral retinacular release. The classification used by Goldberg, et al is helpful for planning appropriate intervention:. Type I fractures: Avulsion type fractures generally involving the periphery of the patella without involving the implant. Type II fractures: Disrupt the cement-prosthesis interfaces of the quadriceps mechanism. Type IIIA fractures: Involve the pole of the patella with disruption of the patella ligament. Type IV fractures: Fracture dislocations of the patella. Non-operative treatment is preferred when fractures are non-displaced