Commercial aviation has recognized since long time that the so called “human factor” is the main responsible for the majority of accidents or near-accidents, which are always reported in aviation but almost never in medicine. Therefore I strongly support the idea that we could much learn from aviation in order to cope with the major cause of our accidents. Like airmen, pilots, air traffic controllers and so on, we also make errors. The first step to reduce the burden of our errors is to be able to admit them in order to analyse their causes, which up to now we are unable to do. Only one medical journal, the Lancet, has started to publish our errors. But beware not to make confusion between, complication, negative outcome and medical error. The “human factor” must not be understood as human error; on the contrary the
Venous Thromboembolism (VTE) prophylaxis is an essential part of orthopaedic surgeries in preventing life-threatening thromboembolic events such as Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). Orthopaedic surgery has the highest incidence rate of thromboembolic events as compared to any other surgical specialities, making it an essential component in managing any orthopaedic case. At Queen's Medical Centre (QMC), a major trauma centre in the United Kingdom (UK), sees up to 750 NOF fracture cases annually, making it one of the busiest trauma and orthopaedic centres in the UK. Our study aims to evaluate how VTE Prophylaxis is conducted in a UK Major Trauma Centre for NOF and pelvic fragility fractures and how
The World Health Organisation (WHO) Surgical Safety checklist is an evidence-based tool shown to reduce surgery-related morbidity and mortality. Despite audits showing 96% checklist compliance, our hospital had 3 surgical never events in 10 months, 2 of which were in orthopaedics. By March 2018, the authors aimed to achieve 100% compliance with all 5 sections of the WHO Five Steps to Safer Surgery bundle for all surgical patients. Additionally, the authors aimed to assess the impact of the quality of bundle delivery on preventable errors related to
INTRODUCTION. Finite element analysis (FEA) is widely used to study micromotion between the glenoid baseplate and bone, as a pre-clinical indicator for clinical stability in reverse total shoulder arthroplasty (rTSA). Various key parameters such as the number, length, and angle of screws have been shown to influence micromotion [1]. This study explores the influence of screw preloads, an insufficiently studied parameter. Specifically, two rTSA configurations with 18mm and 48mm peripheral screws (PS) were analyzed without screw preloads, followed by analysis of the 48mm PS configuration with an experimentally measured screw preload. METHODS. FEA models were created to simulate a fixation experiment inspired by ASTM F2028-14. The rTSA configurations used here have a superior and an inferior PS. The assemblies were virtually implanted into a synthetic bone block as per surgical technique. Sliding contacts were defined to model the interface between screw threads-bone, and between baseplate-bone. To determine the screw preload experimentally, the 48mm screw (n=5) was inserted through a hole in a metal plate, which rested on top of a Futek washer load cell, placed on top of the foam block with a predrilled pilot hole (Figure 1). The screw was inserted using a torque driver until the average
Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria.Aims
Methods
Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre. A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded.Aims
Methods
Negative outcomes, accidents and complications are unavoidable. In surgery as in aviation a major role is played by
The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs). TDABC analysis based on the principles outlined by Kaplan and a clinical pathway that has previously been validated for this institution was used. Staffing cost, consumables, implants, and overheads were updated to reflect 2019/2020 costs. This was compared with the HRG reimbursements.Aims
Methods
Introduction: Closed reduction and percutaneous pinning techniques for displaced supracondylar fractures of the humerus in children have overcome disastrous ischemic complications and long inpatient treatment. Closed reduction of those highly unstable fractures and the demanding pin placement itself are potential sources of failure for the inexperienced reflected by the rate of cubitus varus which is still about 5 to 15% in recent series. Rotational primary and residual displacement has to be appreciated to prevent permanent cosmetic deformity. Malrotation is the major source of instability since bicolumnar support is lost which allows the distal fragment to tilt. Anatomy: The transverse section of the distal humerus is the key to all stability related problems faced in supra-condylar fractures of the humerus in children. In the supracondylar region the radial and ulnar column are only connected by a thin bony wafer which results from the presence of the cubital and olecranon fossa. In case of a fracture. In case of a fracture rotation leads to decrease of bony contact and hence to instability. Epidemiology: Elbow fractures account for 7–10% of all pediatric fractures whereof 80–90% are located at the distal humerus with 80% involvement of the supracondylar region. Most of the supracondylar fractures occur between ages 5 and 10 years. Mechanism of injury: Fall from a height, usually from a household object in the age group <
3 years or from a playground equipment in children >
4 years on the outstretched nondominant arm (indirect elbow trauma). 96% of all supracondylar fractures are extension type injuries. Open fractures, mostly grade 1, occur when the anterior spike of the proximal fragment pierces through the brachialis muscle and the skin of the cubital fossa. Their incidence is about 1–3% in major referral centers. Differential diagnosis: Supracondylar fractures have to be differentiated from transcondylar fractures and dislocations of the elbow. In a supracondylar fracture the fracture line stays proximal to the distal humerus physis. If it runs across it, it is most likely a supracondylar fracture. Dislocations of the elbow typically after the age of 10 years. Neurologic compromise: Fracture related peripheral neuropathies have an incidence of 10 to 17%. With rare exceptions concomitant nerve lesion recover spontaneously within a time range of 1 to 4 months. The rate of iatrogenic nerve injuries is 3%–16% with the ulnar nerve being the most susceptible due to inadvertent pinning. Despite a high recovery rate, they are a nuisance for the patients. Vascular compromise: Early recognition of vascular compromise with subsequent reduction and fixation of the fracture and avoidance of extreme flexion at the elbow have decreased the incidence of ischemic complications. An initially absent radial pulse is found in up to 19% in displaced fractures. Closed reduction restores pulsation in about 80%. Patients with postreduction lack of pulse or poor capillary refill should undergo vascular revision. There is still controversy regarding the management of a post reduction pink, warm but pulse less hand with adequate capillary refill. Simple observation and conservative management leads to a favourable clinical outcome in most cases but cold intolerance or exercise induced ischemic symptoms is a potential sequel. Treatment:. Undisplaced fractures: simple immobilisation e.g. collar and cuff. Incomplete displacement: in case of malrotation and/or age-related unacceptable extension (>
20° in patients older than 6 years) closed reduction and pinning otherwise conservative management. Complete displacement: Attempt for closed reduction and percutaneous pinning. Irreducibility is found in up to 22%. Open reduction is most widely as a last resort. Complications:. Infection. Occasionally, superficial infection after pinning occurs despite all preventive measure (wires left protruding through the skin should not be covered by plaster to prevent rubbing; pin care instruction for the parents; regular follow-up for pin site inspection). Cubitus varus. Most common complication with an overall incidence of about 20%. As a malunion in the coronal plane it has no capacity for remodelling. Although this deformity is mainly a cosmetic problem and does not interfere with the range of motion, it may be a functional problem in some activities e.g. in apparatus gymnastics. Malunion/Stiffness. Even after perfect reduction, lack of full extension is common and usually takes over 6 months to improve. Impaired range of motion may be prolonged or even persistent due to an underlying pathology. Malunion is the most common one. In the sagittal plane, antecurvation leads to hyperextension and reduced flexion of the elbow. Significant remodelling with growth can only be expected below the age of 6 and in antecurvations of less than 20°. Rotatory malunion with an anterior spur restrains flexion. Complete remodelling of the spur usually takes place even in older children. Volkmann’s contracture represents the most severe complication after supracondylar fractures. Fortunately, it has become a rarity. Conclusion:. The
The April 2015 Trauma Roundup360 looks at: Negative presure wound therapy in open tibial fractures; Priority-driven approach to pelvic injuries; Early surgery essential in hip fracture management; Sheer fractures to the posteromedial plateau; Fasciotomy closure under the spotlight; Why do patients die from hip fracture?; Acetabular fractures down the line; Biomechanics of femoral neck fractures reviewed
In revision total hip replacement, bone loss can be managed by impacting porous bone chips. In order to guarantee sufficient mechanical strength, the bone chips have to be compacted. The aim of this study was to determine in an We found that the pneumatic method reached higher values of impaction hardness, contact stiffness and bulk density suggesting an increase in stability of the implant. No significant differences were found between the two different methods concerning the penetration resistance. The pneumatic method might reduce the risk of fracture
Although mechanical stabilisation has been a hallmark of orthopaedic surgical management, orthobiologics are now playing an increasing role. Platelet-rich plasma (PRP) is a volume of plasma fraction of autologous blood having platelet concentrations above baseline. The platelet α granules are rich in growth factors that play an essential role in tissue healing, such as transforming growth factor-β, vascular endothelial growth factor, and platelet-derived growth factor. PRP is used in various surgical fields to enhance bone and soft-tissue healing by placing supraphysiological concentrations of autologous platelets at the site of tissue damage. The easily obtainable PRP and its possible beneficial outcome hold promise for new regenerative treatment approaches. The aim of this literature review was to describe the bioactivities of PRP, to elucidate the different techniques for PRP preparation, to review animal and human studies, to evaluate the evidence regarding the use of PRP in trauma and orthopaedic surgery, to clarify risks, and to provide guidance for future research.
Orthopaedic surgery is in an exciting transitional period as modern surgical interventions, implants and scientific developments are providing new therapeutic options. As advances in basic science and technology improve our understanding of the pathology and repair of musculoskeletal tissue, traditional operations may be replaced by newer, less invasive procedures which are more appropriately targeted at the underlying pathophysiology. However, evidence-based practice will remain a basic requirement of care. Orthopaedic surgeons can and should remain at the forefront of the development of novel therapeutic interventions and their application. Progression of the potential of bench research into an improved array of orthopaedic treatments in an effective yet safe manner will require the development of a subgroup of specialists with extended training in research to play an important role in bridging the gap between laboratory science and clinical practice. International regulations regarding the introduction of new biological treatments will place an additional burden on the mechanisms of this translational process, and orthopaedic surgeons who are trained in science, surgery and the regulatory environment will be essential. Training and supporting individuals with these skills requires special consideration and discussion by the orthopaedic community. In this paper we review some traditional approaches to the integration of orthopaedic science and surgery, the therapeutic potential of current regenerative biomedical science for cartilage repair and ways in which we may develop surgeons with the skills required to translate scientific discovery into effective and properly assessed orthopaedic treatments.