Summary

Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease.

The aim of this study was to perform a systematic review of the literature on Gustilo-Anderson (GA) type IIIB open tibial shaft (AO-42) injuries to determine the consistency of reporting in the literature. A search of PubMed, EMBASE and Cochrane Central Register of Controlled Trials was performed to identify relevant studies published from January 2000 to January 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The study was registered using the PROSPERO International prospective register of systematic reviews. Patient/injury demographics, management and outcome reporting were recorded. There were 32 studies that met the inclusion criteria with a total of 1,947 patients (70.3% male, 29.7% female). There were 6 studies (18.8%) studies that reported on comorbidities and smoking, with mechanism of injury reported in 22 (68.8%). No studies reported on all operative criteria included, with only three studies (9.4%) reporting for time to antibiotics, 14 studies (43.8%) for time from injury to debridement and nine studies (28.1%) for time to definitive fixation. All studies reported on the rate of deep infection, with a high proportion documenting union rate (26/32, 81.3%). However, only two studies reported on mortality or on other post-operative complications (2/32, 6.3%). Only 12 studies (37.5%) provided any patient reported outcomes. This study has demonstrated a deficiency and a lack of standardized variable and outcome reporting in the orthopaedic literature for Gustilo-Anderson type IIIB open tibial shaft fractures. We propose a future international collaborative Delphi process is needed to standardize

This study examined pre-operative measures to predict post-operative biomechanical outcomes in total knee arthroplasty (TKA) patients. Twenty-eight patients (female=12/male=16, age=63.6±6.9, BMI=29.9±7.4 kg/m2) with knee osteoarthritis scheduled to undergo TKA were included. All surgeries were performed by the same surgeon (GD) with a subvastus approach. Patients visited the gait lab within one-month prior to surgery and 12 months following surgery. At the gait lab, patients completed the knee injury and osteoarthritis outcome score (KOOS), a timed up and go (TUG), maximum knee flexion and extension strength evaluation, and a walking task. Variables of interest included the five KOOS sub-scores, TUG time, maximum knee flexion and extension strength normalized to body weight, walking speed, and peak knee biomechanics variables (flexion angle, abduction moment, power absorption). A Pearson's correlation was used to identify significantly correlated variables which were then inputted into a multiple regression. No assumption violations for the multiple regression existed for any variables. Pre-operative knee flexion and extension strength, TUG time, and age were used in the multiple regression. The multiple regression model statistically significantly predicted peak knee abduction moment, post-operative walking speed, and post-operative knee flexion strength. All four variables added statistically significantly to the prediction p<.05. Pre-operative KOOS values did not correlate with any biomechanical indicators of post-operative success. Age, pre-operative knee flexion and extension strength, and TUG times predicted peak knee abduction moment, which is associated with medial knee joint loading. These findings stress the importance of pre-surgery condition, as stronger individuals achieved better post-operative biomechanical outcomes. Additionally, younger patients had better outcomes, suggesting that surgeons should not delay surgery in younger patients. This delay in surgery may prevent patients from achieving optimal outcomes. Future studies should utilize a hierarchical multiple regression to identify which variables are most predictive

Abstract. Objectives. Routine blood test following total shoulder arthroplasty (TSA) cost the NHS more than £72000 in 2018 without definite evidence of their impact on patients’ management or outcomes. This study aimed to ascertain if routine laboratory tests are a necessity post TSA or can be implemented on a per-patient. Methods. A retrospective review of the electronic records completed for 251 patients underwent TSA over 6 years. 193 patients were eligible for analysis. Primary outcomes were interventions to the abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 days and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative haemoglobin (Hb) drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 patients (0.9%) were symptomatic and received RBC transfusion . 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as they have not shown to produce a meaningful clinical impact in this cohort of patients nor on the re-admission rate, causing unnecessary costs. We recommend assessing each patient and request for investigations in a coherent and justified manner. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Postoperative total shoulder arthroplasty (TSA) blood tests cost the National Health Service in the UK more than £72000 annually without definite evidence of their impact on outcomes. This study aimed to ascertain if these blood tests can be implemented on a per-patient basis. Methods. A retrospective review of one centre TSA patients over 6 years. Primary outcomes were interventions to abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative Hb drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 (0.9%) were symptomatic and received RBC transfusion. 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as no detected meaningful clinical impact and should be requested on an individual justified basis

Chronic osteomyelitis is historically treated in a two stage fashion with antibiotic-loaded polymethylmethacrylate (PMMA) as local antibacterial therapy. However, two-stage surgeries are associated with high morbidity, long hospitalization and high treatment costs. In recent years new biomaterials were developed that allow to change this treatment algorithm. S53P4 bioactive glass is such a novel biodegradable antibacterial bone graft substitute that enables a one-stage surgery in local treatment of chronic osteomyelitis. This study aimed to explore the eradication of infection and bone healing capacities of S53P4 bioactive glass in clinical practice. In this prospective longitudinal outcome study, clinical applicability of S53P4 bioactive glass in treatment of patients with chronic osteomyelitis was assessed. All patients with clinically, haematologically and radiologically evident chronic osteomyelitis were included. All patients were treated with an extensive debridement surgery, S53P4 bioactive glass implantation and systemic antibiotic administration. Primary endpoint of this study is eradication of infection. During follow-up eradication was analysed based on clinical outcomes, blood samples (inflammatory parameters) and radiological outcomes. The secondary endpoint, bone healing, is assessed using conventional radiographic images of the treated region. Between 2011 and 2016, 25 patients were included in this study, with a mean follow-up of 23 months (range 4 – 57). Hospital stay was short with a mean of 18 days (range 4 – 40) and patients required an average of 1,4 surgeries (range 1 – 4). The inflammatory parameter C-reactive protein (CRP) showed a normalization after a mean duration of 46 days (range 0 – 211). At the end of follow-up haematological and clinical outcomes showed eradication of infection in 24 (96%) of all patients. Radiologically none of all patients showed persisting signs of infection and bone healing was observed in 22 (88%) patients based on changes on conventional radiographic images. One patient had a persistent infection without any bone healing, this patient had an infected non-union prior to surgery. There were two other patients with an initial infected non-union fracture which was not consolidated at last follow-up, although they had successful infection treatment. Another patient had a femoral fracture after surgery that needed additional surgery which did not interfere with eradication of infection. Four (16%) of all patients had initial wound healing problems related to compromised skin and/or soft tissue prior to surgery. Based on the results of our clinical experience, S53P4 bioactive glass can successfully be used in a one-stage procedure for treatment of chronic osteomyelitis. Eradication of infection was successful in almost all patients and so far no patients required a second surgery due to infection recurrence. Bone healing (incorporation of the bioactive glass) was seen in all patients except for the patients with an initial infected non-union fracture. As a consequence of these results, we changed our institutional protocol for treatment of chronic osteomyelitis to a one-stage approach instead of a two-step approach

The study looked at early outcomes of 55 patients who underwent open reduction and internal fixation of distal radius fracture with a single variable angle volar locking plate (Variax, Stryker), by a single surgeon (GS), between May 2007 and December 2008. A retrospective review of notes and radiographs was performed. Twenty-nine women and 26 men were included. The mean age was 52 years. Mean follow up time was 3 months. The dominant wrist was involved in 38 patients. The mechanism of injury was of low energy in 38 patients and of high energy in 17 patients. All patients had comminuted fractures and 52 patients had intraarticular fractures. Seven patients underwent intraoperative carpal tunnel decompression. At latest follow up, active wrist motion averaged 37° extension, 40° flexion, 70° pronation, and 56° supination. Grip strength averaged 64% and pinch grip 77% of the contralateral wrist. Postoperative complications included one flexor pollicis longus rupture, one malunion and three patients with loosening of screws. There was a higher rate of complications seen in patients with high energy injuries. These early results suggest that volar plating with a variable angle plate is an effective treatment option, especially for complex intraarticular distal radius fractures. A medium term outcomes study of a larger number of patients is planned

Introduction. Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral centre in Ireland. Methods. We identified all patients who were ten years following open reduction and internal fixation of an acetbular fracture in our centre. We invited all of these patients to attend the hospital for clinical and radiographic follow-up. As part of this, three scoring systems were completed for each patient; the Short-form 36 health survey (SF36), the Merle d'Aubigné score and the Short Musculoskeletal Functional Assessment (SMFA). Results. The data represents one year's activity at a new tertiary referral unit. We identified a total of 44 patients who were ten years following ORIF of acetabular fractures in our unit. 21 patients (48%) replied to written invitation and attended the hospital for clinical and radiographic follow-up. A further 7 patients were contacted by telephone and interviewed to gauge their rehabilitation. 3 patients had passed away. The remaining 13 patients were not contactable. Of those who attended in person for follow-up; 18 were male and 3 were female. The mean age at follow-up was 40.5 years (Range 27-60). In terms of fracture pattern epidemiology, 43% of patients sustained posterior column and wall fractures, 29% posterior wall, 14% posterior column alone, 9.5% transverse with posterior wall and 9.5% bicolumnar. 2 patients in the follow-up group had total hip replacements. Of the remaining patients the overall mean SF36 score was 78.8% (SD 16.4). The mean SMFA was 14.1% (SD 5). The mean Merle d'Aubigné score was 14.9 (SD 3.2) with 63% graded as good or excellent. Comparison of outcome between sub-groups according to fracture classification showed no significant difference. Traumatic sciatic nerve injury was sustained by four patients in the follow-up group and all patients continued to complain of ongoing weakness. Of the patients who were contacted via telephone, 2 had total hip replacements. The remaining 5 reported no significant problems with their hips and cited this as the reason for not attending follow-up. Conclusion. Overall the outcome of the patients was more favourable than expected. This was supported by the results of the clinical scoring systems. In some patients this also appeared to be despite poor radiographic findings. Our observations suggest that concomitant injuries, especially sciatic nerve injury have a profound negative influence on the patients' ability to fully rehabilitate. These data provide a valuable tool for the trauma surgeon in providing the patient with an educated prognosis

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metal ware removal rates of up to 80%. In addition studies have shown that conservative treatment provides a good function and pain relief in the elderly and infirm. We aimed to look at all displaced olecranon fractures within our unit over a 4 year period and analyse their case notes for patient features, age stratification, treatment methods, complications and outcomes. We also aimed to compare our results to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications and outcome. X-rays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93, mean was 62.8 years. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), and Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25%) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metal ware removal than published studies. We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metalware removal rates of up to 80%. In addition studies have shown that conservative treatment provides good function and pain relief in the elderly and infirm. To look at all displaced olecranon fractures within our unit (the busiest district general hospital in Scotland) over a 4 year period and analyse for patient features, age stratification, identify treatment methods, complications and outcomes. To compare this to outcomes in studies published by specialist centres. All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications & outcome. Xrays were analysed to classify the fractures and assess outcome of treatment. 71 patients were identified, Male: Female = 33:38. Age range was 7–93. Mean 62.8. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications. In our study group we have demonstrated a lower infection rate and a far lower rate of metalware removal than published studies.?We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group

Spinal nerve roots often sustain compression injuries. We used a Wistar rat model of the cauda equina syndrome to investigate such injuries. Rapid transient compression of the cauda equina was produced using a balloon catheter. The results were assessed by daily neurological examination and somatosensory evoked potential (SEP) recording before surgery and ten weeks after decompression. Compression of the spinal nerves induced changes in the SEP which persisted for up to ten weeks after decompression, but it had no effect on the final neurological outcome. Our study shows the importance of early surgical decompression for cauda equina syndrome

Objectives

To review the systemic impact of smoking on bone healing as evidenced within the orthopaedic literature.