Introduction. There has been little research into the effect of suffering a simultaneous hip and upper limb fragility fracture. The aim of this study is to describe the characteristics of this important group of patients and to define the effect on outcomes such as mortality and length of stay. Materials and methods. Hip fracture data in our unit is collected prospectively and entered into a database. All study data was taken from this database. Patients under 60 years of age were excluded from the study. Results. Between October 1986 and May 2010 we treated 7225 patients with hip fractures in our unit. 71 (1%) of these patients sustained simultaneous upper limb fractures. There were only 12 (0.2%) simultaneous fractures involving the lower limbs or other sites; 1 pelvis, 2 calcaneum, 1 metatarsal, 2 ankle, 1 tibial plateau, 3 rib and 2 bilateral hip fractures. The average age in the simultaneous fracture group was 80.6 years versus 81.5 years in the isolated hip fracture group. In the upper limb fracture group there were 33 distal radius, 21 humerus, 9 elbow, 6 hand and 2 clavicle fractures. There were also 3 shoulder dislocations. 79.7% of the patients with isolated hip fractures were women, compared with 77.8% in the simultaneous fracture group. 63 (88.7%) upper limb fractures occurred on the ipsilateral side. The mean length of stay in the upper limb fracture group was 21.8 days compared with 23.6 days in the isolated hip fracture group. 30 day and 1 year mortality in the upper limb fracture group was 5 (6.2%) and 16 (19.8%) compared with 573 (8%) and 2069 (29%) in the isolated hip fracture group. Discussion. This is the largest published series of patients with simultaneous hip and upper limb fractures to date. Simultaneous upper limb fractures occur much more frequently than lower limb fractures in patients with hip fractures. We found that length of stay was longer and 30 day and 1 year mortality was higher in the isolated hip fracture group

Aim. Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients. Methods. Retrospective single centre consecutive series between 2005–2017. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap and anastomosis used, follow-up duration, time to union and complications. Results. 56 patients (55 tibiae and 1 forearm) were included (mean age 48 years). Thirty-four cases had osteomyelitis (20/34 Cierny-Mader Stage IV) and 22 had an infected non-union (14/22 Weber-Cech Type E or F). Forty-six patients had a segmental defect after resection. Monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, bone transport in 9 and a protective frame in 10. 8/56 had an ankle fusion, 7/56 had an angular deformity corrected at the same time and 32 also had local antibiotic carrier inserted. Forty-six gracilis, 9 latissimus dorsi and 1 rectus abdominus flaps were used. Six cases required urgent flap re-exploration (5 anastomotic revisions and 1 haematoma washout) with 4/6 successfully salvaged. Two cases suffered total flap failure (3.6%). Both had successful revision free muscle flaps with the frame in situ at 10 and 16 days respectively. There were no partial flap failures and no failures in bone transport frames. Mean follow-up was 22 months (4–89). Excluding three cases that still have a frame on, 42/43 (97.7%) achieved bony union. Recurrence of infection occurred in 8.9%. All were infection free at final follow-up after further surgery. Conclusions. With the right expertise, simultaneous Ilizarov frame and free muscle flap is safe and effective in treating complex limb infection, and is not associated with an increased flap failure rate. Level of evidence. III

Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed - the desired - limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21% of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26%). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery.

A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”.

Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation.

Introduction. The purpose of this study was to compare the clinical outcomes and complications following bilateral simultaneous total knee arthroplasty in high body mass index (BMI) patients(>30kg/m. 2. ) to those of patients with a BMI<30 kg/m. 2. . Materials and Methods. Using data from an academic arthroplasty database and review of clinic charts we obtained health related quality of life (SF-12), and disease specific functional outcome scores (WOMAC or Oxford Knee Score). We also assessed length of hospital stay, ASA grade and transfusion requirements. Sixty six patients had a BMI<30 and 151 patients had a BMI>30. Results. Most cases were performed under combined spinal/epidural anaesthesia. We could find no appreciable difference in length of hospital stay, ASA grade or transfusion requirements between the two subgroups. Furthermore, were unable to detect any significant differences in post operative SF-12, WOMAC or Oxford Knee scores. There appeared to be no significant increase in the rate of medical complications between the two subgroups, and while there may have been a slight trend towards higher procedure related complications in the high BMI group, this did not reach statistical significance. Conclusions. In our study increased BMI appears to have no negative effects as regards functional outcomes, hospital stay or transfusion requirements for bilateral sequential knee arthroplasty. However there may be an increase in procedural/device related complications which could result in increased revision rates in these patients

Introduction. The clinical and functional outcome following simultaneous fractures of the acetabulum and pelvic ring represent a challenge for the clinician and are currently obscure in the existing literature. Patients and Methods. Between January 2003 and July 2009 all patients with combined pelvic and acetabular fractures were included in this prospectively study. Demographic details, mechanism of injury, ISS, surgical procedures, post-operative course, length of hospital stay, and radiological (Matta's score) and functional outcomes (The Merle d' Aubigne hip score) were recorded. The minimum follow up was 12 months (12–72). Results. Out of 520 cases, 30 (21 males) patients met the inclusion criteria. The mean age was 32. 55% sustained lateral compression, 40% combined mechanism and 5% anterior/posterior type of injury pattern. 15 out of the 30 patients had sustained other injuries. The mean time from injury to definite reconstruction was 7 days (3–14). Ilioinguinal approach was used in 20 patients, Pfannestiel in 2 and Kocher-Langebeck in 4. A wheelchair was used initially in 22 cases. The median time to FWB was 3 months. One patient underwent a THR at 18 months. 19 patients scored the full 18 points of the Merle score. Matta radiological score was excellent in 16 patients, Good 11, Fair 2, Poor 1. Conclusion. The management of these injuries poses many difficulties to the trauma surgeon. With the available expertise in place good outcomes can be obtained as seen in this series of patients

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Background. To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results. Methods. Adult patients treated using an Ilizarov frame prior to soft tissue management were identified from our Ilizarov database. This data was supplemented by medical record review. Results. 26 cases were identified (22 open fractures (11 IIIA, 11 IIIB), 1 compartment syndrome and 3 infected salvage). All IIIA injuries were closed acutely alongside frame application. In IIIB fractures, 3 were closed following acute shortening, 1 required a local flap and 7 free tissue transfer. Soft tissue reconstruction was simultaneous to frame application in 5 patients, the remainder within 72 hours. In salvage cases, 2 required free and one a local muscle flap, all after frame application. There were no soft tissue cover failures. One patient underwent evacuation of a flap haematoma, there were no other unexpected returns to theatre for soft tissue problems. No patients required adjustment of frame components to allow soft tissue access. Conclusion. This approach appears to simplify treatment, reducing length of stay. We are collecting a matched patient series treated by traditional pathways for comparison

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

The objective of this study was to compare differences in alignment following robotic arm-assisted bi-unicompartmental knee arthroplasty (Bi-UKA) and conventional total knee arthroplasty (TKA). This was a prospective, randomised controlled trial of 70 patients. 39 TKAs were implanted manually, as per standard protocol at our institution, and 31 Bi-UKA patients simultaneously received fixed-bearing medial and lateral UKAs, implanted using robotic arm-assistance. Preoperative and 3-month postoperative CT scans were analysed to determine hip knee ankle angle (HKAA), medial distal femoral angle (MDFA), and medial proximal tibial angle (MPTA). Analysis was repeated for 10 patients by a second rater to validate measurement reliability by calculating the intra-class correlation coefficient (ICC). Mean change in HKAA towards neutral was 2.7° in TKA patients and 2.3° in Bi-UKA patients (P=0.6). Mean change in MDFA was 2.5° for TKA and 1.0° for Bi-UKA (P<0.01). Mean change in MPTA was 3.7° for TKA and 0.8° for Bi-UKA (P<0.01). Mean postoperative MDFA and MPTA for TKAs were 89.8° and 89.6° respectively, indicating orientation of femoral and tibial components perpendicular to the mechanical axis. Mean postoperative MDFA and MPTA for Bi-UKAs were 91.0° and 86.9° respectively, indicating a more oblique joint line orientation. Inter-rater agreement was excellent (ICC>0.99). Early functional activities, according to the new Knee Society Scoring System, favoured Bi-UKAs (P<0.05). Robotic arm-assisted, cruciate-sparing Bi-UKA better maintains the natural anatomy of the knee in the coronal plane and may therefore preserve normal joint kinematics, compared to a mechanically aligned TKA. This has been achieved without significantly altering overall HKAA

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims

Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK.

Aims

The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

Enterococcus faecalis is a rare but recognized cause of prosthetic joint infection. It is notorious for formation of biofilm on prosthetic surfaces. We hypothesized that a ‘serum factor’ was responsible for transformation of E. faecalis from its planktonic form to a biofilm existence upon making contact with prostheses. Using a novel ‘proteomic approach’, we studied the protein expression profiles of this bacterium when grown on an artificial surface in a serum environment against a control. E.faecalis 628 transconjugant formed by conjugation clinical strain (E55) and laboratory strain (JH2-2) was used to inoculate each of rabbit serum (RS) and Brain Heart Infusion (BHI) agar as a control and grown for 24 hours. Proteins were harvested for analysis in fractions including cell surface, membrane and cytosolic proteins. Recovered proteins were separated using 2-dimentional polyacrylamide gel electrophoresis (2D PAGE). Gels were stained and spots of interest harvested. These were analyzed using MALDI mass spectrometry followed by peptide mass fingerprinting using online database searches. Two surface exclusion proteins Sea1 and PrgA were only expressed from the serum culture. These proteins are both encoded by genes very close to the gene for enterococcal aggregation substance PrgB, which plays an integral role in biofilm formation. PrgA and PrgB are both encoded by the prgQ operon and hence expressed simultaneously upon activation of the operon. This tendency for serum only protein expression suggests the possibility of a pheromone-like activator in serum that could be a potential therapeutic target for management of biofilm associated E. faecalis prosthetic infections

Simultaneous bilateral posterior dislocation of the hip is very uncommon and most cases are caused by road accidents. Simultaneous bilateral posterior dislocation of the hip due to convulsions is extremely rare. We report the case of a man who was diagnosed late and operated on 15 weeks after the injury. We discuss the treatment of chronic dislocation of the hip and review the literature

Introduction. The options for the treatment of the young active patient with unicompartmental symptomatic osteoarthritis and pre-existing Anterior Cruciate Ligament (ACL) deficiency are limited. Patients with ACL deficiency and end-stage medial compartment osteoarthritis are usually young and active. The Oxford Unicompartmental Knee Replacement (UKA) is a well established treatment option in the management of symptomatic end-stage medial compartmental osteoarthritis, but a functionally intact ACL is a pre-requisite for its satisfactory outcome. If absent, high failure rates have been reported, primarily due to tibial loosening. Previously, we have reported results on a consecutive series of 15 such patients in whom the ACL was reconstructed and patients underwent a staged or simultaneous UKA. The aim of the current study is to provide an update on the clinical and radiological outcomes of a large, consecutive cohort of patients with ACL reconstruction and UKA for the treatment of end-stage medial compartment osteoarthritis and to evaluate, particularly, the outcome of those patients under 50. Methods. This study presents a consecutive series of 52 patients with ACL reconstruction and Oxford UKA performed over the past 10 years (mean follow-up 3.4 years). The mean age was 51 years (range: 36–67). Procedures were either carried out as Simultaneous (n=34) or Staged (n=18). Changes in clinical outcomes were measured using the Oxford Knee Score (OKS), the change in OKS (OKS=Post-op − Pre-op) and the American Knee Society Score (AKSS). Fluoroscopy assisted radiographs were taken at each review to assess for evidence of loosening, radiolucency progression, (if present), and component subsidence. Results. Five year survival was 90%. At last follow-up, the mean outcome scores for the group were: OKS 40 (SD: 8.3), objective AKSS 77 (SD: 16.1), functional AKSS 93 (SD: 13.7) and OKS of 11. Complications were recorded in three patients, (one early infection requiring a two-stage revision, a bearing dislocation and progression of OA in the lateral compartment). 25 patients, whose procedure occurred under the age of 50, had mean outcome scores of: OKS 38 (SD: 7.7), objective AKSS 73 (SD: 20.2), functional AKSS 93 (SD: 11.9) and OKS 12. No patients had radiological evidence of component loosening. Discussion and Conclusion. This study has demonstrated that combined ACL reconstruction and Oxford UKA provide good medium-term clinical and radiological results. The mobile bearing used in the Oxford knee minimises wear and our radiographic study has seen no suggestions of loosening

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients. Cite this article: Bone Joint J 2014;96-B:157–63

We undertook a simultaneous prospective two-centre study to examine why patients with fractures of the proximal femur experience a delay in undergoing surgery. At centre 1, 23 of 105 patients (22%) suffered an avoidable delay, 18 (78%) because of a lack of theatre capacity while at centre 2, 71 of 130 patients (55%) had an avoidable delay, with 54 (76%) because of this cause. Miscellaneous reasons such as poor ward management, co-existing medical conditions, and lack of equipment were responsible for the remainder of the delays. Without a substantial increase in operating capacity for acute trauma, it will not be possible to comply with guidelines which recommend surgical treatment within 24 hours in elderly and vulnerable patients

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.