The question of whether to reconstruct an ACL-deficient knee as early as possible following injury or to delay surgery remains unanswered. Early reconstruction potentially reduces the risk of secondary damage. However, there is also concern regarding the risk of arthrofibrosis if surgery is undertaken too soon. The aim of this study was to investigate whether injury-to-surgery delay determines ACL-reconstruction outcomes at up to 2years post-operatively.

A retrospective analysis of prospectively collected data from 211 knees with isolated primary ACL ruptures was performed. Patients were examined preoperatively, at 6months, 1 year, and 2 years post-operatively using International Knee Documentation Committee (IKDC) and Lysholm scores. Side to side differences in knee laxity were also measured with a KT1000 arthrometer. Spearman's rho correlations were used to associate injury-to-surgery delay with outcome scores.

Outcomes scores significantly increased for both IKDC (p<0.05) and Lysholm (p<0.05) questionnaires. Significant positive correlations (p<0.05) were also found between injury-to-surgery delay and IKDC and Lysholm subjective scores. Strongest correlation coefficients were noted at the 2yr follow-up for both IKDC and Lysholm scores (r = 0.79 and 0.8 respectively). Side-to-side laxity measures also showed significant positive correlations with injury-to-surgery delay at 1 year (r = 0.17) and 2 year (r = 0.41) follow ups. The positive correlation suggests that delayed surgery is positively related to subjective outcomes, as well as objective measures of knee laxity.

However, this relationship also suggests that other factors such as the patient's functional status at time of surgery may play a role in their post-operative function. For example, those who can compensate for the ruptured ligament may function well following delayed surgery. These findings highlight the need for more detailed investigation of the interaction between functional status, injury-to-surgery delay and post-operative recovery.

Aims

The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression.

Supracondylar fractures of the humerus in children are among the most common paediatric fractures, and yet present one of the greatest technical challenges for management. Traditionally treated as surgical urgencies, recent literature calls that belief into question. The purpose of this study was to determine the influence of the elapsed time from injury to surgery of Gartland Type III supracondylar fractures on operative time and quality of reduction.

A retrospective review of all Gartland Type III supra-condylar factures treated by closed reduction and percutaneous pinning at our hospital between January 2003 and April 2006 was performed. Subjects in this consecutive series underwent a formal chart review to extract necessary data. The intra-operative fluroscopic images were utilised to assess the quality of reduction. All images were analyzed by three independent blinded reviewers on two separate occasions. Parameters measured on the AP images included: Baumann’s Angle, Humerocapitellar angle, Gordon Index, Griffet Index one and two.

Of the one hundred and forty-one charts reviewed, twenty-nine were excluded for various criteria. Of the remaining sample (N=112), sixty-one patients were treated in less than eight hours (Group one), and fifty-one treated after eighthours (Group two). There were sixty-one girls and fifty-one boys, with a mean age of six yrs. There were no cases of compartment syndrome. No subjects required conversion from closed to open reduction. The mean time from injury to surgery was six hundred and seventy minutes (min = 128, max = 3117). The mean for Group one was three hundred and forty-one minutes and one thousand and sixty-five minutes for Group two. The mean operative time was 33.29 minutes, (min=ten, max =eighty-two). The mean operative time in Group one was 33.13 minutes and 33.38 minutes in Group two. Two t-tailed t-test demonstrates no significant difference between the two groups. Radiographic analysis revealed the following means: Baumann’s angle (m = 70.26), humero-capitellar angle (m= 36.19), Gordon Index (m=33.78), Griffet Index 1 (m=0.88) and Griffet Index 2 (m=2.55). Comparison of the radiographic parameters and indices demonstrated no significant difference between the two groups.

This study demonstrates delaying surgery beyond eight hours led to no difference in operative time or quality of reduction. Previous studies have demonstrated no difference in rate of compartment syndrome, presence of complications or need for open reduction between these two groups. Our findings combined with previous retrospective studies support the need for further prospective study and support the surgeon’s clinical judgment in determining the urgency of surgical intervention in this patient population.

Aims. Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. Methods. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). Results. A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. Conclusion. Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222–233

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aims. The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation. Methods. All patients transferred to a national tertiary spinal referral centre for primary surgical fixation of unstable spinal injuries without preoperative neurological deficit between 1 July 2016 and 20 October 2017 were eligible for inclusion. Data were collected retrospectively. Patients were divided into early and late cohorts based on timing from initial trauma to first spinal operation. Early fixation was defined as within 72 hours, and late fixation beyond 72 hours. Results. In total, 86 patients underwent spinal surgery in this period. Age ranged from 16 to 88 years. Mean Injury Severity Score (ISS) was higher in the early stabilization cohort (p = 0.020). Age was the sole significant independent variable in predicting morbidity on multiple regression analysis (p < 0.003). There was no significant difference in complication rates based on timing of surgical stabilization (p = 0.398) or ISS (p = 0.482). Conclusion. Our results suggest that these patients are suitable for early appropriate care with spinal precautions and delayed definitive surgical stabilization. Earlier surgery conferred no morbidity benefit and had no impact on length of stay. Cite this article: Bone Joint J 2020;102-B(5):627–631

Aims

We aimed to characterise the effect of expeditious hip fracture surgery in elderly patients within 24 hours of admission on short-term post-operative outcomes.

Fractures of the hip are common, often occurring in frail elderly patients, but also in younger fit healthy patients following trauma. They have a significant associated mortality and major social and financial implications to patients and health care providers. Many guidelines are available for the management of these patients, mostly recommending early surgery for the best outcomes. As a result, healthcare authorities now put pressure on surgical teams to ‘fast track’ patients with a fracture of the hip, often misquoting the available literature, which in itself can be confusing and even conflicting.

This paper has been written following an extensive review of the available literature. An attempt is made to clarify what is meant by early surgery (expeditious versus emergency), and we conclude with a personal view for the practical management of these patients of variable age, fitness and type of surgery performed within services that are often under considerable pressure of finance and available operating theatres and qualified staff.

Cite this article: Bone Joint J 2016;98-B:1573–81.

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

Aim. In the context of total knee arthroplasty (TKA), trauma with perigenicular fracture fixation or oncological surgical treatment, soft tissue defects can expose critical structures such as the extensor apparatus, the knee joint, bone or implants. This work compares soft tissue reconstruction (STR) between a classical pedicled gastrocnemius (GC) muscle flap and a pedicled chimeric sural artery perforator (SAP) musculocutaneous GC flap in complex orthoplastic scenarios. Method. A retrospective study was conducted on prospectively maintained databases in three University Hospitals from January 2016 to February 2021 after orthopaedic, traumatological or oncological treatment. All patients with a perigenicular soft tissue defect and implant-associated infection were included undergoing STR either with a pedicled GC flap or with a pedicled chimeric SAP-GC flap. The outcome analysis included successful STR and flap related complications. The surgical timing, preoperative planning and surgical technique are discussed together with the postoperative rehabilitation protocol. Results. 43 patients were included (22 GC muscle flaps, 21 SAP-GC musculocutaneous flaps). The GC and SAP-GC patient group were comparable in terms of age, comorbidities, defect size and follow-up. The incidence of flap related complications was comparable among the two groups. Specifically, in the SAP-GC group 1 wound dehiscence at the recipient site occurred as well as 1 distal muscle flap necrosis, 1 distal skin flap necrosis, 1 donor site infection and 1 donor site wound dehiscence. Furthermore, the donor site was closed in 9 patients while a skin graft was used in 12 patients. A significant difference was recorded with regard to re-raising the flap for further orthopaedic treatment: In the SAP-CG group (re-raise in 11 patients) no problems occurred while in the GC group (re-raise in 14 patients) in 6 patients the soft tissue did not heal completely. Conclusions. According to our clinical experience, the pedicled chimeric SAP-CG musculocutaneous flap is a relevant further development of the classical GC workhorse flap for perigenicular STR, in multiple staged procedures

Evaluate the complications and outcomes of off-hours spinal metastasis surgery. Retrospective analysis of a prospective collected data. Preoperative, operative and post-operative data were collected as well as the complications and Frankel score at all time checkpoints. Off-hours surgery was defined as surgery starting between 17:00 and 8:00 the following day or surgery during the weekend. p < 0 .05 was defined as statistical significance threshold. 376 patients were included with an incidence of off-hours surgery of 32%. There was an increase of neurologic complication in the off hours group. This was associated with a higher ASA score and older population group. Oddly, there was decreased operative time with off-hours surgery with no difference in bleeding and number of fusion levels. Nonetheless, there was a higher percentage of neurologic improvement with off hours surgery compared to in-hours surgery. Finally, there were no effect on patients' survival in this patient population. To our knowledge, this is the first report of the effect of off-hours surgery on complications and outcomes of spinal metastasis. Greater neurological compromise and higher age and ASA scores were associated with higher incidence of off-hours surgery. It is associated with decreased surgical time with higher percentage of neurological improvement. Finally, there is no effect of surgical timing on survival rates

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population

The April 2013 Trauma Roundup. 360 . looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction

Hip fracture is a common injury with a high associated mortality. Many recommendations regarding timing of operative intervention exist for patients with such injuries. The Best Practice Tariff was introduced in England and Wales in 2010, offering financial incentives for surgery undertaken within 36 hours of admission. The England and Wales National Institute for Health and Clinical Excellence (NICE) Guidance states that surgery should be performed on the day or day after admission. Due to lack of clear evidence, this recommendation is based on Humanitarian grounds. NICE have called for further research into the effect of surgical timing on mortality. We utilised data from the National Hip Fracture database prospectively collected between 2007 and 2015, comprising 413,063 hip fractures. Using 11 variables, both Cox and Logistic regression analysis was used to establish the effect on mortality of each 12 hour interval from admission to surgery. For each 12 hour time frame from admission to surgery a trend for improved 30 day survival was demonstrated the earlier the surgery was performed. However, this did not reach significance until beyond 48 hours (Hazard ratio of 1.12, 95% CI: 1.04–1.20). Surgery after 48 hours suffered significantly higher chance of mortality compared to surgery done within 12 hours. This is the largest analysis undertaken to date. Lowest mortality rates are found within the 0–12 hour window. After 48 hours there is a significant increased risk of mortality compared to the 0–12 hour time frame. As such, expeditious surgery within 48 hours can be justified both on humanitarian and survivorship grounds. Hip fracture surgery performed within 48 hours is associated with reduced mortality when compared to that beyond this time. This is in agreement with Blue Book recommendations and extends the currently recommended NICE and Best Practice Tariff targets of 36 hours

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

The June 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Proximal femoral unicameral bone cysts: is ESIN the answer?; Hybrid-mesh casts in the conservative management of paediatric supracondylar humeral fractures: a randomized controlled trial; Rate and risk factors for contralateral slippage in adolescents treated for slipped capital femoral epiphysis; CRP predicts the need to escalate care after initial debridement for musculoskeletal infection; Genu valgum in paediatric patients presenting with patellofemoral instability; Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: what about spine and hip?; The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children.

Aims

The purpose of this study is to determine an individual’s age-specific prevalence of total knee arthroplasty (TKA) after cruciate ligament surgery, and to identify clinical and genetic risk factors associated with undergoing TKA.

Aims

The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

The effects of remnant preservation on the anterior cruciate ligament (ACL) and its relationship with the tendon graft remain unclear. We hypothesized that the co-culture of remnant cells and bone marrow stromal cells (BMSCs) decreases apoptosis and enhances the activity of the hamstring tendons and tenocytes, thus aiding ACL reconstruction.