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Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_18 | Pages 9 - 9
1 Nov 2016
Khan M Faulkner A Macinnes A Gwozdziewicz L Sehgal R Haughton B Misra A
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Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation.

A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input.

56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks.

The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 42 - 42
1 May 2018
Mazoochy H Vris A Brien J Heidari N
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Introduction

Segmental bone defect is a challenging problem. We report our experience of bone transport by hexapod external fixator in patients with segmental defects if the tibia.

Method

We report herein 15 patients with segmental bone defect of tibia who completed their treatment protocol. All patients were treated had bone transport with Taylor Spatial Frame from 2012 to 2017. All were treated by the senior author NH. Parameters measured included age, sex, diabetes, smoking, diagnosis, method of fixation prior to treatment use of a free flap, bone defect size, frame-time, external fixation index.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_19 | Pages 2 - 2
1 Nov 2017
Smith M Neilly D Woo A Bateman V Stevenson I
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Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms. All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams. 36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality. Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_13 | Pages 18 - 18
1 Jun 2017
Ferguson J Nagarajah K Stubbs D McNally M
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Aims. To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union. Patients and Methods. A consecutive series of 76 patients with infected tibial non-union were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (25 cases), monofocal compression (18), bifocal compression/distraction (16) and bone transport (17). Median duration of non-union was 10.5 months (range 2–546 months). All patients underwent at least one previous operation, 36 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases had a new muscle flap at the time of Ilizarov surgery and 24 others had pre-existing flaps. Results. Infection was eradicated in 74 cases (96.1%) at a mean follow-up of 42 months (range 8–131). Both infection recurrences were in the monofocal compression group. Union was achieved in 66 cases (86.8%) with the initial Ilizarov method alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96% and 93.8% respectively. Monofocal compression was successful in only 77.8% of mobile non-unions. Bone transport secured initial union in 76.5% with a 47% unplanned reoperation rate. However, following further treatment union was 100% in the bone transport group compared to 88.9% in the monofocal compression group. Six cases sustained a refracture, with 5/6 occurring in the monofocal compression group, representing a 27.7% refracture rate. ASAMI scores were also significantly lower for the monofocal compression group. Conclusion. We do not recommend monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was more effective achieving higher rates of infection clearance, lower refracture rates and better ASAMI scores


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 25 - 25
1 Sep 2012
Sadoghi P Vavken P Leithner A Müller P Hochreiter J Weber G
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Introduction. Insufficient arthroscopic cuff tear reconstruction leading to massive osteoarthritis and irreparable rotator cuff tears might be salvaged by implantation of an inverted total shoulder prosthesis Delta in the elderly. However, despite the generally high success rate and satisfying clinical results of inverted total shoulder arthroplasty, this treatment option has potential complications. Therefore, the objective of this study was a prospective evaluation of the clinical and radiological outcome after a minimum of 2 years follow-up of patients undergoing inverted shoulder replacement with or without prior rotator cuff repair. Patients and Methods. Sixty-eight shoulders in 66 patients (36 women and 30 men) operated between February 2002 and June 2007 with a mean age of 66 years (ranging from 53 to 84 years) were first assessed preoperatively and then at minimum 2 years follow-up, using the Constant score for pain, Constant Shoulder Score, Oxford Shoulder Score, UCLA Shoulder rating scale, DASH Score, Rowe Score for Instability and Oxford Instability Score. 29 patients (Group A) had undergone previous shoulder arthroscopy for cuff tear reconstruction at a mean of 29 months (range 12 to 48 months) before surgery and 39 patients (Group B) underwent primary implantation of an inverted total shoulder prosthesis Delta. Any complications in both groups were assessed according to Goslings and Gouma. Results. We report statistically significant improvements of all obtained scores at a mean follow-up of 42 months (ranging from 24 to 96 months) in both groups. Significant outcome differences between 29 patients with previous shoulder arthroscopy for cuff tear reconstruction and 39 without previous shoulder arthroscopy were not observed. Eight complications occurred altogether, in terms of a nerve lesion once, loosening of the humeral stem three times, and loosening or fracture of the glenoid component four times. Conclusion. We did not detect any statistically significant impact of previous insufficient shoulder arthroscopy for cuff tear reconstruction on the outcome and survival rate after the implantation of the inverted total shoulder prosthesis Delta. We conclude that reverse total shoulder arthroplasty with the Delta prosthesis is significantly beneficial in terms of less shoulder pain, higher stability and gain of range of motion without this beneficial effect being significantly weakened by previous insufficient shoulder arthroscopy for cuff tear reconstruction. We believe that previous arthroscopic cuff tear reconstruction should therefore be included in the treatment algorithm


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 178 - 183
1 Jan 2021
Kubik JF Rollick NC Bear J Diamond O Nguyen JT Kleeblad LJ Wellman DS Helfet DL

Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

Methods

Three observers reviewed 213 bilateral lower limb CT scans of uninjured ankles. Multiple measurements were recorded on the axial CT 1 cm above the plafond: anterior syndesmotic distance; posterior syndesmotic distance; central syndesmotic distance; fibular rotation; and sagittal fibular translation. Previously studied malreduction standards were evaluated on bilateral CT, including differences in: anterior, central and posterior syndesmotic distance; mean syndesmotic distance; fibular rotation; sagittal translational distance; and syndesmotic area. Unilateral CT was used to compare the anterior to posterior syndesmotic distances.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1307 - 1312
1 Oct 2019
Jacxsens M Schmid J Zdravkovic V Jost B Spross C

Aims

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

Patients and Methods

Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up.


The Bone & Joint Journal
Vol. 100-B, Issue 12 | Pages 1618 - 1625
1 Dec 2018
Gill JR Kiliyanpilakkill B Parker MJ

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

Patients and Methods

Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year.


The Bone & Joint Journal
Vol. 100-B, Issue 7 | Pages 973 - 983
1 Jul 2018
Schmal H Froberg L S. Larsen M Südkamp NP Pohlemann T Aghayev E Goodwin Burri K

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

Patients and Methods

The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality.


The Bone & Joint Journal
Vol. 99-B, Issue 1 | Pages 122 - 127
1 Jan 2017
Weinberg DS Narayanan AS Moore TA Vallier HA

Aims

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

Patients and Methods

A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS).


The Bone & Joint Journal
Vol. 98-B, Issue 7 | Pages 1003 - 1008
1 Jul 2016
Fenton P Al-Nammari S Blundell C Davies M

Aims

Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them.

Patients and Methods

We performed a retrospective review of patients with radiologically reported cuboid fractures. Fractures were grouped according to commonly occurring patterns of injury. A total of 192 fractures in 188 patients were included. They were classified into five patterns of injury.


The Bone & Joint Journal
Vol. 96-B, Issue 11 | Pages 1535 - 1539
1 Nov 2014
Tonne BM Kempton LB Lack WD Karunakar MA

The purpose of this study was to describe the radiological characteristics of a previously unreported finding: posterior iliac offset at the sacroiliac joint and to assess its association with pelvic instability as measured by initial displacement and early implant loosening or failure. Radiographs from 42 consecutive patients with a mean age of 42 years (18 to 77; 38 men, four women) and mean follow-up of 38 months (3 to 96) with Anteroposterior Compression II injuries, were retrospectively reviewed. Standardised measurements were recorded for the extent of any diastasis of the pubic symphysis, widening of the sacroiliac joint, static vertical ramus offset and a novel measurement (posterior offset of the ilium at the sacroiliac joint identified on axial CT scan). Pelvic fractures with posterior iliac offset exhibited greater levels of initial displacement of the anterior pelvis (anterior sacroiliac widening, pubic symphysis diastasis and static vertical ramus offset, p < 0.001,0.034 and 0.028, respectively). Pelvic fractures with posterior ilium offset also demonstrated higher rates of implant loosening regardless of fixation method (p = 0.05). Posterior offset of the ilium was found to be a reliable and reproducible measurement with substantial inter-observer agreement (kappa = 0.70). Posterior offset of the ilium on axial CT scan is associated with greater levels of initial pelvic displacement and early implant loosening.

Cite this article: Bone Joint J 2014;96-B:1535–9.


The Bone & Joint Journal
Vol. 96-B, Issue 7 | Pages 978 - 983
1 Jul 2014
Wadsten MÅ Sayed-Noor AS Englund E Buttazzoni GG Sjödén GO

This paper investigates whether cortical comminution and intra-articular involvement can predict displacement in distal radius fractures by using a classification that includes volar comminution as a separate parameter.

A prospective multicentre study involving non-operative treatment of distal radius fractures in 387 patients aged between 15 and 74 years (398 fractures) was conducted. The presence of cortical comminution and intra-articular involvement according to the Buttazzoni classification is described. Minimally displaced fractures were treated with immobilisation in a cast while displaced fractures underwent closed reduction with subsequent immobilisation. Radiographs were obtained after reduction, at 10 to 14 days and after union. The outcome measure was re-displacement or union.

In fractures with volar comminution (Buttazzoni type 4), 96% (53 of 55) displaced. In intra-articular fractures without volar comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106 of 145) displaced while in non-comminuted fractures (Buttazzoni 1), 16 % (13 of 81 ) displaced.

A total of 32% (53 of 165) of initially minimally displaced fractures later displaced. All of the initially displaced volarly comminuted fractures re-displaced. Displacement occurred in 31% (63 of 205) of fractures that were still in good alignment after 10 to 14 days.

Regression analysis showed that volar and dorsal comminution predicted later displacement, while intra-articular involvement did not predict displacement. Volar comminution was the strongest predictor of displacement.

Cite this article: Bone Joint J 2014;96-B:978–83.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 11 | Pages 1469 - 1473
1 Nov 2006
Ekholm R Adami J Tidermark J Hansson K Törnkvist H Ponzer S

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 6 | Pages 829 - 836
1 Jun 2005
Kreder HJ Hanel DP Agel J McKee M Schemitsch EH Trumble TE Stephen D

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups.

During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.