Background. Surgical wound closure is not the surgeon”s favorite part of the total knee arthroplasty (TKA) surgery however it has vital rule in the success of surgery. Knee arthoplasty wounds are known to be more prone to infection, breakdown or delayed healing compared to hip arthroplasty wounds, and this might be explained by the increased tensile force applied on the wound with knee movement. This effect is magnified by the enhanced recovery protocols which aim to obtain high early range of movement. Most of the literature concluded that there is no difference between different closure methods. Objectives. We conducted an independent study comparing the complication rate associated with using barbed suture (Quill-Ethicon), Vicryl Rapide (polyglactins910-Ethicon) and skin staples for wound closure following TKA. Study Design & Methods. Retrospective study where the study group included all the patients admitted to our unit for elective primary knee arthroplasty in 2015, we excluded patients admitted for partial knee arthroplasty, revision knee arthroplasty or arthroplasty for treatment of acute trauma due to the relatively higher complication rates. All the patients notes were reviewed to identify wound related problems such as wound dehiscence, wound infection and delayed healing (defined as delayed wound healing more than 6 weeks). Results. 327 patients were included in this study; 151 in Quill group, 99 in staples group and 77 in the last group where the wound closed with Rapide. We identified 9 (5.9%) cases of wound dehiscence in the Quill group, 3 cases of wound dehiscence in each of other two groups (3.8%) with Rapide and (3%) with staples. On the other hand superficial wound infection was higher with staples with 6 (6%) cases of wound infection compared to the other groups, wound infection occurred in 2 patients (2.5%) with Rapide and 5 patients (3.3%) in the Quill”s group. Most of the delayed wound healing happened after using Quill where it is reported in 5 patients (3.3%) and the lowest was in staples group with 1 patient (1%) and slightly higher percentage in Rapide group 2 patients (2.5%). The total figure of wound related problems was the highest in Quill”s group with 19 reported cases (12.5%), lower in staples” group with 10 cases (1.1%) and the lowest in Rapide”s group with 7 cases (9%). Conclusions. Our study showed different results to the reported literature suggesting that each closure method has its own advantages and disadvantages. Quill is quick, knotless and absorbable but on the other side it is significantly more expensive than other alternatives and it is associated with the highest complication rates. On the other hand Rapide is cheap absorbable alternative with the lowest percentage of wound problems but on the negative side it is time consuming. Finally staples method is the quickest, relatively cheap and rarely associated with wound dehiscence but it is not absorbable which might cause inconvenience to patients

Introduction. Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications. Methods. Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were offered postoperative slab/cast and this was continued for six weeks. The remaining 22 patients were not offered any plaster. All patients were followed-up for two years. Results. The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p = 0.02). Also, significantly lower heel widening was reported in the plaster group (p = 0.03). Although, there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusion. Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures

Blood management protocols attempt to reduce blood loss by strategies including autologous blood donation, red cell salvage, normovolaemic haemodilution and haemostatic agents such as tranexamic acid (TXA). TXA usage in particular has become increasingly commonplace with numerous studies demonstrating a significant reduction in peri-operative blood loss and proportion of patients requiring transfusion, without increasing the risk of venous thromboembolism. Tourniquet usage has now become ubiquitous in TKA operations with reported benefits of improved visualization, shorter operative time and decreased intra-operative bleeding. However, its use is not without considerable complications including wounding dehiscence, increased venous thromboembolism, superficial wound infection and skin blistering. It is therefore imperative that we review tourniquet usage in light of ever evolving blood management strategies. The aim of this study was to evaluate the effect of stopping tourniquet usage in primary TKRs, performed by an experienced surgeon, in light of new blood reduction measures, such as a TXA. A retrospective analysis identified a total of 31 patients who underwent primary TKR without the use of a tourniquet from January 2018 to March 2019. This was compared to an earlier group of patients from the same surgeon undergoing TKR with the use of a tourniquet; dating from July 2016 to November 2017. All surgeries were performed within the same hospital (CXH). Peri-operative factors and outcome measures were collected for analysis. There was no significant difference in post-operative haemoglobin drop (Tourniquet, 23.1 g/L; No Tourniquet, 24.4 g/: p=0.604) and fall in haematocrit (Tourniquet, 0.082; No Tourniquet, 0.087: p=0.604). Allogenic blood transfusion rates were the same in both groups at 12.9% (2 patients) and blood loss was not found to be significantly different (Tourniquet, 1067ml; No tourniquet, 1058mls). No significant difference was found in operative time (Tourniquet, 103 minutes; No Tourniquet, 111.7 minutes: p=0.152) or length of stay (Tourniquet, 5.5 days; No Tourniquet, 5.2 days: p=0.516). Tranexamic acid usage was not found to be significant (p=1.000). ROM of motion and analgesia requirement was significantly better in the no tourniquet group on one post-operative day out of five analysed (p=0.025, p=00.011). No post-operative thromboembolic events were reported in either group. There was no significant difference in readmission rates (p=0.492) or complications (p=0.238). The increase in minor complications and potential increased VTE risk with tourniquet usage must be balanced against an improved visual field and reduced blood loss in TKR patients. Our study found no difference in post-operative blood loss and transfusion rates between tourniquet and no tourniquet groups. With ever evolving and improving blood loss management strategies, including the use of TXA, the application of tourniquet may not be needed. Further prospective RCTs are needed to assess the impact of tourniquet usage in light of this

A suitable wound closure is an indispensable requirement for an uncomplicated and expedient recovery after an abdominal surgery. The closure technique will have a great impact on the healing process of the wound. Surgical complications, such as wound dehiscence (sometimes associated with evisceration), infection, hernia, nerve injury and incisional pain are very common in the postoperative period of an abdominal surgery. Besides, although their development can be promoted by other risk factors like age, sex, lifestyle, diet, health condition, the closure method can also influence the emergence of these undesirable complications. For this reason, and having the wellbeing and quality of life of the patients in mind, particularly high-risk patients, a closure system consisting of anchors applied on either side of the wound that aims to reduce the tension caused on the surrounding tissues of a wound and, consequently, decrease the risk of herniation was evaluated in a pilot animal study and compared with the traditional suture approach

Orthopaedic surgical site infections (SSI's) prolong total hospital stays by a median of 2 weeks per patient, approximately double re-hospitalization rates, and increase healthcare costs by more than 300%. Patients with orthopaedic SSI's have significant reductions in their health-related quality of life. We performed a systematic review and meta-analysis to compare differences in outcomes between use of sutures and non-absorbable staples for closure of orthopaedic surgical wounds in adults. The primary outcomes were rates of superficial and deep SSI. Secondary outcomes included wound dehiscence, length of hospital stay, patient satisfaction and pain during removal of closure material. Data sources including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, . clinicaltrials.gov. , National Institute for Health and Research, UK clinical trials gateway were searched for randomised controlled trials (RCT's) meeting inclusion criteria. Sixteen RCT's published between 1987 and 2017 were included. Overall, wound infection outcomes (superficial and deep infections combined) showed no statistically significant difference between closure with staples compared with sutures with arelative risk of 1.17 (95% CI 0.59–2.30, p=0.66). A subgroup was performed specific to hip wound infection outcomes. Interestingly, a sensitivity analysis demonstrated sutures to be statistically favourable (p=0.04) in terms of hip wound infection outcomes. There was no statistically significant difference among secondary outcomes between sutures and staple groups. Overall it appears the choice of sutures or staples in closure of orthopaedic wounds has no effect on wound complications. However, caution is needed in applying the findings to different population groups due to heterogeneity across studies

The incidence of wound complications after a hip or a knee replacement is well established, but there is no such data about foot/ankle surgery. Without this data it is difficult to compare performance between different care-providers. It is also difficult to benchmark services that could potentially be provided by a wide range of care providers (chiropodists, podiatrists, podiatric surgeons, general orthopaedic surgeons with a small foot/ankle practice, etc). Our aim was to establish the incidence of wound complications after foot/ankle surgery and provide a baseline for future comparison. Our study was done in two parts. First part was to conduct an opinion-survey of BOFAS members with a substantial foot/ankle practice, on wound complications from foot/ankle surgery in their own practice. Second part was to conduct a prospective study on the incidence of wound complications from our own foot/ankle practice. The study was registered as an audit and did not require ethical approval. All wound complications (skin necrosis, wound dehiscence, superficial and deep infections) were recorded prospectively. Record of such data was obtained by an independent observer, and from multiple sources, to avoid under-reporting. 60 % of the responders to our survey had a predominant foot/ankle practice (exclusive or at least 75 % of their practice was foot/ankle surgery) and were included for further analysis of their responses. A large majority of these responders (64%) reported a rate of 2–5 % for superficial infection, and a significant majority (86 %) reported a deep infection rate of less than 2 %. Results from our own practice showed an incidence of superficial infection of 2.8 % and deep infection of 1.5 %. With increasing focus on clinical outcome measures as an indicator of quality, it is imperative to publish data on wound complications/ infection after foot/ankle surgery, and in the absence of such data, our two-armed study (survey-opinion and prospective audit) provides a useful benchmark for future comparisons

Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we did a postal questionnaire survey to determine the current practice and trend among knee surgeons throughout the United Kingdom. A postal questionnaire was sent out to 100 knee surgeons registered with British Association of Knee Surgeons ensuring that the whole of United Kingdom was well represented. The questions among others included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. We received 82 responses. 46.3% of the respondents performed MUA routinely, 42.6% sometimes, and 10.9% never. Majority (71.2%) performed MUA within 3 months of the index procedure. 67.5% routinely used CPM post-manipulation while 7.3% of the respondents applied splints or serial cast post MUA. 41.5% of the surgeons routinely used Patient Controlled Analgaesia +/− Regional blocks. Majority (54.8%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion that can be achieved which is determined by more dominant factors such as preoperative flexion and diagnosis. Manipulation should be reserved for the patient who has difficult and painful flexion in the early postoperative period

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use. All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery. Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed). In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010

We investigated the effect of mitomycin-C on the reduction of the formation of peritendinous fibrous adhesions after tendon repair. In 20 Wistar albino rats the tendo Achillis was cut and repaired using a modified Kessler technique. The rats were divided into two equal groups. In group 1, an injection of mitomycin-C was placed between the tendon and skin of the right leg. In group 2, an identical volume of sterile normal saline was injected on the left side in a similar fashion. All the rats received mitomycin-C or saline for four weeks starting from the day of operation. The animals were killed after 30 days. The formation of peritendinous fibrous tissue, the inflammatory reaction and tendon healing were evaluated. The tensile strength of the repaired tendons was measured biomechanically. Microscopic evidence of the formation of adhesions and inflammation was less in group 1. There was no significant difference in the tensile load required to rupture the repaired tendons in the two groups.

Mitomycin-C may therefore provide a simple and inexpensive means of preventing of post-operative adhesions.

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7).

Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used.

Significantly more fractures had healed by 16 (p = 0.039) and 20 weeks (p = 0.022) in the BMP group compared with the matched group. The mean time to union (p = 0.002), the duration of absence from work (p = 0.018) and the time for which external fixation was required (p = 0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group.

RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation.