Introduction. Skin closure methods are various in total knee arthroplasty (TKA). Subcuticular skin closure techniques, which do not require postoperative stitch removal, are considered to be useful for excellent cosmesis and patients' satisfaction. Basically, subcuticular skin closure provides the tightness and water-tight seal, which leads to loss of postoperative normal physiologic drainage. As a routine wound closure, we performed the subcuticular skin closure with use of absorbable sutures or barbed sutures without staples. According to some previous reports, subcuticular skin closure using barbed sutures resulted in worse clinical outcomes, comparing with conventional skin staples. However, little attention has been paid to the differences between conventional absorbable and barbed sutures in both capsular and subcuticular skin closures. Our purpose was to investigate the efficacy and safety of the barbed suture, comparing to conventional absorbable sutures in TKA. Methods. A total of 81 knees in 75 patients (60 females and 15 males) were enrolled in the current investigation. Mean age was 73 (58–89) years old. All the subjects underwent unilateral or staged bilateral TKA using Balanced Knee System, posterior stabilized design (Ortho Development, Draper, UT). All knees were divided into two groups, as presented in Table 1. In conventional group, capsule was repaired using interrupted number 1 braided absorbable sutures, followed by closure of subdermal layer using a 3-0 monofilament absorbable suture with inverted interrupted knots. Thereafter, subcuticular skin closure was done using 4-0 monofilament absorbable suture, followed by adhesive tape. On the other hand, in barbed suture group, 1-0 and 4-0 unidirectional barbed suture (V-Loc, Covidien, Mansfield, Massachusetts) was used for capsule and subcuticular skin closure, respectively. Drains were removed on postoperative day 2. We evaluated closure time from capsule to skin, range of motion (ROM), Hollander Wound Evaluation Score (HWES: maximum score 6/6), and complications. Postoperative ROM and HWES were evaluated on postoperative day 14. As a statistical analysis, the data was compared between groups using Mann-Whitney U-test and Fisher exact probability test. P-values of < 0.05 were considered as significant. Results. 20 knees were allocated to conventional group and 61 knees were allocated to barbed suture group. Preoperative patients' demographics were seen in Table 2. No significant differences were found between groups preoperatively. In terms of clinical results, surgical closure time was significantly fast in barbed suture group, while postoperative range of motion and HWES were not significantly different between groups. In each group, wound related complication was not found. Discussion. According to previous reports, V-Loc provided worse clinical outcomes in wound related complications. However, in the current investigation, barbed suture was safe in wound cosmesis and effective in surgical closure time, comparing to conventional closure. We considered that barbed suture would be safe and effective as a closure method in TKA

Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Introduction. Joint reconstruction remains a successful and popular surgery with advances in approaches, implants and techniques continually forthcoming. Various methods of skin closure exist to address issues in efficiency, aesthetics, and barrier to infection. While subcuticular skin closure techniques offer an aesthetic advantage to conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-loc absorbable suture, theoretically distribute tension evenly through the wound and help decrease knot-related complications. To our knowledge, no literature exists on the rate of wound complications in joint arthroplasty with the use of V-loc suture for skin closure. We hypothesize that despite theoretical gains, skin closure with a V-loc (Covidien, Mansfield, MA) absorbable suture should be performed with caution. Methods & Materials. A retrospective chart review was conducted of 278 consecutive primary joint reconstruction cases performed by a single surgeon in 12 months from July 2009 through June 2010. Pre-operative history & physical reports were evaluated for co-morbidities (i.e diabetes mellitus), smoking status and body mass index (BMI). Operative dictations by the attending surgeon provided information on the surgical procedure, use of drain, wound closure technique and type of suture/staple used for skin closure. Skin was closed by the primary surgeon and his chief resident. Wounds were closed via staple gun or subcuticular stitch (3-0 Biosyn vs V-Loc) in a consecutive manner, depending on the surgeon's preference in that period. Post-operative clinic notes were reviewed to determine the occurrence of wound complications, issuance of antibiotic prescriptions, or return to the operating room. The cohort consisted of 106 males and 161 females at an average age of 63 years (range: 18–92). Overall, there were 153 procedures at the knee (including TKA, uni-compartmental arthroplasty, patello-femoral arthroplasty) and 125 procedures at the hip (including THA and hemi-arthroplasty). Results. In review of 278 consecutive primary joint reconstruction cases, there were 17 (6.1%) post-operative wound complications noted, including cellulitis, stitch abscesses, wound dehiscence, and deeper infections requiring OR irrigation and debridement. In 181 cases, staples were used for skin closure; in these cases, seven wound complications were noted (7/181, 3.9%). In 49 cases closed via a subcuticular Biosyn suture there were 4 wound complications noted (4/49, 8.1%). Six wound complications occurred in cases closed with a V-loc suture (6/45, 13.3%). Discussion. Aesthetics and efficiency often are the driving forces of innovation. We present the rate of wound complications in various superficial wound closure methods, including the V-loc, an innovative absorbable barbed suture. Based on our clinical experience, we promote consideration of wound and infectious complications when choosing a method of skin closure in joint reconstruction procedures

Isolated rupture of short head of biceps is a rare injury. There have been no published reports of rupture at the musculotendinous junction. We report two cases of complete rupture of the musculotendinous junction of the short head of biceps in young males both occurring during water skiing. Two males sustained water skiing injuries where the handle was forced against the flexor region of the arm. Whilst trying to adduct and flex the extended arm, they both sustained complete musculotendinous ruptured of their short head of biceps. Both underwent pre-operative magnetic resonance imaging and one underwent isokinetic strength testing of elbow flexion and supination. Surgical repair was performed using absorbable sutures. One patient had the short head muscle belly flipped distally to lie in a subcutaneous plane in front of the elbow. Post-operative management included cast immobilisation for three weeks then gentle range of motion exercises. Both patients recovered their full range of motion in the arm. There were no complications. Post-operative strength testing was performed and will be presented. This is a unique series of complete musculotendinous rupture of the short head of biceps. The mechanism of injury was resisted adduction and flexion against the towrope handle with the arm in extension. These ruptures occurred in high impact high velocity accidents. Surgical repair lead to an excellent outcome

A seventy-five-year-old female patient presented with pain and deformity of her left leg of three days duration. Hybrid THRA has been done 11 years ago at her left hip for the treatment of osteoarthritis. Massive osteolysis and pathologic fracture were observed on plain radiograph (Fig. 1). Revision THRA using an allograft prosthesis composite (APC) was planned for solution of extensive bone loss of the proximal femur. Surgical exposure was performed through extended trochanteric osteotomy with the patient supine. Step-cut osteotomy was done at the remained proximal part of host femur to make match with the distal part of APC. Meticulous removal of granulation tissues and remaining cement was done. As Acetabular cup was stable, 60 mm sized high-walled polyethylene liner was exchanged. Calcar reconstruction prosthesis was cemented into a proximal femoral allograft measuring 15 cm and cement at the vicinity of the step-cut osteotomy was removed for later bony union at interface. After solid fixation of APC with cement, the distal half of APC was cemented with the host femur. Step-cut osteotomy was wired and autogenous bone grafts from the greater trochanter were added at the interface. Leg length and stability were rechecked using a standard necked 28 mm metal head and reduction was done stably. Greater trochanter was fixed over the trimmed proximal allograft with multiple wiring and paper-thin host femur was enveloped around the femoral allograft using absorbable sutures. Following insertion of the closed suction drainage drains, closure was done as routine fashion and healing of the wound was uneventful (Fig. 2). An abduction brace was applied post operatively for a period of four weeks. Crutch walking with partial weight bearing was started at four weeks and crutch protection was applied for a period of six months. Incorporation of allograft with the host bone was observed on two-year follow-up radiographs. At seven-year follow-up, the patient walks well with a mild limp, and Harris score is 90. We report on a seven-year follow-up case of revision THRA with APC with references (Fig. 3)

Introduction:. Purpose of mini-invasive hip arthroplasty, is least damage to skin and muscles. Unlike Roettinger modification to Watson-Jones, our approach requires no special table or instruments. Besides, direction of skin incision is perpendicular to interval between glutei and tensor muscles, thus called a Crisscross Approach. Incision is at direction of retractors causing less skin damage; and parallel to femur allowing expansion. No tendon or muscles are severed achieving a true inter-muscular non invasive approach. Unlike anterior approach, femoral circumflex vessels and lateral femoral cutaneous nerve are spared. Material and Methods:. 240 prospective patients underwent mini-invasive crisscross technique since December 2006. A standard non-cemented hip was implanted. Previously disrupted hip muscles patients were excluded. In the operating room, patients were secured in a lateral decubitus position with the pelvis flexed at 20°–30° to allow operated leg to extend beyond the table to be placed in a standard plastic bag. The anterior superior iliac spine (ASIS), the greater trochanter (GT) and its tubercle are identified and marked. A line is drawn between ASIS and GT tubercle representing the interval between the glutei and the tensor fascia lata muscles. Another line representing the skin incision is drawn perpendicular. It may be curved a little toward the femur starting two inches inferior and posterior to ipsilateral ASIS extending distally for 3 inches or more for obese or muscular patients. The Crisscross Approach starts with a skin incision being made as above and through the subcutaneous fat identifying the inter-muscular interval between the glutei and the tensor fascia lata. Sharp dissection is made in the connecting fascia only and blunt dissection is needed to separate the two muscles. A branch of the superior gluteal nerve proximally crossing from the glutei to the tensor fascia lata may be encountered but it should not be disturbed as long as blunt dissection is maintained. Curved retractors are placed one above and the other below the femoral neck exposing the anterior capsule. Incision is made in the capsule and the retractors are re-placed to better expose the femoral neck. The appropriate level of neck is osteotomized and the head is extracted as routine. Acetabulum is further exposed by placing the curved retractors at about mid anterior and mid posterior. The final appropriate cup size and orientation is implanted routinely. Before exposing the femoral canal the deep fascia at the junction of the glutei and the vastus lateralis should be incised (about 2–3 inches). This will tremendously help femoral canal exposure. Then the surgeon is positioned anterior, the patient is made fully paralyzed and the table is tilted 20°–30° posteriorly (away from the surgeon). Hip extended 20°–30°, externally rotated to 80°–90° and adducted with a retractor underneath femoral neck and a curved one on greater trochanter to protect the glutei. Leg is allowed to drop in a bag (posteriorly). Canal finder is helpful to avoid going through the cortex Broaching or reaming and final implant insertion as routine. Posterior capsule need not be disturbed; however, the superior and inferior capsule should be detached from the neck to allow better exposure of the femoral canal. Closure starts with one or two stitches in the remainder of the capsule. Then suture deep fascia at the junction of glutei and vastus lateralis with absorbable suture. Finally, subcutaneous fat and skin are closed as routine. Results:. There was no major neurovascular damage or complications related to this exposure. Follow up to a maximum of 75 months revealed no deep infection and no dislocation or fracture. We undersized three stems at the beginning but that did not require re-operation. Surgery time averaged 15 minutes longer but that was reduced as we gained experience. Cup position was navigated and postoperative CT scan confirmed satisfactory cup and stem position. One case that had an undersized prosthesis settling to about half an inch short which required a 3/8 inch insole for the patient to wear. Rehab goals were met after 4–6 sessions in all patients. Patients were allowed to go home on two crutches in 2–3 days. Full weight bearing was allowed in 2–4 weeks. No limping noted at 3 months follow up. Discussion:. Crisscross approach differs by transecting no tendon or muscles, requiring no special table or instruments with incision parallel to femur facilitating expansion and reducing skin damage resulting in true non-invasive approach

Operative repair of tendo Achilles ruptures is associated with a lower re-rupture rate. A medial approach is made and the tendon ends debrided. The tendon is repaired with two non-absorbable core sutures and an absorbable perimeter suture, with care to avoid any lengthening of the musculotendinous unit. The tendon sheath is repaired, with a deep fascial releasing incision to allow apposition of the edges if necessary. In the case of insertional avulsions, the avulsed bony fragment is excised and the tendon repaired to bone with a 3.5 mm corkscrew anchor and non-absorbable suture. A frontslab is applied with the ankle in gravitational equinus and worn for eight weeks with protected weight bearing. Sutures are removed at 10 to 14 days and active range of motion commenced. At eight weeks, weight bearing as tolerated is allowed with a heel raise and physiotherapy for calf strenghthening is commenced. Recovery of full strength will take one year

Aims

COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the ‘hotspots’ in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19.

Aim

The coronavirus disease 2019 (COVID-19) pandemic presents significant challenges to healthcare systems globally. Orthopaedic surgeons are at risk of contracting COVID-19 due to their close contact with patients in both outpatient and theatre environments. The aim of this review was to perform a literature review, including articles of other coronaviruses, to formulate guidelines for orthopaedic healthcare staff.

An extensive review of the spinal and arthroplasty literature was undertaken to evaluate the effectiveness of local antibiotic irrigation during surgery. The efficacy of antibiotic irrigation for the prevention of acute post-operative infection after total joint arthroplasty was evaluated retrospectively in 2293 arthroplasties (1990 patients) between January 2004 and December 2013. The mean follow-up was 73 months (20 to 139). One surgeon performed all the procedures with minimal post-operative infection.

The intra-operative protocol included an irrigation solution of normal saline with vancomycin 1000 mg/l and polymyxin 250 000 units/l at the rate of 2 l per hour. No patient required re-admission for primary infection or further antibiotic treatment. Two morbidly obese patients (two total hip arthroplasties) developed subcutaneous fat necrosis requiring debridement and one was revised because the deep capsular sutures were contaminated by the draining subcutaneous haematoma. One patient who had undergone total knee arthroplasty had unrecognised damage to the lateral superior geniculate artery and developed a haematoma that became infected secondarily four months after the surgery and underwent revision.

The use of antibiotic irrigation during arthroplasty surgery has been highly effective for the prevention of infection in the author’s practice. However, it should be understood that any routine prophylactic use of antibiotics may result in resistant organisms, and the wise stewardship of the use of antibiotics is an important part of surgical practice.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):23–6.

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results.

Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.