Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review.

A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information.

30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1.

Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve.

Introduction. Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS). Materials & Methods. The telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires. Results. Baseline data collected from April 2019 to April 2021 showed that our median LOS for patients undergoing external fixation was 6 days with 36% of patients being discharged at day 4 or earlier. After implementation of telemedicine, median LOS reduced to 4 days with 50% of patients leaving hospital in 4 days or less. Service user responses demonstrated that 100% felt that sufficient information was provided by the CNS team, a mean score of 8.4/10 was reported when asked how confident they were when adjusting the fixator. When asked how the service could be improved access to a recorded video was suggested. Conclusions. Initial fixator adjustment support via telemedicine is not appropriate for all of our patient group due to a lack of access or co-morbidities/ social issues that necessitate a prolonged hospital stay. However, this project has demonstrated that it has had positive long-term benefits within our service through reducing our median length of stay by 2 days without compromising patient satisfaction with their care

Aims. The COVID-19 pandemic has triggered transformative change in how clinicians interact with their patients. There has been a shift away from face-to-face toward virtual consultations. However, the evidence to support this change in practice is unclear. The aim of this study was to systematically review the evidence base for virtual consultations for orthopaedics. Materials and Methods. Two independent reviewers performed a literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and Scopus databases. Only studies reporting outcomes following the use of telemedicine for diagnosis, consultation, rehabilitation, and follow-up were included. Outcomes analyzed were: 1) Patient and clinician satisfaction, 2) Clinical outcome measures, and 3) Cost analysis of traditional vs teleconsultation. Results. A total of 41 studies were included. Fifteen studies compared clinical outcomes of telemedicine against a matched traditional cohort. Of these 15 studies, two demonstrated non-inferiority, nine showed no statistically significant difference and four found telemedicine to be superior. Eleven studies recorded patient reported outcomes, which demonstrated high patient satisfaction. Nine studies reported decreased costs when telemedicine was compared to traditional care. The remaining 6 studies had varied aims and methodologies that didn't fit well with any of these sub-headings. Conclusion. While the available evidence is limited, the studies assessed in this systematic review show that telemedicine can deliver high quality healthcare with good clinical outcomes and high patient satisfaction in a cost effective manner. Further studies are required to validate telemedicine for specific trauma and orthopaedic diagnoses

Introduction. Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates. Materials & Methods. Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome. Results. 175 patients were included in the final analysis, 70 in the dynamised and 103 in the not dynamised groups, median follow-up was 33 months. 3 patients in the dynamised group failed dynamisation and had their period of fixation extended, subsequently having their frames removed without complication. Two patients suffered a refracture or non-union after frame removal in the dynamised group and none in the not dynamised group, this difference was not statistically significant. Conclusions. In our practice, selective frame removal without a period of dynamisation appears safe. This has the potential to shorten frame time and reduce the number of clinic appointments and radiographic investigations for these patients. Some patients find the period of dynamisation uncomfortable and associated with pin site infection, which can be avoided. We plan to continue this practice and collect further data to confirm these findings in a larger dataset

Introduction. Mode of non-operative management of thoracolumbar spine fracture continues to remain controversial with the most common modality hinging on bracing. TLSO is the device with a relative extension locked position, and many authors suggest they may have a role in the healing process, diminishing the load transferred via the anterior column, limiting segmental motion, and helping in pain control. However, several studies have shown prolonged use of brace may lead to skin breakdown, diminished pulmonary capacity, weakness of paraspinal musculature with no difference in pain and functional outcomes between patients treated with or without brace. Aims. To identify number of spinal braces used for spinal injury and cost implications (in a DGH), to identify the impact on length of stay, to ascertain patient compliance and quality of patient information provided for brace usage, reflect whether we need to change our practice on TLSO brace use. Methods. Data collected over 18-month period (from Jan.2020 to July 2021). Patients were identified from the TLSO brace issue list of the orthotic department, imaging (X-rays, CT, MRI scans) reviewed to confirm fracture and records reviewed to confirm neurology and non-operative management. Patient feedback was obtained via post or telephone consultation. Inclusion criteria- patients with single or multi -level thoracolumbar osteoporotic or traumatic fractures with no neurological involvement treated in a TLSO brace. Exclusion criteria- neurological involvement, cervical spine injuries, decision to treat surgically, concomitant bony injuries. Results. 72 braces were issued in the time frame with 42 patients remaining in the study based on the inclusion/exclusion criteria. Patient feedback reflected that 62% patients did not receive adequate advice for brace usage, 73% came off the brace earlier than advised, and 60% would prefer to be treated without a brace if given a choice. The average increase in length of stay was 3 days awaiting brace fitting and delivery. The average total cost burden on the NHS was £127,500 (lower estimate) due to brace usage. Conclusion. If there is equivalence between treatment with/without a brace, there is a need to rethink the practice of prescribing brace for all non-operatively treated fractures and a case-by-case approach may prove more beneficial

Aim. Swedish guidelines on antibiotic prophylaxis in arthroplasty surgery recommend cloxacillin in fixed doses that pay little attention to the patient's renal function and weight. Nevertheless, there are no studies on whether the resulting free prophylactic cloxacillin in vivo concentrations are optimal. We aimed to evaluate whether the current recommended prophylactic dosage of cloxacillin is adequate. Method. We performed a prospective two-centre study, measuring the free (active) cloxacillin concentrations in plasma throughout surgery, in patients subject to primary hip and knee prosthetic joint replacements, aiming at 100 patients per centre. To account for plasma-bone exposure differences, concentrations were considered adequate if twice the epidemiological cut-off value for cloxacillin concerning wild type Staphylococcus aureus whereas two-three times were labelled threshold values. The two enrolling hospitals are acute care hospitals in central Sweden, also performing 600 - 1200 primary hip and knee joint arthroplasties annually. All patients scheduled for elective primary hip or knee replacements from January 2022 to April 2024 were eligible for participation. Exclusion criteria were allergy towards penicillins, cognitive disorders leading to inability to sign informed consent, and an absence of interpreter in case of a patient not speaking Swedish or English. Results. We present results from the first 49 patients included. Four patients had free cloxacillin concentrations below cut-off (8.2%). These four cases had prolonged surgeries of 77-100 minutes. An additional 5/49 (10.2%) had threshold values. Conversely 5/49 (10.2%) cases had concentrations exceeding 15 times the needed. No cases with threshold or low cloxacillin concentrations were attributable to a lack of concerning timing and dosing of cloxacillin. All concentrations were above or equal to our cut-off at the start of surgery. Eighteen percent of patients were of normal of weight (BMI 18.5- 25). Of the rest 4% were morbidly obese (BMI >40), 41% obese (BMI 30-40) and 37% overweight (BMI 25-30). Twenty seven percent (43/159) had diabetes and 45% suffered cardiac disease. Conclusions. Some patients in our cohort had insufficient active cloxacillin levels at the end of prosthetic joint surgery. Previous studies indicate that insufficient prophylactic antibiotic concentrations might lead to an enhanced risk of prosthetic joint infections. Other patients were massively overdosed, leading to unnecessary ecological effects and potentially adverse reactions. As inadequate cloxacillin concentrations were not associated with a lack of compliance to current guidelines a change in practise might be needed. Our final results may help to determine how dosing should be adjusted

Aims. In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery. Methods. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”. Results. A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training. Conclusion. Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640

We report decreased clinical VTE rates following increased use of mechanical prophylaxis in elective kip and knee arthroplasty. Usage of intermittent pneumatic compression (IPC) increased due to the increased availability of pump machinery. Timing of IPC use also changed with IPC used intraoperatively on the unoperated limb and for a longer period postoperatively Clinical VTE rates are assessed for two years prior to the change in practice (1140 procedures) and two years afterwards (1285 procedures). There was no other change in practice (chemical thromboprophylaxis, anesthetic technique, use of compression stockings, usage of tourniquet or usage of cement) or in patient profile. Overall clinical VTE rates during admission dropped from 2.98% to 0.62% (p<0.0001). This decrease was seen in both hips 1.77% to 0.2% (p=0.029) and knees 3.97% to 0.89% (p=0.0002). There was a decrease in both pulmonary emboli 1.14% to 0.16% (p=0.0043) and symptomatic DVT 1.84% TO 0.47% (p=0.0023). There was no change in the rate of post discharge VTE events recorded 1.07% (p=0.57), either for DVT or PE (P=0.74 for each). We conclude that IPC with non-sequential calf compression is effective in reducing the rates of clinical in-hospital VTE after elective hip and knee arthroplasty

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. Methods. Adapting to the crisis locally involved five operational elements: 1) triaging and workflow of orthopaedic patients; 2) operation theatre feasibility and functioning; 3) conservation of human resources and management of workforce in the department; 4) speciality training and progression; and 5) developing an exit strategy to resume elective work. Two hospitals under our trust were redesignated based on the treatment of COVID-19 patients. Registrar/consultant led telehealth reviews were carried out for early postoperative patients. Workflows for the management of outpatient care and inpatient care were created. We looked into the development of a dedicated operating space to perform the emergency orthopaedic surgeries without symptoms of COVID-19. Between March 23 and April 23, 2020, we have surgically treated 133 patients across both our hospitals in our trust. This mainly included hip fractures and fractures/infection affecting the hand. Conclusion. The COVID-19 pandemic is not the first disease outbreak affecting the UK, nor will it be the last. The current crisis has necessitated rapid development of new hospital guidelines and early adaptive strategies in our services. Protocols and directives need to be formalized keeping in mind that COVID-19 will have a long and protracted course until a definitive cure is discovered

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates. The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates. There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection. The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces

Assessing risk is a key skill for all surgeons, playing a vital role in such diverse settings informed consent, audit and surgical planning. We undertook this study to define what is an acceptable level of risk for orthopaedic surgeons undertaking lower limb arthroplasty in today's medicolegal climate. We surveyed all consultants and trainees registered with the NZOA and asked them what change in their complication rate would cause them to consider changing their practice. We also asked them how certain they would have to be that this change was real and not simply due to chance (the so-called “cluster effect”). The specific complications we considered were DVT/PE, dislocation of total hip replacement or deep infection in lower limb arthroplasty patients. This allowed us to calculate with 95% accuracy the levels of complication surgeons would deem unacceptable. Using Cochrane's criteria for statistically valid survey results we obtained a greater than 95% representative sample. From these responses we calculated levels of complication which would worry the “average” surgeon (median value), the “vast majority” (95%) of surgeons and a change in complication rate which would be required to satisfy “statistical significance” (i.e. the level set literature proof with p<0.05 and power of 0.8). When considering deep infection following hip or knee arthroplasty: using a baseline of 0.9% as an average published rate, the average surgeon would consider changing their practice if their rate reached 2.5% and 95% of surgeons would consider changing if their rate reached 5%. For hip dislocation the baseline was set at 2.5% with the average surgeon intervening if their rate rose to 4% and the vast majority of surgeons intervening at 10%. For fatal PE the baseline was given as 0.2% with the average surgeon auditing their practice at 0.8% and the vast majority of surgeons concerned with a rate of 2.2% or higher. No difference was found in consultant/trainee responses except in the reason given for use of thromboprophylaxis where consultants used it for prevention of fatal PE and registrars for non-fatal PE. These results could be used both as a potential guide for trainees and consultants in audit and also in guiding the use of, for instance, thromboprophylaxis where the “number needed to treat” for low molecular weight heparin to prevent one fatal pulmonary embolus in a year would necessitate national use/guidelines

Aim. Deep infection following endoprosthetic replacement (EPR) of long bones is a devastating complication occurring in 15% of musculoskeletal tumour patients. The recently published PARITY Trial demonstrated that extending antibiotic prophylaxis from 24 hours to 5 days does not reduce infection rates. However, questions remain about the optimal antibiotic choice and dose. Method. A 23-question multiple-choice questionnaire was designed and piloted through an iterative feedback process until the final version was agreed by all authors. Open and closed-ended questions were used to gather information on practice and Likert-type scale responses were used to grade responses to ascertain surgeon perceptions and preferences. The online survey was sent to all surgeon delegates of the 34th Annual Meeting of the European Musculo-Skeletal Oncology Society in London in October 2022. Results. Amongst 61 respondents, 43 were based in Europe and 18 outside of Europe. The majority (48/61) had been in clinical practice over 11 years. Antibiotic choice. 1st or 2nd generation cephalosporins were the first line choice practiced among 49 (80.3%) of respondents. Of these, 39 responded had a 2nd line protocol for beta-lactam allergy which was most commonly clindamycin (18), vancomycin (11) or a combination of a glycopeptide or clindamycin plus gentamicin (4). Respondents changed their first line regimen for radiotherapy in 6/61, chemotherapy in 8/61 and tumour site in 20/61. Re-dosing. Intraoperative re-dosing intervals of 1st and 2nd generation cephalosporins ranged from 2 to 8 hourly. Re-dosing for blood loss ranged from never to when 2 litres was lost. Of the 47 respondents, 24 said intraoperative re-dosing is always reliably administered. Duration. Six (10%) of 61 respondent routinely cover the intraoperative period only, whereas 30 (49%) give 24 hours, 16 (give 48 hours or longer and 8 continue until surgical drains are removed. 31 of 61 change duration depending on clinical situation. The most common reasons for changing were patient risk factors, soft tissue status and previous radiotherapy. 57/61 surgeons were aware of the PARITY Trial. When these respondents were asked whether they had changed practice based on PARITY, 12 said yes, 24 said no and 21 said they always give 24 hours anyway. Conclusions. Amongst an international cohort of orthopaedic oncology surgeons there was a wide variation in practice. Further research should focus on the optimum choice and re-dosing strategy, which have not been defined

Ten RCTs published between 2000 and 2013 support treating distal radius buckle fractures and other low-risk distal radius fractures with a removable splint and with no orthopaedic follow-up. Application of this evidence has been shown to be variable and suboptimal resulting in unnecessary costs to a strained healthcare system. The Canadian evidence on this topic has been generated by subspecialist physicians working in paediatric hospitals. It is unclear what factors affect the dissemination of this information. We investigated the association of hospital type and physician type with the application of best-evidence treatment for low-risk distal radius fractures in children with the goal of improving our understanding of evidence diffusion in Ontario for this common injury. We performed a retrospective population-based cohort study using linked health care administrative data. We identified all children aged 2–14 treated in Ontario emergency departments from 2003–2015 with distal radius fractures with no reduction and no operation within a six week period. We excluded refractures and children with comorbidities. We evaluated the followup received – orthopaedic, general practitioner, or none. We examined the data for trends over time. Multivariable log binomial regression was used to quantify associations between hospital and physician type and best-evidence treatment. We adjusted for patient-related variables including age, sex, rural or urban location, and socioeconomic status. 70,801 fractures were analyzed. Best-evidence treatment was more likely to occur in a small (RR 1.86, 95%CI 1.72–2.01), paediatric (RR 1.16, 95%CI 1.07–1.26), or community (RR 1.13, 95%CI 1.06–1.20) hospital compared with treatment in a teaching hospital. Best-evidence treatment was more likely if initial management was by a paediatrician with additional emergency medicine training (RR 1.73, 95%CI 1.56–1.92) or paediatrician (RR 1.22, 95%CI 1.11–1.34). Paediatric and teaching hospitals have improved their use of best-evidence over time while other hospital types have stagnated or deteriorated. Paediatricians, paediatricians with additional emergency medicine training, and emergency medicine residency trained physicians have improved their use of best-evidence over time, while other physician types have stagnated or deteriorated. Overall, only 20% of patients received best-evidence treatment and 70% had orthopaedic follow-up. Significant over-utilization of resources for low-risk distal radius fractures continues decades after the first randomized trials showed it to be unnecessary. Physician type and hospital rurality are most strongly associated with best-evidence treatment. Physician types involved in generating, presenting, and publishing best-evidence for this fracture type are successfully implementing it, while others have failed to change their practices. Rural hospitals are excellent resource stewards by necessity, but are deteriorating over time. Our results strongly indicate the need for targeted implementation strategies to explicitly apply clinical evidence in clinical practice Canada-wide, with the goal of providing more cost-effective care for common children's fractures

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

Total hip arthroplasty (THA) has been cited as one of the most successful surgical procedures performed today. However, as hip surgeons, we desire constantly improving outcomes for THA patients with more favorable complication rates. At the same time, patients desire hip pain relief and return to function with as little interruption of life as possible. The expectation of patients has changed; they have more physical demands for strength and flexibility, and aspire to achieve more in their recreational pursuits. Additionally, health care system constraints require the THA episode of care to become more efficient as the number of procedures increases with time. These factors, over the past fifteen years, have led to a search for improved surgical approaches and peri-operative pain and rehabilitation protocols for primary THA. The orthopaedic community has seen improved pain control, length of stay, and reduction in complications with changes in practice and protocols. However, the choice of surgical approach has provided significant controversy in the orthopaedic literature. In the 2000s, the mini-posterior approach (MPA) was demonstrated as the superior tissue sparing approach. More recently, there has been a suggestion that the direct anterior approach (DAA) leads to less muscle damage, and improved functional outcomes. A recent prospective randomised trial has shown a number of early deficits of the posterior approach when compared to the direct anterior approach. The posterior approach resulted in patients taking an additional 5 days to discontinue a walker, discontinue all gait aids, discontinue narcotics, ascend stairs with a gait aid, and to walk 6 blocks. Patients receiving the posterior approach required more morphine equivalents in the hospital, and had higher VAS pain scores in the hospital than the direct anterior approach. Interestingly, activity monitoring at two weeks post-operatively also favored DAA with posterior approach patients walking 1600 steps less per day than DAA patients. There has been little difference in the radiographic outcomes or complications between approaches in prospective randomised trials. A number of randomised clinical trials have demonstrated that both the direct anterior and posterior approach provided excellent early post-operative recovery with a low complication rate. DAA patients have objectively faster recovery with slightly shorter times to achieve milestones of function, with similar radiographic and clinical outcomes at longer-term outcomes, with a similar complication rate

Clinical laxity tests are frequently used for assessing knee ligament injuries and for soft tissue balancing in total knee arthroplasty (TKA). Current routine methods are highly subjective with respect to examination technique, magnitude of clinician-applied load and assessment of joint displacement. Alignment measurements generated by computer-assisted technology have led to the development of quantitative TKA soft tissue balancing algorithms. However to make the algorithms applicable in practice requires the standardisation of several parameters: knee flexion angle should be maintained to minimise the potential positional variation in ligament restraining properties; hand positioning of the examining clinician should correspond to a measured lever arm, defined as the perpendicular distance of the applied force from the rotational knee centre; accurate measurement of force applied is required to calculate the moment applied to the knee joint; resultant displacement of the knee should be quantified. The primary aim of this study was to determine whether different clinicians could reliably assess coronal knee laxity with a standardised protocol that controlled these variables. Furthermore, a secondary question was to examine if the experience of the clinician makes a difference. We hypothesised that standardisation would result in a narrow range of laxity measurements obtained by different clinicians. Six consultant orthopaedic surgeons, six orthopaedic trainees and six physiotherapists were instructed to assess the coronal laxity of the right knee of a healthy volunteer. Points were marked over the femoral epicondyles and the malleoli to indicate hand positioning and give a constant moment arm. The non-invasive adaptation of a commercially available image-free navigation system enabled real-time measurement of coronal and sagittal mechanical femorotibial (MFT) angles. This has been previously validated to an accuracy of ±1°. Collateral knee laxity was defined as the amount of angular displacement during a stress manoeuvre. Participants were instructed to maintain the knee joint in 2° of flexion whilst performing a varus-valgus stress test using what they perceived as an acceptable load. They were blinded to the coronal MFT angle measurements. A hand-held force application device (FAD) was then employed to allow the clinicians to apply a moment of 18Nm. This level was based on previous work to determine a suitable subject tolerance limit. They were instructed to repeat the test using the device in the palm of their right hand and to apply the force until the visual display and an auditory alarm indicated that the target had been reached. The FAD was then removed and participants were asked to repeat the clinical varus-valgus stress test, but to try and apply the same amount of force as they had been doing with the device. Maximum MFT angular deviation was automatically recorded for each stress test and the maximum moment applied was recorded for each of the tests using the FAD. Means and standard deviations (SD) were used to compare different clinicians under the same conditions. Paired t-tests were used to measure the change in practice of groups of clinicians before, during and after use of the FAD for both varus and valgus stress tests. All three groups of clinicians initially produced measurements of valgus laxity with consistent mean values (1.5° for physiotherapists, 1.8° for consultants and 1.6° for trainees) and standard deviations (<1°). For varus, mean values were consistent (5.9° for physiotherapists, 5.0° for consultants and 5.4° for trainees) but standard deviations were larger (0.9° to 1.6°). When using the FAD, the standard deviations remained low for all groups for both varus and valgus laxity. Introducing the FAD overall produced a significantly greater angulation in valgus (2.4° compared to 1.6°, p<0.001) but not varus (p = 0.67) when compared to the initial examination. In attempting to reach the target moment of 18Nm, the mean ‘overshoot’ was 0.9Nm for both varus and valgus tests. Standard deviations for varus laxity were lower for all groups following use of the FAD. The consultants' performance remained consistent and valgus assessment remained consistent for all groups. The only statistically significant change in practice for a group before and after use of the FAD was for the trainees testing valgus, who may have been trained to push harder (p = 0.01). Standardising the applied moment indicated that usually a lower force is applied during valgus stress testing than varus. This was re-enforced by clinicians, one third of whom commented that they felt they had to push harder for valgus than varus, despite the FAD target being the same. We have successfully standardised the manual technique of coronal knee laxity assessment by controlling the subjective variables. The results support the hypothesis of producing a narrow range of laxity measurements but with valgus laxity appearing more consistent than varus. The incorporation of a FAD into assessment of coronal knee laxity did not affect the clinicians' ability to produce reliable and repeatable measurements, despite removing the manual perception of laxity. The FAD also provided additional information about the actual moment applied. This information may have a role in improving the balancing techniques of TKA and the management of collateral ligament injuries with regard initial diagnosis and grading as well as rehabilitation. Finally, the results suggest that following use of the FAD, more experienced clinicians returned to applying their usual manual force, while trainees appeared to use this augmented feedback to adapt their technique. Therefore this technique could be a way to harness the experience of senior clinicians and use it to enhance the perceptive skills of more junior trainees who do not have the benefit of this knowledge

Tropical pyomyosistis is an uncommon condition in the United Kingdom. Early diagnosis and appropriate treatment are crucial for a good outcome. We had seen 13 cases in our previously published series from 1998 to 2009. This is an update showing a significantly increased incidence from 2010 to 2016. A retrospective review of all cases of pelvic pyomyositis in our centre from January 2010 to April 2016 was undertaken from case notes and radiology reports. All children with clinical and radiographic evidence of pyomyositis were included. Since our previous publication we had changed our practice to get an MRI scan in all children who presented with a limp, fever and raised inflammatory markers, and had no effusion in the hip ultrasound scan. We identified 24 children with a mean age of 7 years (range, 1 week to 14 years). MSSA (Methicillin-Sensitive Staphylococcus aureus) was the most common cultured organism (n=8). Median hospital stay was 9 days (3 to 12). Obturator internus was the most common muscle affected. All patients had appropriate antibiotics with 2 patients requiring surgical drainage of abscesses. The majority of children (n=22) showed a complete recovery with antibiotics only. Incidence of pyomyositis has increased dramatically in our population and early diagnosis can result in a good outcome. We recommend MRI scan in all patients who present with a clinical picture of septic arthritis of the hip but with no effusion

Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction

Peri-prosthetic joint infection (PJI) is one the most devastating complications of joint arthroplasty. Although PJI is an infrequent complication (the reported incidence is 1%-2% in the United States), it is the most common indication for revision total knee arthroplasty in the Medicare population and the third most frequent indication for revision total hip arthroplasty. Moreover, the prevalence of PJI appears to be on the rise, with a projected number exceeding 60,000 to 70,000 cases in the United States by 2020. It is estimated that more than 25% of revision procedures annually are attributed to PJI and this number is expected to increase in the upcoming years. The increase in the prevalence of obesity, diabetes, and other comorbidities among the patient population and the emergence of resistant infecting organisms are some of the reasons for the expected rise in the number of infections that medical community will witness. The challenges that PJI present to the orthopaedic community are on many fronts. Prevention of PJI has proven to be a difficult task indeed. Effective strategies for prevention of PJI are being refined. The Center for Disease Control will be publishing its updated Surgical Site Prevention Guidelines in the next few months that consists of specific recommendations for prevention of PJI. In recent years, strides are made in introducing novel molecular techniques for diagnosis of PJI, which may stand to change our practices. The current surgical technique for management of PJI, besides the immense cost, fall short of delivering high success to the patients. The major problem in eradication of infection relates to formation of biofilm on the implant surface and internalization of the organisms by affected cells. Biofilm is a sophisticated structure comprising of organisms embedded in multiple layers of glycoccalyx that allows the organisms to evade host immunity and is impenetrable to antibiotics. These organisms are capable of communicating through molecular mechanisms such as quorum sensing that affords them advantage for survival in the host environment. In recent years strategies to prevent colonization of the implant surface, an essential first step in formation of biofilm, or biofilm disruption techniques have been introduced. A recent International Consensus meeting on PJI that assembled more than 350 experts identified some of the best practices in this field and identified areas in need of future research. Moving into the future, the field of orthopaedics in general and PJI in particular stand to benefit from the discoveries in the field of molecular diagnostics, metabolomics and epigenetics