Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965

Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision. Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery. Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort. Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome

Current knowledge regarding outcomes following surgical treatment of Morton's neuroma remains incomplete. This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma. Over a seven year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Statistically significant differences were found between the mean pre- and post-operative MOXFQ and physical component of the SF-12 (p<0.05). No difference in outcome was identified in patients in whom multiple neuromas were operated compared to single site surgery. However, revision surgery proved to statistically worsen MOXFQ outcomes post-operatively p<0.004. Overall satisfaction was reported as excellent (49%) or good (29%) by the majority of patients but 10% were dissatisfied with poor (8%) or very poor (2%) results expressed. Only 64% were pain free at the time of follow-up and 8% of patients MOXFQ scores worsened. These findings illustrate that overall, patient reported outcomes following resection of symptomatic Morton's neuroma are acceptable but may not be as favourable as earlier studies suggest. Caution should be taken when considering revision surgery which has shown to be a poor prognostic indicator. Contrary to current knowledge, multiple site surgery can be safely undertaken

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size. A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis. All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars. There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars. A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection. In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size

Brachial plexus tumours (BPT) and peripheral nerve sheath tumours (PNST) are largely benign in nature, with malignant tumours being rare and presenting significant surgical challenges. Excision of benign tumours may relieve pain and other symptomology. This retrospective study analysed data from 138 PNST and 92 BPT patients managed by a single consultant orthopaedic or plastic surgeon experienced in nerve tumour surgery between January 1999 to December 2019. The most common benign tumours were schwannomas and neurofibromas, with sarcomas being the most common malignant tumour. In the PNST group 30 patients were managed by observation only. Twenty patients underwent trucut biopsy, 21 patients underwent biopsy and surgical excision and 56 patients underwent surgical excision only. There were nine complications, with two significant neurological deficits requiring further surgical intervention. No recurrence of tumours occurred in this group. In the BPT group 16 patients were managed by observation only. Seven patients underwent trucut biopsy, 16 patients biopsy and surgical excision and 44 BPT patients underwent surgical excision only. Sixteen patients had complications with two significant complications requiring urgent further surgical intervention. Seven patients had recurrence of tumours which presented as metastases, with three patients requiring further surgery to remove recurrence of tumours. BPT patients are more complex and present with both benign and malignant lesions and are therefore more prone to complications due to the complex nature of the surgery and higher recurrence rate of tumours than PNST. Benign tumours in both groups can be safely managed conservatively if patients’ symptomology is acceptable

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. Results. Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home. Conclusion. Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty

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Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK.

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Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Percutaneous biopsies can lead to seeding of tumour cells along the biopsy tract. Correct surgical management requires preoperative identification and excision of the biopsy tract at time of surgery. These tracts become increasingly difficult to identify with time, leading to risk of inadequate excision of the biopsy tract and recurrence of the tumour at the biopsy site. We conducted a prospective study involving 45 patients who had tissue biopsies for bone and soft tissue tumours between February and May 2008. All the biopsies were performed by consultant radiologist under ultrasound or CT guidance. Case note analysis, patient history and examination at the time of surgery were used to collect data. 23 of 45 patients had accurate identification of the biopsy tract by the surgeon at the time of excision. The mean time between biopsy and excision was 52 days (range 6–140). 22 of 45 patients had unidentifiable biopsy site, with the mean time between biopsy and excision being 98 days(range 13–164) p=0.0004(paired t test). All 4 patients who received post-biopsy radiotherapy had unidentifiable biopsy site tract (mean duration 104 days) and 11 of the 18 patients who underwent neoadjuvant chemotherapy had an unidentifiable biopsy tract (mean duration 108 days). We concluded that identification of biopsy site was more difficult after 50 days, especially in patients who underwent radiotherapy and chemotherapy. Following this study, all the patients who had biopsies of tumours had the site marked with India ink tattoo. We, then prospectively reviewed 36 patients between July and September 2010 who underwent excision of bone and soft tissue tumours and had their biopsy sites marked with India ink tattoo. After needle biopsy, one drop of the dye was applied at the site of the biopsy. This was taken up by capillary action beneath the dermis and remained present until the patient returned for their definitive surgery. The biopsy site was easily identifiable by the patients and the operating surgeon in all 36 patients. The mean time between biopsy and surgery was 77 days (range 10–299 days). Tattooing of the skin enabled the surgeon to accurately excise the biopsy tract along with the tumour. We recommend this technique of tattooing of the biopsy site with India ink, as it is safe, easily recognisable and permits accurate excision of the tract (including the tattoo), therefore preventing biopsy tract recurrence

Aim. Previous studies of primary internal fixation of infected non-unions have reported high failure rates. Local antibiotic carriers and coatings have been advocated to reduce infection around implants and allow bone healing. We evaluated the effect of a calcium sulphate/hydroxyapatite antibiotic-loaded composite on bone healing and the eradication of infection in combination with internal fixation. Method. Twelve cases of established infected non-union, with segmental bone loss of up to 1cm were treated using a multidisciplinary protocol. This included; excision, deep sampling, stabilisation, local and systemic antibiotics, and soft-tissue closure. We treated 5 femurs, 4 humeri, 1 tibia and 2 periarticular non-unions at the ankle. Mean age was 59.8 years (34–75) and 9 patients had systemic co-morbidities (C-M Type B hosts). 9 patients had single stage surgery, with 5 IM Nails and 4 plates. Three patients had planned second stage internal fixation after external fixation to correct deformity. Staph. aureus was the commonest pathogen (5 cases) with polymicrobial infection in 3 cases. Results. All 12 patients were infection-free at a mean follow-up of 23 months (range 13–34 months). Union was achieved in 11/12 (92%) with the primary surgery alone. The single failure was the tibial case, who remains with an infection-free, stiff non-union. Conclusion. This protocol offered good results, mainly with a single stage treatment. Primary internal fixation was possible in 9 cases, without recurrent infection. The combination of excision of infected dead bone and a high level of local antibiotics above the Minimum Inhibitory Concentration and Minimum Biofilm Eradication Concentration levels for common bacteria, allowed a high success rate in these difficult cases

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Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

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Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° (. sd. 4) and extension by a mean of 9° (. sd. 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space. We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome

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The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population.

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The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

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The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

Digital Mucous Cysts (DMCs) arise from the distal inter-phalangeal joints of the digits. They often rupture spontaneously and nail deformities are common. Although surgical excision is recognised as the most successful treatment, there is no clear consensus as to the most appropriate operative technique. We performed a retrospective review identifying all patients who underwent excision of a DMC using a local rotation skin flap by the senior author over a ten-year period. Patients were all seen pre-operatively and at a minimum of six months post-operatively. Sixty-nine patients were included in the study and were reviewed at an average of 37.7 months post-operatively. No patients were lost to follow-up. There was only one cyst recurrence (1.4%). Sixty-seven (97.1%) patients were happy with the scar and sixty-three patients (91.3%) said they would have the procedure performed again. Sixty-six patients (95.7%) were content with their post-operative range of movement, which was on average 8.1° less than pre-operative values. Thirty-six patients had a nail deformity pre-operatively and twenty-one reported that the deformity grew out following the procedure. Only one patient (3.0%) developed a new deformity post-operatively. Five patients reported infection post-operatively with four prescribed oral antibiotics, but all resolved following one week of treatment. This study, which is one of the largest analyses of an operative treatment for DMCs, demonstrates that cyst excision with a local rotation skin flap is a safe and effective technique with a low recurrence rate and a high patient satisfaction

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Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence. Cite this article: Bone Joint J 2013;95-B:151–9

In this retrospective observational cohort study, we describe 17 patients out of 1775 treated for various fractures who developed mycobacterium tuberculosis (MTB) infection after surgery. The cohort comprised 15 men and two women with a mean age of 40 years (24 to 70). A total of ten fractures were open and seven were closed. Of these, seven patients underwent intramedullary nailing of a fracture of the long bone, seven had fractures fixed with plates, two with Kirschner-wires and screws, and one had a hemiarthroplasty of the hip with an Austin Moore prosthesis. All patients were followed-up for two years. In all patients, the infection resolved, and in 14 the fractures united. Nonunion was seen in two patients one of whom underwent two-stage total hip arthroplasty (THA) and the other patient was treated using excision arthoplasty. Another patient was treated using two-stage THA. With only sporadic case reports in the literature, MTB infection is rarely clinically suspected, even in underdeveloped and developing countries, where pulmonary and other forms of TB are endemic. In developed countries there is also an increased incidence among immunocompromised patients. In this paper we discuss the pathogenesis and incidence of MTB infection after surgical management of fractures and suggest protocols for early diagnosis and management. Cite this article: Bone Joint J 2015;97-B:1279–83