Background

For some time, optimized perioperative pathway protocols have been implemented in orthopedic surgery. In our hospital an accelerated clinical pathway has been successfully in effect for several years, focused on safely decreasing patients' length of stay and increasing their function at the time of discharge. The aim of the present project was to evaluate whether a further optimization is even more promising regarding early postoperative outcome parameters.

Introduction

Rapid identification of bacteria from extemporaneous samples would greatly help management of prosthesis joint infection. The aim of the present retrospective study was to evaluate a new molecular assay (GeneXpert MRSA-SA SSTI (Cepheid)) for detecting Staphylococcus aureus (SA) and methicillin resistance directly from bone and joint samples in less an hour (58 minutes).

This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation. This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service. The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies. The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours. This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development

Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services. This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018. 11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation. Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

Aims. This is a prospective randomised controlled trial comparing the functional outcomes of plate fixation and elastic stable intramedullary nailing (ESIN) of completely displaced mid-shaft fractures of the clavicle in the active adult population. Patients and Methods. We prospectively recruited 123 patients and randomised them to either plate fixation or ESIN. Patients completed the Quick Disabilities of the Arm, Shoulder and Hand (DASH) score at one to six weeks post-operatively. They were followed up at six weeks, three and six months and one year with radiographs, and their clinical outcome was assessed using both the DASH and the Constant Score. Results. Plate fixation provided a faster functional recovery during the first six months compared with ESIN, but there was no difference after one year. The duration of surgery was shorter for ESIN (mean 53.4 minutes, 22 to 120) than for plate fixation (mean 69.7 minutes, 35 to 106, p < 0.001). The recovery after ESIN was slower with increasing fracture comminution and with open reduction (p < 0.05). Conclusion. Both methods return the patients to their pre-injury functional levels, but plate fixation has a faster recovery period in comminuted fractures than ESIN. ESIN has a shorter operative time and lower infection and implant rates of failure when using 2.5 mm nails or wider, suggesting that this is the preferred method in mid-shaft fractures with no comminution, whereas plate fixation is the superior method in comminuted fractures. Cite this article: Bone Joint J 2017;99-B:1095–1101

Aims. Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation. Patients and Methods. In a multicentre, parallel randomized controlled trial, 146 adult patients with an acute displaced fracture of the midthird of the clavicle were randomized to either nonoperative treatment with a sling (71, 55 men and 16 women with a mean age of 39 years, 18 to 60) or fixation with a pre-contoured plate and locking screws (75, 64 men and 11 women with a mean age of 40 years, 18 to 60). Outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, the Constant Score, and radiographical evidence of union. Patients were followed for one year. Results. A total of 60 patients in the nonoperative group and 64 in the operative group completed one-year follow-up. At three months’ follow-up, both the median DASH (1.7 vs 8.3) and median Constant scores (97 vs 90) were significantly better in the operated group (both p = 0.02). After six months and one year, there was no difference in the median DASH or Constant scores. The rate of nonunion was lower in the operative group (2 vs 11 patients, p < 0.02). Nine patients in the nonoperative group underwent surgery for nonunion. The plate was subsequently removed in 16 patients (25%). One patient had a new fracture after removal of the plate and one underwent revision surgery for failure of fixation. Conclusion. Fixation of a displaced midshaft clavicular fracture using a pre-contoured plate and locking screws results in faster functional recovery and a higher rate of union compared with nonoperative management, but the function of the shoulder is equal after six months and at one year. Cite this article: Bone Joint J 2018;100-B:1385–91

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions. Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed. There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)). ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction

Aims

To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial.

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

Aims

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.

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Aims

To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Aims. We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy. Materials and Methods. Iliosacral screws were introduced percutaneously into the first sacral body (S1) of ten human cadavers, four men and six women. The mean age was 77 years (58 to 85). Screws were introduced using a standard technique into the left side of S1 using C-Arm fluoroscopy and then into the right side using O-Arm/Stealth Navigation. The radiation was measured on the surgeon by dosimeters placed under a lead thyroid shield and apron, on a finger, a hat and on the cadavers. Results. There were no neuroforaminal breaches in either group. The set-up time for the O-Arm was significantly longer than for the C-Arm, while total time for placement of the screws was significantly shorter for the O-Arm than for the C-Arm (p = 0.001). The mean absorbed radiation dose during fluoroscopy was 1063 mRad (432.5 mRad to 4150 mRad). No radiation was detected on the surgeon during fluoroscopy, or when he left the room during the use of the O-Arm. The mean radiation detected on the cadavers was significantly higher in the O-Arm group (2710 mRem standard deviation (. sd. ) 1922) than during fluoroscopy (11.9 mRem . sd 14.8). (p < 0.01). Conclusion. O-Arm/Stealth Navigation allows for faster percutaneous placement of iliosacral screws in a radiation-free environment for surgeons, albeit with the same accuracy and significantly more radiation exposure to cadavers, when compared with standard fluoroscopy. Take home message: Placement of iliosacral screws with O-Arm/Stealth Navigation can be performed safely and effectively. Cite this article: Bone Joint J 2016;98-B:696–702

Objectives. The monitoring of fracture healing is a complex process. Typically, successive radiographs are performed and an emerging calcification of the fracture area is evaluated. The aim of this study was to investigate whether different bone healing patterns can be distinguished using a telemetric instrumented femoral internal plate fixator. Materials and Methods. An electronic telemetric system was developed to assess bone healing mechanically. The system consists of a telemetry module which is applied to an internal locking plate fixator, an external reader device, a sensor for measuring externally applied load and a laptop computer with processing software. By correlation between externally applied load and load measured in the implant, the elasticity of the osteosynthesis is calculated. The elasticity decreases with ongoing consolidation of a fracture or nonunion and is an appropriate parameter for the course of bone healing. At our centre, clinical application has been performed in 56 patients suffering nonunion or fracture of the femur. Results. A total of 39 cases of clinical application were reviewed for this study. In total, four different types of healing curves were observed: fast healing; slow healing; plateau followed by healing; and non-healing. Conclusion. The electronically instrumented internal fixator proved to be valuable for the assessment of bone healing in difficult healing situations. Cost-effective manufacturing is possible because the used electronic components are derived from large-scale production. The incorporation of microelectronics into orthopaedic implants will be an important innovation in future clinical care. Cite this article: B. Kienast, B. Kowald, K. Seide, M. Aljudaibi, M. Faschingbauer, C. Juergens, J. Gille. An electronically instrumented internal fixator for the assessment of bone healing. Bone Joint Res 2016;5:191–197. DOI: 10.1302/2046-3758.55.2000611

Introduction. Anatomical reduction of articular fragments in tibial plateau fractures often leads to a void and there is a need to fill dead space and support the articular fragment. MIIG X3 is marketed as high strength injectable graft, which resorbs and remodels fast. Efficacy and complications related to the use of this bone graft substitute were evaluated in this study. Methods. Between January 2012 and December 2016 we injected calcium sulphate (MIIGX3) in 50 out of 126 consecutive complete articular (AO type C3) tibial plateau fractures that were stabilised with Ilizarov ring fixator. Postoperative CT scans after weight bearing and sequential radiographs were evaluated for union, graft resorption and subsidence. IOWA functional outcome score and complications were recorded. Results. The median age was 52 (Range 17–87) years. Post-operative CT scans showed leak of the graft into the joint in 11 patients and around the proximal tibiofibular joint in 2 patients but this disappeared spontaneously in all patients. Average time for graft resorption was 3.1 months. Union occurred in all patients. Minor subsidence was noted in almost half of these patients. There was no significant difference in IOWA knee score between those with or without MIIGX3 at final follow up. (p value > 0.05). Conclusion. MIIGX3 is effective as a void filler providing articular support, eradicating dead space and potentially reducing the risk of infection. Leak in the joint or soft tissue resorbed spontaneously in all cases without complications or need for surgical removal. Its use may also be associated with lack of significant late subsidence

Background. Elderly patients with hip fractures are often malnourished and in a catabolic state upon admission to hospital. Waiting time for surgery is commonly unpredictable, and often more than 24 hours. Due to an assumed stress-induced delayed gastric emptying time with a possible associated risk of aspiration, fasting guidelines are the same as for other trauma patients. This leads to prolonged fasting time in these patients who are often metabolically compromised, with negative effects on post-operative recovery and prolonged hospital stay. The aim of this study was to investigate if 400 ml of a carbohydrate-rich beverage could be given to patients with a hip fracture 2–3 hours before surgery without carrying a risk of pulmonary aspiration. Methods. The gastric emptying rate of 400 ml 12.6 % carbohydrate rich drink was investigated in ten elderly women with a hip fracture awaiting surgery. The emptying rate was assessed by an indirect method, the paracetamol absorption technique. Results were compared with two control groups of healthy persons. Results. In the hip fracture patients, the mean gastric half-emptying time was 57 ± 5 minutes and displayed a normal emptying profile. The corresponding result in the control group was 58 ± 5 minutes. One hip fracture patient was excluded due to vomiting before finishing intake, i.e. before the anaesthesia procedure. Conclusions. In this pilot study, gastric emptying in nine elderly women with a hip fracture was not delayed. We suggest that it should be possible to give a carbohydrate-rich beverage 2–3 hours before surgery to most hip fracture patients. Patient selection is an issue