Cite this article: Bone Joint J 2023;105-B(11):1133–1134.

Introduction. Hip fracture is a worldwide problem, not only as far as epidemiology is concerned but also regarding economical issues. Surgery is the current standard treatment. However owing to age, and patients co-morbidities complications are common. Surgical site infection is directly related to operative procedure, and surgeons' experience may be very important when making plans for outcome improvement. In this paper we study the role of hip surgeons versus general orthopaedic surgeons in relation to postoperative site infection. Operative hypothesis determines that hip surgeons have less infection rates than general orthopaedic surgeons. Null hypothesis that infection rates are rather the same. Material and Methods. In a prospective controlled cohort study 820 patients presenting with a hip fracture were randomizelly operated on by a group of orthopaedic surgeons of the same Hospital Department. Patients were then classified according to surgeons adscription either to a Hip Unit (Group A=215 cases) or not (Group B=605). Variables studied included age, gender, treatment (osteosynthesis or joint replacement), co-morbidities (according to Charlson, s index), and infection rate. Fisher, and Ranksum statistical tests, and simple and multiple logistic regression, for univariate and multivariate, analysis was performed. Results. 237 (28,93 %) patients were male, and 583 (71,06 %) females. Mean age for both groups was 77,58 years (r=16−105; group A=78, group B=81). 215 patients were included in group A, and 605 in group B. 534 (65.12%) underwent an osteosynthesis, and 272 (33,17%) a joint replacement. 14 patients were not operated. Both groups were homogeneous regarding gender, surgical technique, Charlson's index, and functional outcome (Fisher test p=0,777). 17 patients (2,073%) sustained a surgical site infection (group A=7 cases out of 215 [3,27%], and group B=10 cases out of 605 [1,65%]). Multivariate logistic regression showed that there was no relation between gender, surgical site infection, Charlson index, surgical technique, or groups (A or B). Only age was a determinant factor (Raksum test p=0,003; OR 95% CI=1,08, p=0,005). Conclusion. Since there are no differences in the outcomes between surgeons dedicated to a Hip Unit and general orthopaedic surgeons as far as postoperative surgical site infection is concerned, delaying operative treatment for hip fracture or creating a special Unit for that is unworthy. Only age appears as a significant variable

Aims. The aim of this study was to assess the current trends in the estimation of survival and the preferred forms of treatment of pathological fractures among national and international general and oncological orthopaedic surgeons, and to explore whether improvements in the management of these patients could be identified in this way. Materials and Methods. All members of the Dutch Orthopaedic Society (DOS) and the European Musculoskeletal Oncology Society (EMSOS) were invited to complete a web-based questionnaire containing 12 cases. Results. A total of 96 of 948 members of the DOS (10.1%; groups 1 and 2) and 33 of 182 members of the EMSOS (18%; group 3) replied. The estimation of survival was accurate by more than 50% of all three groups, if the expected survival was short (< 3 months) or long (> 12 months). General orthopaedic surgeons preferred using an intramedullary nail for fractures of the humerus and femur, irrespective of the expected survival or the origin of primary tumour or the location of the fracture. Oncological orthopaedic surgeons recommended prosthetic reconstruction in patients with a long expected survival. Conclusion. Identifying patients who require centralized care, as opposed to those who can be adequately treated in a regional centre, can improve the management of patients with pathological fractures. This differentiation should be based on the expected survival, the type and extent of the tumour, and the location of the fracture. Cite this article: Bone Joint J 2018;100-B:1392–8

Spezializing in subfields of Orthopaedics is common in anglo-american countries for more than 20 years. IThe aim of this paper is to demonstrate the necessity of fellowship programms in extremity orientated subfileds of orthopaedics. Analyzing the results of ankle arthrodesis performed by general orthopaedic surgeons campared to ankle arthrodesis performed by spezialized foot and ankle surgeons the difference in results will be demonstrated. Patients and methods. In 40 patients an ankle arthrodesis was performed between 1998 and 2012. Group A was formed by 20 consecutive patients treated by spezial trained Foot and Ankle surgeons and group B was formed by 20 patients treted by general orthopaedic surgeons. The average age in group A at the time of surgery was 59,9y (34 to79y) compared to 63,4y (41 to 80y) in group B. The average follow up was 34 months respectively 32 months after surgery. The study included a spezial questionnaire with the AOFAS score and rating of patients dissatisfaction. The successful healing of the arthrodesis was determied by using standardized radiographs, Furthermore a pedobarography, and a videoanalyzis of the walking was incuded. Results. All procedures in group A were performed using an anterior approach. Neither pseudarthroses, equinus or other malositions were detected in this group. In group B wurdenin 16 patients an anterior and in 4 patients a lateral approach was used. Complications included 3 pseudarthroses, 4 equinus malpositions, 4 varus malpositions, 4 valgus malpositions and 8 penetrations of the subtalar joint. The AOFAS score on average was 78 (46–92) points in group A and 75 (34 – 94) in group B. Conclusion. The analyzis of the data revealed that the results in Group A were comparable to the results published in the literature. Results in group B were inferior to those in group A and to the results published in the literature of Foot and Ankle surgery. Foot and Ankle surgery became more demanding over the last decades. As already shown in anglo-american countries spezializing in certain fields of orthopaedics is a necessity. More complex hindfoot surgery should be performed in special centers with an adequate case load

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity

About 20% of orthopaedic surgery is foot and ankle. This area of orthopaedics has undergone huge changes in last few decades. Not that long ago we were still performing Keller's procedure for bunions and using a Charnley clamp for ankle fusions. It is becoming increasingly more difficult for the general orthopaedic surgeon to stay abreast of current surgical treatment. Some of the newer foot and ankle surgical surgical techniques will be discussed. Ankle arthroplasty is undergoing a period of revival. This is a difficult procedure with results not as reliable as hip and knee arthroplasty and I would not recommend it to the occasional foot and ankle surgeon. Ankle arthroscopy is now a commonly performed procedure and with the right equipment is a procedure that is useful to the generalist. Foot and ankle fusion are now performed with rigid internal fixation. The actual procedures are not difficult but it does require a reasonable amount of experience to obtain the correct position of the fusion. Bunion surgery is commonly done and can result in disappointment for all. The newer surgical options for the correction of hallux valgus will be discussed

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries. 57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented. The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics. This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes

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

The February 2023 Knee Roundup³⁶⁰ looks at: Machine-learning models: are all complications predictable?; Positive cultures can be safely ignored in revision arthroplasty patients that do not meet the 2018 International Consensus Meeting Criteria; Spinal versus general anaesthesia in contemporary primary total knee arthroplasty; Preoperative pain and early arthritis are associated with poor outcomes in total knee arthroplasty; Risk factors for infection and revision surgery following patellar tendon and quadriceps tendon repairs; Supervised versus unsupervised rehabilitation following total knee arthroplasty; Kinematic alignment has similar outcomes to mechanical alignment: a systematic review and meta-analysis; Lifetime risk of revision after knee arthroplasty influenced by age, sex, and indication; Risk factors for knee osteoarthritis after traumatic knee injury.

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

The October 2023 Wrist & Hand Roundup³⁶⁰ looks at: Distal radius fracture management: surgeon factors markedly influence decision-making; Fracture-dislocation of the radiocarpal joint: bony and capsuloligamentar management, outcomes, and long-term complications; Exploring the role of artificial intelligence chatbot in the management of scaphoid fractures; Role of ultrasonography for evaluation of nerve recovery in repaired median nerve lacerations; Four weeks versus six weeks of immobilization in a cast following closed reduction for displaced distal radial fractures in adult patients: a multicentre randomized controlled trial; Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study; On the road again: return to driving following minor hand surgery; Open versus single- or dual-portal endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.

Aims

This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?

50 consecutive cases of Scaphoid non-union were treated by open reduction and internal fixation. Average age of non-union was 2.8 yrs ranging fron 6 months to 6 years. Most common approach used was volar. Herbert screw was used to fix 48 non-unions while K wires were used in 2 cases. Bone graft was harvested from patient’s iliac crest and was used in nearly all cases. Wrist was immobilised in a plaster for an average duration of 12 weeks post operatively. All the cases were done by a single surgeon and the cases were recorded by an independent observer. The average follow up was 2 years ranging from 1 year to 6 years. Radiographic union was achieved in 45(80%) cases. Failure of union was seen in 10 cases out of which 5 were proximal pole fractures of which 2 went into avascular necrosis. Denervation of wrist, proximal row carpectomy and four corner fusion was used in 5 cases to salvage the wrist. This modest study carried out at a district general hospital of South East England suggests that scaphoid bone continues to be a challenge for general orthopaedic surgeon as some of these fractures are missed initially. Open reduction and internal fixation of Scaphoid non-union continues to give a predictable outcome

Aims

Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

The aim of the New Zealand Elbow Arthroplasty Register is to evaluate the provision of elbow arthroplasty across the entire country by both recording accurate technical information and measuring the clinical outcomes of all elbow replacements performed in New Zealand. An initial form is completed at the time of surgery which includes details of the patient, surgical indications, the surgical procedure, the implant and the operating surgeon. Six months following surgery, all registered patients are asked to complete a questionnaire to measure the pain and function of the replaced elbow and to comment on any post operative complications. Data from 99 consecutive primary and 16 revision elbow arthroplasties was prospectively collected from January 2000 till December 2003. Rheumatoid arthritis was the commonest indication (63 cases) and the outcome was significantly better than for trauma and osteoarthritis. The Coonrad-Morrey was the most commonly used prosthesis (86 cases) followed by the Kudo (eight cases) and the Acclaim (five cases). 21 surgeons performed elbow arthroplasty during the study period but only five performed on average more than one case per year. Their results at six months were statistically superior to those provided by other surgeons. The number of complications reported by patients and the revision rate within the study period was low. An infection was seen in only two patients. The New Zealand Elbow Arthroplasty Register has become a robust method of assessment of the provision of elbow arthroplasty within the country. Our findings support the idea that elbow arthroplasty should not be performed by general orthopaedic surgeons on an occasional basis

To evaluate how much tendon may be safely excised in insertional Achilles tendonitis without predisposing the patient to Achilles tendon rupture. Insertional Achilles tendonitis commonly affects runners and is frequently managed by general orthopaedic surgeons. Most patients may be managed non-operatively but those who do not respond to conservative measures may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture. This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of 6 months post-operatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilised free of a cast. There were two failures using this regimen. One patient had inflammatory arthritis and was taking significant immunosuppressive therapy. The second patient was keen for simultaneous bilateral procedures. In retrospect the senior surgeon acknowledges that this was somewhat enthusiastic as even with the most compliant of patients true partial weight-bearing in such a situation is extremely difficult. This review supports biomechanical data which demonstrates up to 50% of the tendon may be safely resected. We suggest that it is not necessary to immobilise all patients in a cast following surgery for insertional Achilles tendonitis when less than 50% of the tendon is excised. We recommend that patients with inflammatory arthritis or recent immunosuppressive therapy and those in whom greater than 50% of the tendon has been excised should be immobilised in a cast for six weeks. We do not recommend that simultaneous bilateral procedures are performed

Introduction and Aims: Dysplasia of the femoral sulcus is one component that may be present in patients presenting with patellar instability. Rarely the dysplasia is so severe that a dome rather than groove is present. Dejour has reported an operation that deepens the groove, unlike the Albee which elevates it. This study reports the development of a modification of the Dejour trochleoplasty reporting the clinical and radiological results. Method: A consecutive case series of the first 15 patients (17 knees) who underwent a trochleoplasty with a minimum one-year follow-up. There were 11 females and four males with an age range from 15 to 47 years old. Nine patients had had previous operations. The pre-operative length of symptoms ranged from one to 30 years. The patellar instability was managed operatively using the Dejour protocol measuring the patellar height, boss height, tibial tubercle-trochlear groove distance and patellar tilt angle. The Kujala score was used for functional assessment and a subjective assessment was also made. CT scans as well as plain films were used for radiological assessment. The operative technique changed in the light of experience from metallic to absorbable screws as the former abraded the patella. Results: The boss height was reduced from an average of 7.5mm to 1mm (normal 0mm). Tracking became normal in 11 knees and had a slight J-shape in six. Seven knees had a mild residual apprehension. Five patients were very satisfied, eight were satisfied, and two were disappointed. The Kujala score improved from an average of 48 to 73 out of 100. Three patients returned to full sports. Eight patients required further operations apart from the removal of metallic screws in 10 knees. Five of these were arthrolysis for stiffness at about six weeks post-operatively. As a result, patients were placed on a continuous passive motion machine for three to four days to avoid this. One patient went on to have autologous chondrocyte implantation for a defect on the lateral femoral condyle involving the tibial surface. This was after a new injury following a return to sports and not in the area affected by the trochleoplasty. Conclusion: Trochleoplasty for severe dysplasia of the femoral sulcus is a developing procedure. It requires careful attention to detail. For a rare condition the results have been gratifying with an acceptable level of complications. It is not recommended that this procedure be performed by general orthopaedic surgeons

Introduction: The balance between achieving stable fixation and maintaining hand and wrist function during the treatment of distal radius fractures has continuously plagued the orthopaedic surgeon. A radio-radial external fixation system was developed by Dr. Guillermo Bruchmann to address these concerns. This study was designed to evaluate the immediate functional and anatomical results of the fixation system on intra-articular and extra-articular fractures. This is the first study documenting the use of this technique in Asia. Materials and methods: Fifty-four consecutive patients, 18 male and 36 female, with 56 distal radius fractures were treated with closed reduction and application of the COBRA radio-radial external fixator. The operative procedure is described in detail. Immediate use of the affected hand for activities of daily living (ADL’s) was encouraged. Each patient was evaluated regarding functional and anatomical recovery at 2, 4 and 6 weeks postoperatively. Using the modified system of Green and O’Brien, functional recovery was based on the presence of pain, ability to do ADL’s, and range of motion. The grading system of Sarmiento was used to evaluate the overall maintenance of anatomic reduction by comparing the post-operative radiographs with those taken at 2, 4 and 6 weeks and on removal of the fixator. Results: Assessment of functional status showed that patients had occasional to no pain at the pin sites at 2 weeks; improving on biweekly follow-up. Those with extra-articular fractures were able to do restricted ADL’s wearing the device within the 1st 2 weeks; with wrist motion arc between 50–75°. Patients with intra-articular fractures were functionally delayed by 2 weeks but with a dramatic improvement at 3–4 weeks, doing light ADL’s with wrist motion between 20–60°; progressively improving on follow-up. Biweekly radiographic evaluation showed good to excellent maintenance of reduction for both intra- and extra-articular fractures up to time of fixator removal. Average time of fixation was 7 weeks (range, 6 – 9 weeks) with removal depending on radiographic evidence of fracture union. Summary: The COBRA external fixator is a versatile tool in the treatment of intra-articular and extra-articular fractures that any general orthopaedic surgeon can use. The overall functional and anatomical outcome is good to excellent during the time of fixation up to the time of fixator removal. Hand and wrist function is initiated immediately markedly limiting the usual complications of stiffness and disability commonly associated with these fractures