Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods. A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results. A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). Conclusions. Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively. Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596

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To investigate if preoperative CT improves detection of unstable trochanteric hip fractures.

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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.

Hand fasciotomy is a rarely performed procedure which should be considered by military surgeons, and performed where necessary. Maximising hand function is vital in all military patients, but is even more significant in those who have lost multiple limbs and require maximal function from remaining hands, which are commonly injured too. It is vital that compartments are decompressed expediently to minimize muscle ischaemia. Cases were identified from the JTTR from March 2003. Data were collected prospectively from Aug 2009 to Feb 2010. Patient notes were analysed and the following recorded –demographics, mechanism of injury (MOI), associated injuries, echelon of care at which fasciotomy was performed, indication recorded by operating surgeon, and specialty of operating surgeon. 9 patients were identified, median age was 23, MOI was IED in 8/9 and mine in 1/9/. All were multiply injured. 4/9 (44%) were performed at R3 and 5/9 (56%) at R4. All fasciotomies at R4 were performed at the first debridement, intrinsic muscles were found to be necrotic in 1 case. At R3 3/4 were performed by orthopaedic surgeons and 1/4 by a plastic surgeon, at R4 all were performed by hand surgeons, either orthopaedic or plastic. All fasciotomies performed at R4 were at the first debridement, and 1 revealed necrotic intrinsic muscles. This implies that some of these patients may have benefited from earlier procedures. In upper limb injury where it is not possible to passively flex the metacarpophalangeal joints to 90 degrees, decompressing the hand should be considered

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Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

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Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

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The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

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The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR).

Surgical planning is the first step in operative fracture management. Complex situations are often faced which pose difficulties on both technical and logistic fronts. Surgical planning is the first step in operative fracture management. The degree of planning that is required is therefore determined by a number of factors including: the nature of the injury mechanism and its concomitant physiological insult, complexity of the fracture and region, expertise of the surgical team and equipment limitations. This paper explores a novel planning process in orthopaedic trauma surgery based upon British Military Doctrine. The seven questions of surgical planning represent a novel method that draws inspiration from the combat estimate process. It benefits from a global approach that encompasses logistic as well as surgical constraints. This, in turn, allows the surgical team to form an understanding of the nature of the fracture in order to develop, document and deliver a surgical plan. This has benefits for the operating surgeon, operating room practitioners and trainees alike and ultimately can result in improved patient care

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The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.

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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.

Pain produced by the tourniquet is a common source of complaint for patients undergoing carpal tunnel decompression. Practice varies as to tourniquet position. There is little evidence to suggest benefit of one position over another. Our aim was to compare the experience of both the patient and the surgeon with the tourniquet placed either on the arm or the forearm. Ethical approval was granted. Following power calculation and a significance level set at 0.05, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomised to arm or forearm group. Visual Analogue Scores (VAS) (0–100) for pain, blood pressure and heart rate were taken at 2 minute intervals. The operating surgeon provided a VAS for bloodless field achieved and obstruction caused by the tourniquet. The demographics of the groups was similar. There were no statistically significant differences in any measure between the groups. Average tourniquet times were 8.8 minutes (forearm) and 8.2 minutes (arm). The average VAS score for forearm and arm was 13 and 11 respectively for bloodless field, 9 and 2 for obstruction. Average overall VAS for pain was 27 in each group, however interval VAS scores for pain were higher in the arm group. The average change Mean Arterial Pressure was −5 mmHg (forearm) −2 mmHg (arm) pulse rate was −1 bpm (forearm) and −2 bpm (arm). Tourniquet placement on the arm does not result in significant difference in patient pain, physiological response or length of operation. Surgeons reported less obstruction and better bloodless fields with an arm tourniquet, however there was a trend for forearm tourniquet to result in less pain for the patient

A review of current literature describes varying 10-year survival rates for the Oxford Unicompartmental Knee Replacement (Biomet Orthopedics Inc, Warsaw, Ind). Application of rigorous indications and meticulous surgical technique are two factors considered to reduce revision rates. A retrospective case-note review was conducted for 96 patients (128 knees) aged 42–89 (mean 57) who had an Oxford unicompartmental knee replacement for medial compartment osteoarthritis between January 2000 and January 2011. All procedures were performed, or directly supervised, by one 5 surgeons. The aim of the study was to ascertain the rate of revision to bicompartmental knee replacement and any associated contributory factors. Of the 128 unicompartmental knees, 10.9% were revised to either mobile- or fixed-bearing total knee replacements due to septic (0.5%) and aseptic (1.5%) loosening, patello-femoral pain (3.9%), periprosthetic fracture (0.8%) and bearing dislocation (3.1%). Of those knees requiring revision, mean patient age was 73 years, 50% had wound complications and 42% were performed by senior trainees. All patients had intact ACL and medial osteoarthritis. Mean time to revision was 2.7 years. In conclusion, revision of the unicompartmental knee was related to patient age > 65 years and early post-operative complications; grade of operating surgeon had little apparent effect

Introduction. Analysing the results of angular stable osteosynthesis in large groups of patients can give us an indication of the possibilities and limitations of both angular stable nailing and plating. Material and Methods. Fractures have been classified using the AO-classification system. To judge vascularisation of the head fragment we use the criteria as described by Hertel. We considered fracture reduction as adequate when the CCD-angle could be restored, with a maximum of 10° varus or valgus malalignment and a maximal persistent tuberosity displacement equal to or less than 3 mm in any direction. An independent investigator collects information on reoperations based on: patient interview, hospital data and contact with the operating surgeon if the revision took place elsewhere. Reoperation is defined as any secondary surgical procedure after the initial open reduction and fixation. Results. In the period between December 2001 and June 2006 383 patients have been treated for proximal humerus fracture using one of the above described implants. There were 70 reoperations (i.e. 22,6%) of which 31 hardware removals. In C-type fractures there were significantly more reoperations than in B-type fractures (p<0,0001). Although statistically not significant (p = 0,053) there was a lower reoperation rate in A-type fractures than in C-type fractures. Neither gender nor ASA classification did have any influence on reoperation rate (p = 1 for both gender and ASA 3 or more versus less than 3). Avascularity of the head (p<0,001) and quality of reduction (p<0,0001) did have a significant influence on reoperation rate. Based upon these observations and on the fact that secondary surgery in the friable ASA 3+ patient does put this patient at an increased risk of morbidity and mortality, we developed a scoring system to differentiate indications for osteosynthesis from those of primary arthroplasty

Title. 3D distribution of cortical bone thickness in the proximal humerus, implications for fracture management. Introduction. CT imaging is commonly used to gain a better understanding of proximal humerus fractures. the operating surgeon however has a limited capacity to evaluate the internal bone geometry from these clinical CT images. our aim was to use clinical CT in a novel way of accurately mapping cortical bone geometry in the proximal humerus. we planned to experimentally define the cortico-cancellous border in a cadaveric study and use CT imaging software to map out cortical thickness distribution in our specimens. Methodology. With ethical approval we used fifteen fresh frozen human proximal humeri. These were stripped of all soft tissue and transverse CT images taken with a GE VCT Lightspeed scanner. The humeral heads were then subsequently resected to allow access to the methaphyseal area. Using currettes, cancellous bone was removed down to hard cortical bone. Another set of CT images of the reamed specimen were then taken. Using Mimics imaging software[Materialise, Leuven] and a CAD interface, 3-matic [Materialise, Leuven], we built 3D model representations of our intact and reamed specimens. We first had to define an accurate CT density threshold for visualising cortical contours. We then analysed cortical thickness distribution based on that experimented threshold. Results. we were able to statistically determine the CT threshold, in Hounsfield Units, that represents the cortico-cancellous interface in the proximal humerus. Our 3D colour models provide an accurate depiction of the distribution of cortical thickness in the proximal humerus. Discussion/Conclusions. Our Hounsfield value for the cortico-cancellous interface in the proximal humerus agrees with a similar range of 400 to 800 HU reported in the literature for the proximal femur. Knowledge of regional variations in cortical bone thickness has direct implications for basic science studies on osteoporosis and its treatment, but is also important for the orthopaedic surgeon since our decision for treatment options is often guided by local bone quality

Background. With the recent trend towards enhanced care in joint replacement, it has become increasingly important to identify and address the areas that affect early patient length of stay, while ensuring that practice remains safe. As part of an enhanced care program we conducted two prospective studies of factors delaying discharge following hip replacement in 2006 and 2010. Materials and Methods. In each limb of the study data was collected prospectively daily, by an independent observer, on 100 consecutive primary cemented total hip replacements. Reasons for delay to the discharge and variation from the patient pathway were identified and addressed. Results. The mean length of stay in hospital in 2006 was 4.8 days (target for discharge 4 days) and in 2010, 3.6 days (target for discharge 3 days). In 2006, 31 patients had a stay of more than 4 days, 17 due to inadequate physiotherapy provision, 10 for medical and 4 for other reasons. In 2010, 29 patients had a stay of more than 3 days (though only 15 stayed longer than 4 days), only 2 patients had inadequate physiotherapy provision, in 7 cases discharge was delayed because of need for blood transfusion and 11 because of need for catheterisation. Women, aged more than 70 with preoperative Hemoglobin of less than 12 g/dL were at particularly high risk of requiring transfusion (p = 0.0001). Catheterisation was also identified as a factor causing significant increase in length of stay (p = 0.003). Patients going home in less than 3 days were more likely to have had their operation in the morning. In both studies patients attending the preadmission Joint Group education session were less likely to have a delayed discharge. Discharge was not affected by the type of anesthetic or the experience of the operating surgeon. Conclusions. Patient length of stay is multifactorial and can be continually reduced by close management of patient expectations and incremental identification and improvements in the care pathway. Recommendations. Regular review of a hip replacement care pathway can bring about incremental changes that together have a significant impact on reducing length of stay

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

About 81,000 total knee replacements are implanted in the United Kingdom annually. Conventionally pneumatic tourniquet and surgical drains have been used in total knee arthroplasty. However, no definite evidence or guidelines exist to support their use. The present study aims to look for any difference in perioperative recovery and complications following use of pneumatic tourniquet and surgical drains in knee replacement surgery. We retrospectively analysed 60 total knee arthroplasties performed by 3 different surgeons at our hospital during January 2007 to June 2010. A sample size of 20 patients in each group was evaluated. Group 1: used tourniquet and drain; Group 2: used tourniquet but no drain; Group 3: didn't use tourniquet but used drain. Data was collected and analysed using statistical means, t-test & analysis of variance. Parameters compared were surgical (anaesthetic) time, mean postoperative haemoglobin at 24 hrs, blood transfusion rate, haematoma formation, wound infection, pain, deep vein thrombosis and infection at discharge. At 6 weeks clinical follow up letters were analysed. Our results reveal that there is no significant difference in duration of surgery in either group. Use of tourniquets didn't improve on surgical time (123–133 minutes). Our Local Hospital Pain Score was used (1 no pain, 2 mild, 3 moderate, 4 severe and 5 worst imaginable pain). No difference at discharge was seen in either group. Similarly no difference was seen in either group with postoperative haematoma formation with one case (5%) in Group 1 and 3 respectively. Although the immediate postoperative haemoglobin (Hb%) was comparable in all 3 groups, Group 3 patients received more blood transfusion compared to other groups based on clinical grounds. About 50 % of Group 3 needed blood transfusion compared to 10% in Group 1 and 5% in Group 2. There was only one proven case of superficial infection at 6 weeks (Group 2) which responded well to antibiotics. There were 4 cases of cellulitis noted at 6 weeks (3 in Group 2 and 1 in Group 3) which responded to oral antibiotics. No deep infection was noted. The mean hospital stay in hospital was 6.5 days in Group 1, 5.5 days in Group 2 and 8 days in Group 3. There was no difference in rate of post-operative deep vein thrombosis (5% in Group 1 and 3). The present study with the use of tourniquet and surgical drain in total knee arthroplasty showed no significant difference in surgical time and incidence of postoperative haematoma, deep vein thrombosis. Pain score at discharge was comparable and so was the infection rate. Patients in Group 2 (used tourniquet but no surgical drain) had least hospital stay (mean 5.5 days) and least blood transfusion rate (5%). Decision to use pneumatic tourniquet & drain still lies with the operating surgeon. We recommend a randomised control study for further evidence

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Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

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Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the “cleanyourhands” campaign on rates of MRSA SSI and patient outcome.