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

Aims. A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial. Methods. We collected 11 audio recordings of recruitment appointments and interviews of research team members (principal investigators and research nurses) from five hospitals involved in recruitment to an orthopaedic trial. We analyzed the qualitative data sets thematically with the aim of identifying aspects of informed consent and information provision that was either unclear, disrupted, or hindered trial recruitment. Results. Recruiters faced four common obstacles when recruiting to a surgical orthopaedic trial: patient preferences for an intervention; a complex recruitment pathway; various logistical issues; and conflicting views on equipoise. Clinicians expressed concerns that the trial may not show significant differences in the treatments, validating their equipoise. However, they experienced role conflicts due to their own preference and perceived patient preference for an intervention arm. Conclusion. This study provided initial information about barriers to recruitment to an orthopaedic randomized controlled trial. We shared these findings in an all-site investigators’ meeting and encouraged researchers to find solutions to identified barriers; this led to the successful completion of recruitment. Complex trials may benefit for using of a mixed-methods approach to mitigate against recruitment failure, and to improve patient participation and informed consent. Cite this article: Bone Jt Open 2021;2(8):631–637

Introduction. Surgical site infections (SSI) are related to a surgical procedure and affect the surgical wound or deeper tissues. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results. Rates of morbidity and mortality may play important roles in these assessments. When crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. The aim of this study is to fix SSI incidence in relation to surgical procedure. Methods. This report contains data of 19.948 procedures collected from 1996 to 2008 at a Specialist Orthopaedic Hospital and analyzed by a specific software designed for the study of infection in orthopaedic and trauma surgery. The SSI surveillance is focused on categories of surgical procedure (Hip Arthroplasty, Knee Arthroplasty, Spine Surgery and Hip Fracture Surgery) with each category containing a defined set of similar procedures. A basic of demographic data and details about operation itself are collected for each procedure. Patients are followed up throughout their hospital stay and after hospital discharge. We present the incidence of SSI by risk group and surgical procedure. SSI are categorized in type, moment of diagnosis and micro-organisms reported. Analysis of the data was performed (SPSSv15.0 ®). Statistical methods used to determine significance were the independent samples t test, Pearson X2 test, Odds ratio and Spearman correlation coefficient, with a significance level of p<0,05. Results. Rates of SSI are highest in hip hemiarthroplasty after fracture and in hip and knee revision procedures. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. The most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance. Conclusions. Our results confirm difference in rates of SSI depending of surgical procedure in orthopaedic and trauma surgery. We believe that our decision to monitor infection with a long term follow up it's the better way to avoid under-reporting of infection. Our study has also demonstrated the extent to which the emerging problem of infection due to MRSA has affected orthopaedic surgery. The risk of acquiring SSI caused by MRSA was particularly high in patients after hip fracture surgery. Rates of SSI increase with the number of risk factors present in the patient, especially after fracture procedures. Globally, the most common infecting micro-organism was coagulase-negative staphylococcus, followed by Staphylococcus aureus, enterococci and streptococci. 38% of the infections arise after one year of surveillance

In performing posterior cruciate ligament- retaining total knee arthroplasty (CR-TKA), the original surgical instrument was devised to obtain the range of motion and stability of the knee joint adequate for daily life of Japanese people. We have presumed the tentative joint line as intercondylar notch point of the distal femur, and performed surgery using surface replacement to resect metal width of the femoral component for the distal femur by setting the knee to the original position based on understanding of the shape of anterior curvature of the distal femur in Japanese people in case of implanting the femoral component. In order to obtain stability of the knee, we have minimally released the soft tissue and resected the anterior cruciate ligament (ACL), whereas completely preserved the posterior cruciate ligament (PCL) and maintained physiological ligament balance of the knee joint by resecting the medial condyle of the tibia (genu varus). Our surgical procedure enabled deep flexion knee (knee embracing) greater than 145 degrees in 9.7% and also allowed Japanese sitting in three different designs of total knee joints

Purpose: Aim of this study was to analyse the incidence of infection in orthopaedic oncology after major surgical procedures for bone tumors. Materials and Methods: We included patients with primary sacral tumors treated by major surgical procedure and patients with bone tumors of the upper and lower limb treated by resection and prosthetic reconstruction. Demographic data, surgery, adjuvant treatments, type of reconstruction were analyzed. Special attention was given to the infection: incidence, classification, microbic agents, treatment and outcome. Infections in the first 4 weeks were considered “postoperative”, those in the first 6 months were judged “early”, while “late” those diagnosed after 6 months. Overall 1462 patients treated in one institution from 1076 to 2007. Were considered 1036 patients with tumors of the lower limb, 344 patients with tumors of the upper limb and 82 sacral tumors. Univariate analysis with Kaplan-Meier actuarial curves was used in evaluating risk factors and implant survival to infections. Results: In the lower limb, infection occurred in 80 cases (7.7%). Most frequent bacteria were gram positive. Infection was postoperative in 9 cases, early in 12, late in 59 cases and generally monomicrobial. Surgical treatment was “two stage” in 73 patients, “one stage” in 4 and primary amputation in 3 cases. Revisions for infection were successful in 63 pts (79%), while 17 pts were amputated (21%). In the upper limb, in 20 patients (5.8%) a revision for deep infection was required. Two infections were postoperative, 7 early and 11 late. S. Epidermidis and S. Aureo were the most frequent bacteria causing infection (45%). “Two stage” treatment of infection was performed, but a new prostheses was implanted in 3 cases. In 17 the spacer was never removed. In the sacrum, no deep infections were observed after intralesional excision for giant cell tumors. In 23/52 resections (44%) for chordoma (3 pts. died postoperatively and were excluded), infection occurred: in 16 patients postoperatively, in 7 within 6 months. Bacteria causing infection were mostly gram negative: in 74% of cases infection was multiagent. Surgical treatment consisted in one or more surgical debridements with antibiotics therapy according to coltures: infection healed in all cases. Conclusion: Infection is a severe complication in prosthetic reconstructions for tumors of the upper and lower limb. Its incidence in the extremities (7.7% and 5.8%) is lower than after sacral surgery (44%). Infections are mostly late, monomicrobial and caused by gram positive in extremities, while early, multimicrobial and caused by gram negative in the sacrum

Bone sarcomas are rare cancers and orthopaedic surgeons come across them infrequently, sometimes unexpectedly during surgical procedures. We investigated the outcomes of patients who underwent a surgical procedure where sarcomas were found unexpectedly and were subsequently referred to our unit for treatment. We identified 95 patients (44 intra-lesional excisions, 35 fracture fixations, 16 joint replacements) with mean age of 48 years (11 to 83); 60% were males (n = 57). Local recurrence arose in 40% who underwent limb salvage surgery versus 12% who had an amputation. Despite achieving local control, overall survival was worse for patients treated with amputation rather than limb salvage (54% vs 75% five-year survival). Factors that negatively influenced survival were invasive primary surgery (fracture fixation, joint replacement), a delay of greater than two months until referral to our oncology service, and high-grade tumours. Survival in these circumstances depends mostly on factors that are determined prior to definitive treatment by a tertiary orthopaedic oncology unit. Limb salvage in this group of patients is associated with a higher rate of inadequate marginal surgery and, consequently, higher local recurrence rates than amputation, but should still be attempted whenever possible, as local control is not the primary determinant of survival. . Cite this article: Bone Joint J 2014;96-B:665–72

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

We report the results of a new surgical procedure for spastic equinovarus deformity due to cerebral palsy. This is the transfer of the anterior half of the split tibialis posterior to the dorsum of the foot through the interosseous membrane. We performed the operation on 23 feet in 18 children. All patients were assessed before operation and at follow-up at a mean of 8.4 years postoperatively. Using the criteria of Kling et al (1985), excellent results were obtained in 14 feet, good results in eight, and a poor result in only one

Between 1985 and 1998, 12 331 patients were included in the general neonatal ultrasound hip screening programme for developmental dysplasia of the hip (DDH). Patients who needed treatment (604) were compared with a second group of 73 unscreened children treated conservatively and surgically for DDH. The incidence of Graf sonographic hip types IIc to IV varied throughout the observation period. Femoral and pelvic osteotomies were almost entirely restricted to the unscreened group of patients. The six to ten per year recorded in the period 1985 to 1990 declined subsequently to three or less per year. The yearly admissions to hospital fell noticeably after six years of screening. Late presentations of DDH were reduced to three or less per year from 1990 to 1994, none between 1995 and 1998 and one or two per year from 2000. We conclude that general neonatal sonographic hip screening can reduce significantly surgical procedures, hospitalisation and late presentation of DDH

Introduction: Between the elderly affected by femoral neck or diaphyseal fractures are emerging few serious complications as delate union, instability of osteosynthesis, re-fracture or periprosthetic fracture. In addition the co-morbidity elevate ulteriorly the risks of the new operation which is often impossible or refused. Recently it has been recommended to orthopaedic surgeons the managment and treatment of osteoporosis. The aim of this study was to consider at 2 years follow-up the functional outcome of femoral fracture in osteoporotic elderly treated with a surgical procedure followed by daily assumption of teriparatide, an anabolic agent increasing bone mineral content, density and strength. Materials and Methods: 21 compliant female between 63 and 94 years-old presenting a femoral fracture were recruited. Before operation they undergone to a routinary instrumental examins completed by bone metabolism screening. This was constituted by biochemical bone turnover markers, standard radiograms of dorsal and lumbar spine. Lumbar and contralateral femoral BMD was measured by DXA during hospitalization before the assumption of anabolic agent. They received daily subcutaneous teriparatide (20 microg) per day for 18 months, 1g of calcium and 800 UI of vitamin D3 daily as oral supplementation from day 15 by operation. All the patients repeated: xrays of affected segment at 2, 4, 6 months; biochemical bone markers 1, 3, 6, 12, 18 and 24 months; DEXA at first and second year. The evaluation of the quality of life was evaluated in terms of recovery of walking, need of re.operation, occurance of new fracture and with a questionnaire. Results: eleven lateral femoral neck fracture treated with endomedullary nail, six medial femoral neck fracture treated with cemented endoprosthesis, four periprosthetic fracture of the femur treated with plaque and screws. The healing was detected with radiograms before 4th month. The vitamin D was at lower levels at admission but the supplementation was sufficient to normalize. The other biochemical variables of bone formation and resorption peaked within the consolidation process then remained normalized for two years. Lumbar and contralateral femoral BMD were increased after 12 months and maintained at 24 months. At 2 years follow-up all patients live, walk in autonomy without or with stick and none of them have needed a re-operation or was afflicted by new vertebral or non vertebral fracture. Conclusions: The clinical relevance of the present study is the significant improvement of functional outcome and quality of life after femoral fracture in osteoporotic elderly with post-operative assumption of anbolic agent as Teriparatide

Background: Iatrogenic hallux varus is a very disappointing potential complication following hallux valgus surgery. Depending on its clinical and radiological form, a possible surgical technique is the reconstruction of the lateral components of the first metatarsophalangeal joint.

Methods: A new surgical technique of ligamentoplasty based upon the use of the abductor hallucis tendon is described. The new method was applied in 5 patients (6 feet) with a mean follow-up of 25.8 months. Four hallux varus deformities were operated by only the transplant of the abductor hallucis tendon and two were associated with the use of an osseous buttress.

Results: We found a radiographic correction of most of the factors considered as being at the origin of the iatrogenically induced deformity. All of our patients considered the result as very good and no complications were noticed.

Conclusion: This new technique is a reliable, anatomic reconstruction with the use of the tendon participating in the physiopathology of the hallux varus deformity. No other functional tendon is harvested.

Introduction: Tibial plateau fracture is an intra-articullar complex fracture. Surgery aim is to restore articular surface height, preserve knee joints stability and alignment in order to obtain maximal range of motion and to prevent future joint degenerative changes. Ilizarov external frame using ligamentotaxis, minimal invasive techniques, smooth or olive wires (sometimes augmented by screws) allows articular surface reconstruction and stabilization. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring.

Study Aims: To assess the results of complex tibial plateau fracture treated with Ilizarov external fixator.

Materials and Methods: Between 1997–2005, twenty five patients with complex fractures of the tibial plateau, Schatzker type V–VI fractures (all closed), average age 45 years old (range 30–78) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. 11 out of 25 patients were treated with ligamentotaxis using extension of the frame to the femur with hinges on the center of joint rotation. Some of these patients (10 out of 11) required lateral minimal opening for joint surface elevation. 8 out of the 25 patients needed additional bone graft/ substitute supplementation. One needed 6.5 mm canulated cancellous screw augementation. Patients with below knee frame remain non-WB for 6 weeks and partial WB for another 6 weeks. Patients with above knee frame were allowed full WB. In 3 months the frame was removed under anesthesia and the knee was manipulated. Patients were placed in a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: All fractures united with an average time of 12 weeks. 22 patients had full extension with 100 degree of flexion or more. 3 patients had extension lag of 10–20 degree, one of them had 20 degree of posterior slop of the tibial plateau. All patients had normal axial alignment, except one case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient). One had mild unstable knee. One patient developed posttraumatic osteoarthrosis. There were no cases of postoperative infection, septic arthritis or neuro-vascular complications were reported. Pin site infection was resolved locally.

Conclusion: The use of Ilizarov external fixation in the management of complex tibial plateau fractures results in satisfactory out come as an alternative to the traditional tibial plateau open surgery. This minimal invasive intervention allowed the surgeons to reduce and fixate the tibial articular surface with out further damaging the soft tissue envelope.

Introduction: Treating tibial plateau fractures extreme care should be given to restore articular surface height preserving knee joint stability to be able to obtain maximal range of movement and to prevent future joint degenerative changes. Preoperative evaluation with CT and 3-D reconstruction is mandatory to understand the topography of the fracture for surgical planning. Traditional bone grafting techniques together with newer bone substitutes should be utilized in addition to ligamentotaxis when necessary. Fixation with smooth or olive wires (in occasions with washers for wider contact), sometimes augmented by screws is used with the Ilizarov external frame for stabilization avoiding extended incisions. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring. Guided by these principles, complex tibial plateau fractures were treated in our department and the results are reported.

Materials and Methods: Ten patients 40.6 years old on average (30–70) with Schatzker type V–VI fractures (all closed) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. Six were treated by ligamentotaxis and Ilizarov fixation alone and minimal opening for joint surface elevation when needed. The remaining 4 needed 6.5 mm canulated cancellous screw augmentation and 2 of them additional bone graft supplementation. Two patients needed extension of the frame to the femur with hinges on the center of joint rotation. All patients remain non-WB for 6 weeks and partial WB for another 6 weeks. Within 3 months the frame was removed and replaced by a brace or a cast-brace with full WB. Physiotherapy started early after the operation.

Results: The results were analyzed over an average follow-up period of 22.6 months (range 3–53). All fractures healed in an average of 12 weeks. Range of motion in all patients included full extension with 90° of flexion or more. No postoperative infections, septic arthritis or neurovascular complications were reported. Pin site infection was resolved locally. One case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient).

Discussion: Ilizarov external fixation for complex tibial plateau fractures offers the advantage of minimal invasive interventions with a high level of functionality since the early post operative period. The combination with minimal invasive opening for joint surface elevation and additional screws or bone graft extends even more the scope of the treatment. Functional results were similar to previous reported series. The good observance of traditional tibial plateau surgery principles should guide the surgeons when using this modality of treatment for optimal results.

Introduction: The use of a trans-physeal, trans-articular suture anchor across a joint as a means of internal stabilisation has not previously been described. This study assesses the damage caused by the procedure to the immature porcine hip.

Methods: Six twelve week old pigs underwent unilateral hip surgery. Anteroposterior pelvic radiographs were taken preoperatively and six weeks post-operatively. The acetabular index and diameter of the femoral head ossific nucleus of both hips were measured and compared. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions and for evidence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis and proximal femoral physeal arrest.

Results: In four out of six specimens the rate of change of the acetabular index slowed as compared to the unoperated side, though none worsened. The diameter of the femoral ossific nucleus continued to increase in size at a similar rate to the unoperated side on radiological examination. Similar findings were seen with the macroscopic analysis. Gross and histological analysis of the articular cartilage showed only local areas of chondrolysis, related to the drilling. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure.

Discussion: The use of a trans-articular suture-anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The trans-physeal approach to the hip does not appear to affect proximal femoral physeal or epiphyseal growth in the short-term, and the presence of a bioabsorbable suture within the joint did not result in chondrolysis.

Background

Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery.

Aims

The aim of this study was to determine whether chilled irrigation saline decreases the incidence of clinical upper limb palsy (ULP; a reduction of one grade or more on manual muscle testing; MMT), based on the idea that ULP results from thermal damage to the nerve roots by heat generated by friction during bone drilling.

Aims. We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes. Methods. A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included. Results. A total of 31 studies were identified, of which 13 described universal screening and 20 described selective screening. Two studies described both. The prevalence of late DDH was 0.10 per 1,000 live births (95% confidence interval (CI) 0.00 to 0.39) in the universal screening group and 0.45 per 1,000 live births (95% CI 0.31 to 0.61) in the selective screening group. Abduction bracing treatment was performed on 55.54 per 1,000 live births (95% CI 24.46 to 98.15) in the universal screening group versus 0.48 per 1,000 live births (95% CI 0.07 to 1.13) in the selective screening group. Both the universal and selective screening groups had a similar prevalence of surgical procedures in childhood for dysplasia being performed (0.48 (95% CI 0.32 to 0.63) vs 0.49 (95% CI 0.31 to 0.71) per 1,000 live births, respectively). Conclusion. Universal screening showed a trend towards lower prevalence of late DDH compared to selective screening. However, it was also associated with a significant increase in the prevalence of abduction bracing without a significant reduction in the prevalence of surgical procedures in childhood for dysplasia being performed. High-quality studies comparing both treatment methods are required, in addition to studies into the natural history of missed DDH. Cite this article: Bone Joint J 2023;105-B(2):198–208

Aim. There are no studies in literature that analyze the effectiveness of closed-incisional negative pressure wound therapy (ciNPWT) in the treatment of bone and joint infections (BJI). The aim of the study was to evaluate the efficacy and the safety of the application of ciNPWT in the postsurgical wound management of patients with osteoarticular infections. Method. We conducted a perspective single-center study on patients with BJI treated between 01/2022 and 10/2022 with ciNPWT dressing application at the end of the surgical procedure. All patients were treated by a multidisciplinary team (MDT) approach and operated by the same surgical equipe. Inclusion criteria were: presence of periprosthetic joint infection (PJI), fracture-related infection (FRI), osteomyelitis (OM), septic arthritis (SA) surgically treated, after which ciNPTW was applied over the closed surgical wound. 30 patients (19M, 11F) have been analyzed with mean age of 56,10±17,11 years old; BJIs were all localized in the lower limb (16 PJI, 12 FRI, 1 SA, 1 OM). Results. We considered the following clinical local pre-operative parameters: presence of fistula (10 patients, 33,33%), presence of erythema (18 patients, 60%), presence of previous flap in the incisional site (7 patients, 23,33%). In 11 cases (36,67%) more than 3 previous surgical procedures were performed in the surgical site. The following surgical procedures were performed: 8 debridement and implants removal, 7 DAIR, 3 one-stage exchange, 6 two-stage exchange, 3 spacer exchange, 3 resection arthroplasty. Nineteen patients (63,34%) showed no occurrence of any local post-operative complication (erythema, hematoma, wound breakdown, wound blister, necrosis). Seven (23,33%) patients showed the presence of one or more postoperative complications that didn't require additional surgery. We observed four (13,33%) failures, defined as the need for further surgical procedures following the onset of a local complication: two patients had a wound breakdown before wound closure and two had a recurrence of infection after an uneventfully wound closure. All failures were within the group of joint infection (PJI+SA) and were affected by a multi drug resistant pathogen. Conclusions. In our series four patients required further surgery, but only two cases were related to incisional wound problems, that is consistent with aseptic joint revision surgeries data that are available in literature (3.4%-6.9%)[1-2]. Patients affected by BJI are a group with significant high risk of failure and therefore the use of ciNPWT should be considered. However, randomized clinical trials are needed to establish the superiority of the ciNPWT dressing over the standard one