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Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_9 | Pages 16 - 16
1 May 2014
Robiati L Nicol A
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Musculoskeletal injuries are one of the leading causes for morbidity within military personnel on operations and are the leading cause for aeromedical evacuation of British military personnel from Afghanistan for Disease and Non-Battle Injury. The objective of this study was to improve our knowledge relating to these injuries.

This prospective cohort study included all British military personnel presenting with musculoskeletal injuries to primary healthcare in Camp Bastion and the rehabilitation team working in British bases forwards of Bastion, Afghanistan. Injury report forms were completed by medical officers and physiotherapists. Data was collected over two separate two week periods during the first and second half of the tour.

273 injury forms were completed in total. Most injured body parts were back (23%), knee (17%), shoulder (13%) and ankle (13%). 53% were attributed to training, 25% were due to overuse and 37% were old injuries.

Leading cause for musculoskeletal injuries sustained on operations was training, not sport. Further studies are required to clarify what training factors are attributing to injuries which will enable design and implementation of prevention strategies.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_18 | Pages 17 - 17
1 Dec 2023
Sharma N George A Hampton M Barnett A
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Introduction. Trochleoplasty is an effective surgical procedure for patients with severe trochlear dysplasia and recurrent patella instability. Previous work has suggested patients demonstrate early improvements in knee function and quality of life. However, concerns regarding longer term outcomes due to the development of stiffness and patellofemoral osteoarthritis remain a concern for these patients. Our aim was to assess mid-term patient-reported outcome and quality of life measures for trochleoplasty performed at a single centre for severe trochlear dysplasia. Methods. Retrospective review of 28 knees (23 patients) having undergone trochleoplasty for severe trochlear dysplasia were reviewed. Due to the non-parametric nature of the data, median and interquartile range (IQR) were determined for pre-operative and mid-term follow-up scores. Statistically significant differences between groups were assessed using paired Wilcoxon-signed rank test with statistical significance set at p<0.05. Data were analysed using a statistical software package (IBM® SPSS® Statistics 26.0). Results. Median time from surgery to follow-up for all patients in the series was 5.3 years (IQR 3.9 – 7.0 years). Median pre-operative Kujala score improved from 57.0 (IQR 45 – 66) to 96.3 (IQR 83 -100). Median pre-operative IKDC score improved from 42.6 (IQR 35.9 – 51.3) to 92.6 (IQR 71.6 – 98.7). Median EQ-5D score also improved from 0.691 (IQR 0.414 – 0.727) to 1.000 (IQR 0.8178 – 1.000). Improvement in Kujala scores, IKDC scores and EQ-5D were all statistically significant with p<0.001 in all domains. Discussion. Our data suggests patients experience significant improvements in knee function and quality of life following trochleoplasty surgery for severe dysplasia. We demonstrate an absolute improvement in scores at a mean of 5.3 years follow-up of 39.3 points for Kujala, 50 for IKDC and 0.309 for EQ-5D. Minimal clinically important differences (MCID) have been reported to be in the region of 10 for the Kujala score, 8.8–15.6 for IKDC and 0.085 for EQ-5D. Our data shows improvements which far exceed the published MCID, suggesting trochleoplasty confers a large treatment effect and patients benefiting from sustained improvements in knee function and overall quality of life at mid-term follow-up. Conclusion. Following trochleoplasty for severe trochlear dysplasia, patient reported outcomes demonstrate continued improvements in knee function and quality of life at mid-term (5-year) follow-up. There is a large absolute treatment effect which likely impacts on both physical and psychological wellbeing for these patients. Continued surveillance of patient reported outcomes in this clinically complex cohort is indicated


Bone & Joint Research
Vol. 6, Issue 3 | Pages 144 - 153
1 Mar 2017
Kharwadkar N Mayne B Lawrence JE Khanduja V

Objectives. Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. Methods. We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. Results. Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. Conclusions. This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes. Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144–153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1


The Bone & Joint Journal
Vol. 100-B, Issue 6 | Pages 787 - 797
1 Jun 2018
Shuler MS Roskosky M Kinsey T Glaser D Reisman W Ogburn C Yeoman C Wanderman NR Freedman B

Aims. The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS). Patients and Methods. NIRS sensors were placed on 86 patients with, and 23 without (controls), severe leg injury. NIRS values were recorded for up to 48 hours. Longitudinal data were analyzed using summary and graphical methods, bivariate comparisons, and multivariable multilevel modelling. Results. Mean NIRS values in the anterior, lateral, superficial posterior, and deep posterior compartments were between 72% and 78% in injured legs, between 69% and 72% in uninjured legs, and between 71% and 73% in bilaterally uninjured legs. In patients without ACS, the values were typically > 3% higher in injured compartments. All seven limbs with ACS had at least one compartment where NIRS values were 3% or more below a reference uninjured control compartment. Missing data were encountered in many instances. Conclusion. NIRS oximetry might be used to aid the assessment and management of patients with ACS. Sustained hyperaemia is consistent with the absence of ACS in injured legs. Loss of the hyperaemic differential warrants heightened surveillance. NIRS values in at least one injured compartment(s) were > 3% below the uninjured contralateral compartment(s) in all seven patients with ACS. Additional interventional studies are required to validate the use of NIRS for ACS monitoring. Cite this article: Bone Joint J 2018;100-B:787–97


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 53 - 53
1 Sep 2012
Esteve C Esteve C Garcia-Forcada I Gina J
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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


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_7 | Pages 10 - 10
1 May 2019
Yousuf UBJ Skipsey DA Goodwin AM Stevenson IM
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Atypical femoral fractures (AFFs) are reported in patients taking bisphosphonates (BPs). This study aims to describe demographics, potential risk factors and outcome of fixation in AFFs. Forty-three patients with AFF were identified retrospectivity from all identified patients with subtrochanteric or diaphyseal fractures within NHS Grampian between 2008–2018. Patients were identified via hospital coding and electronic search of patients undergoing femoral fixation. AFFs were diagnosed by the 2014 American Society of Mineral and Bone Research diagnostic criteria by electronic patient record review by two investigators. Within this cohort, the incidence of AFF was 8.25% with male to female ratio of 10:1 and a mean of presentation age 73.3 years. 27.9% of AFFs occurred in the diaphysis. 22% of AFFs were bilateral. Mean follow-up was 11.5 months. 87.5% of patients had documented prodromal symptoms. 35% had proven radiological changes before fracture. All patients identified were on BPs. Duration of BPs before fracture was 5 months- 13.2 years (mean 6.3 years). Concurrent use of BPs with steroid and proton pump inhibitors was seen in 58.5%. All patients had intramedullary fixation with 8 (18.6%) requiring revision for non-union. For those that united radiologically it took on average 304 days (220–513). BPs were only stopped in 45% of patients after fixation. AFFs in this cohort appear to be associated with BP use, female sex, clinical and radiological prodrome. AFF remain a difficult clinical problem with a high revision rate. Further work is required to identify the temporal relationships and to raise awareness to improve surveillance/management


The Bone & Joint Journal
Vol. 104-B, Issue 10 | Pages 1156 - 1167
1 Oct 2022
Holleyman RJ Khan SK Charlett A Inman DS Johansen A Brown C Barnard S Fox S Baker PN Deehan D Burton P Gregson CL

Aims

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

Methods

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.


Bone & Joint Open
Vol. 3, Issue 9 | Pages 710 - 715
5 Sep 2022
Khan SK Tyas B Shenfine A Jameson SS Inman DS Muller SD Reed MR

Aims

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

Methods

Patient identifiers for a consecutive cohort treated between 1 January 2003 and 31 December 2011 were linked to radiographs, surgical notes, clinic letters, and mortality data from a national dataset. This allowed charting of their postoperative course, complications, readmissions, returns to theatre, revisions, and deaths. We also identified all postoperative attendances at the Emergency and Outpatient Departments, and recorded any subsequent skeletal injuries.


The Bone & Joint Journal
Vol. 106-B, Issue 7 | Pages 720 - 727
1 Jul 2024
Wu H Wang X Shen J Wei Z Wang S Xu T Luo F Xie Z

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Methods

A total of 1,047 limb osteomyelitis patients aged 18 years or older who underwent debridement and intraoperative culture at our clinic centre from 1 January 2011 to 31 December 2020 were included. Patient characteristics, infection eradication, and complications were analyzed between culture-negative and culture-positive cohorts.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 5 | Pages 679 - 686
1 May 2010
Das De S Setiobudi T Shen L Das De S

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_19 | Pages 3 - 3
1 Nov 2017
Tsang S McHugh M Guerendiain D Gwynne P Boyd J Walsh T Laurenson I Templeton K Simpson A
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Nasal carriers of methicillin sensitive Staphylococcus aureus (MSSA) have an increased risk for health-care associated infections. There is currently no national screening policy for the detection of MSSA in the UK. This study aimed to: evaluate the diagnostic performance of molecular and culture techniques in MSSA screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on MSSA detection in orthopaedic patients. Paired nasal swabs for PCR assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint replacement surgery. The prevalence of MSSA nasal colonisation was found to be between 22.4–35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p=0.005), failing to identify its presence in ∼1/3 of patients undergoing joint replacement surgery. Modelling these results to national surveillance data, it was estimated that 800–1200 MSSA surgical site infections could be prevented annually in the UK by using alternative diagnostic methods to direct culture in pre-operative MSSA screening and eradication programmes


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 554 - 554
1 Sep 2012
Sukeik M Ashby E Sturch P Aboelmagd K Wilson A Haddad F
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Introduction. Wound surveillance has been reported to result in a significant fall in the incidence of wound sepsis in total knee arthroplasty (TKA). However, there is currently little guidance on the definition of surgical wound infection that is best to be used for surveillance. The purpose of this study was to assess the agreement between three common definitions of surgical wound infection as a performance indicator in TKA; (a) the CDC 1992 definition, (b) the NINSS modification of the CDC definition and (c) the ASEPSIS scoring method applied to the same series of surgical wounds. Methods. A prospective study of 500 surgical wounds in patients who underwent knee arthroplasties between May 2002 and December 2004 from a single tertiary centre were assessed according to the different definitions of surgical wound infection. Results. A total of 500 wounds were assessed in 482 patients. Mean age of patients was 70+/−11 years, 61.6% were females, duration of surgery was 101+/−49 minutes and mean follow-up was 35.2+/−25.7 months. The most commonly isolated species were Coagulase negative staphylococci (33.3%), Staphylococcus aureus (25%) and Pseudomonas aeruginosa (16.6%). The mean percentage of wounds classified as infected differed substantially with different definitions: 5.8% with the CDC definition, 3.6% with the NINSS version and 2.2% with an ASEPSIS score > 20. When superficial infections (according to CDC category) were included, 5.2% (26) of all observed wounds received conflicting diagnoses, and 1.4% (7) were classified as infected by both ASEPSIS and CDC definitions. When superficial infections were excluded, the two definitions estimated about the same overall percentage infection (2.2% and 2.6% respectively), but there were almost three times as many conflicting infection diagnoses (n=14) as concordant ones (n=5). Conclusion. Distinctions in surgical wound infection definitions contribute to notable differences in how infections are classified after TKA. Even small changes made to the CDC definition, as with the NINSS version, caused major variation in estimated percentage of wound infection. A single definition used consistently can show changes in wound infection rates over time at a single centre. However, differences in interpretation prevent comparison between different centres


The Bone & Joint Journal
Vol. 103-B, Issue 12 | Pages 1802 - 1808
1 Dec 2021
Bruce J Knight R Parsons N Betteridge R Verdon A Brown J Campolier M Achten J Costa ML

Aims

Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

Methods

Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_19 | Pages 6 - 6
1 Nov 2017
Reidy M Collins C MacLean J Campbell D
Full Access

Following the neonatal examination the 6–8 week ‘GP check’ forms the second part of selective surveillance for developmental dysplasia of the hip (DDH) in the UK. We aim to investigate the effectiveness of this 6–8 week examination for DDH. This is a observational study including all infants born in our region over 5 years. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment record for early and late DDH as well as referrals for ultrasound (US) following the 6–8 week check were analysed. The attendance at the 6–8 week examination in those patients who went on to present with a late DDH was also analysed. 23112 live births, there were 141 confirmed cases of DDH. 400 referrals for ultrasound were received from GP; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended the 6–8 week examination and no abnormality had been identified. The sensitivity of the examination was 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%. For many years the 6–8 week ‘check’ has been thought of as a safety net for those children with DDH not identified as neonates, however we found that 4 out of every 5 children with DDH were not identified. It is essential efforts are made to impove detection as the long term consequences of late presentation can be life changing


Bone & Joint Open
Vol. 2, Issue 11 | Pages 958 - 965
16 Nov 2021
Craxford S Marson BA Nightingale J Ikram A Agrawal Y Deakin D Ollivere B

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Methods

Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 170 - 177
4 Jan 2021
Craxford S Marson BA Oderuth E Nightingale J Agrawal Y Ollivere B

Aims

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.

Methods

A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality.


Bone & Joint Open
Vol. 1, Issue 8 | Pages 481 - 487
11 Aug 2020
Garner MR Warner SJ Heiner JA Kim YT Agel J

Aims

To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

Methods

We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1307 - 1312
1 Oct 2019
Jacxsens M Schmid J Zdravkovic V Jost B Spross C

Aims

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

Patients and Methods

Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up.


The Bone & Joint Journal
Vol. 102-B, Issue 2 | Pages 155 - 161
1 Feb 2020
McMahon SE Diamond OJ Cusick LA

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Methods

We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59).


The Bone & Joint Journal
Vol. 101-B, Issue 9 | Pages 1129 - 1137
1 Sep 2019
Leer-Salvesen S Engesæter LB Dybvik E Furnes O Kristensen TB Gjertsen J

Aims

The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR).

Patients and Methods

A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours.