Introduction

We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame.

Introduction

Infection is disastrous in arthroplasty surgery and requires multidisciplinary treatment and debilitating revision surgery. Between 80-90% of bacterial wound contaminants originate from colony forming units (CFUs) present in operating room air, originating from bacteria shed by personnel present in the operating environment. Steps to reduce bacterial shedding should reduce wound contamination. These steps include the use of unidirectional laminar airflow systems and the introduction of theatre attire modelled on this principle (e.g. total body exhaust suits). Our unit introduced the use of the Stryker Sterishield Personal Protection System helmet used with laminar flow theatre systems. This study compares an enclosed helmet system used with standard gowns, with standard hood and mask attire.

With increased shift working, multiple hand-overs, demand for trauma beds frequently outstripping supply, split-site working, shared care with other specialties and tertiary referrals awaiting transfer, keeping track of trauma patients can be difficult. To solve this problem we developed the Virtual Trauma Orthopaedic Management System (VTOMS) to monitor pre-operative trauma inpatients. VTOMS is a secure, networked system linked to the patient administration system (PAS). It can be accessed by the entire multidisciplinary team from any PC in the Trust. The main information is also displayed on plasma screens in the trauma unit.

The status of patients requiring surgery is displayed (e.g. fit and ready, awaiting investigation, or unfit) with alerts on acutely unwell or unstable patients. Further details can be obtained by ‘drilling down’. The system has an inbuilt patient clock which ‘traffic lights’ patients awaiting theatre, providing a visual warning if waiting time is prolonged. Amber is set at 48 hours and red is 72 hours for most injuries. This facilitates real-time management of the trauma workload, allowing extra resources to be deployed early if it is seen that waiting times are climbing, or the case-mix is particularly complex.

After successful use on trauma inpatients, the VTOMS system was extended to create a ‘virtual trauma ward’ where patients are pre-assessed in hospital and, if clinically appropriate, wait at home until a suitable theatre slot becomes available. The patient is contacted daily to monitor their clinical situation and brought in fasting on the morning of surgery. Using this ‘just in time’ philosophy 195 patients passed through our ‘virtual trauma ward’ in the six months to December 2009. The reduced length of stay saved 514 bed days, equivalent to £115,650 (£231,300 per annum), and minimised the impact of trauma on the elective service.

We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame.

A retrospective review of 40 patients treated between 2003 and 2009. There were 19 cases of infected non union, 9 cases of acute bone loss following fracture, 6 cases of chronic osteomyelitis, 4 cases of aseptic non union, 1 case of neurofibromatosis and 1 case of a loose and infected total ankle replacement.

Twenty-eight out of the 40 patients reviewed have completed their treatment. Of these 28 patients, bony union was achieved in 23 patients, of whom 22 were assessed at discharge to have regained good to excellent limb function, a functional assessment was not available for review in the remaining patient.

In 5 patients, docking site union failed, 3 of whom then underwent below knee amputation. Two patients required treatment with an intramedullary nail following frame treatment to achieve consolidated union of the docking site.

Anatomic sagittal and coronal alignment was achieved in 19 out of 23 patients.

The mean bone regenerate was 53.3 mm (range: 15-180mm), with a mean healing index of 9.2 days/mm (range: 4.4-25 days/mm)

The majority of patients experienced at least one complication, these included pin site and soft tissue infections, refracture, nerve palsy and joint stiffness. Surgical stimulation of the docking site was required in 12 of the 28 patients to promote union.

The use of a stacked Taylor Spatial Frame system is effective for restoring bone length and limb function in patients with bone loss following complex trauma and orthopaedic cases. The computer assisted nature of the spatial frame allows for predictable bone regenerate, minimal residual deformity and accurate bone docking

Aim

Biomechanical models of the shoulder have been used to measure forces and glenohumeral pressures. Their results have been found to vary. The aim of this study was to produce a biomechanical model to replicate the biomechanical principles of the glenohumeral joint and to measure the centre of pressure on the glenoid through a mid-range of arm movement with an intact and a compromised rotator cuff.

Background

Salvage procedures on the 1^st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem.

If excellence in patient care is to be our aim and priority then serious deviations from this path must be defined and dealt with early in the life and practice of any surgeon. ‘Red flags’ are often seen in training years but should have been recognised and dealt with prior to selection (or even undergraduate years).

Dealing with the dysfunctional or incompetent ‘registered surgeon’ may not be quite as simple, however, and is doubly difficult if the ‘surgeon of concern’ seeks to ‘cross borders’ or seek registration in other countries/states. Although registration boards/councils have been the ‘gate-keepers’ of this process in the past, the complexity and volume of work has expanded enormously. The legal system has been involved (with great and good effect in some instances) but perhaps to the detriment of the process and certainly in a form that becomes a serious impediment to rapid resolution of the problem both in time and cost.

In Australia, states and territories have set up Commissions that may be more effective. Legislatively, the ‘Health Quality and Complaints Commission’ in Queensland was set up to deal with complaints about medical/surgical health care delivery in all sectors of the community.

The author looks at the ways in which surgeons' input into these structures might assist and substantially improve the processes by which the continuing problems surrounding poor surgical practice and professional behaviour may be effectively dealt with in a time- and cost-effective manner.

Aims

To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years.