Aims

As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency.

Aims

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths.

Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Cite this article: Bone Joint J 2014;96-B:1090–7.

Certain acetabular fractures involve impaction of the weight-bearing dome and medialisation of the femoral head. Intra-operative fracture reduction is made easier by traction on the limb, ideally in line with the femoral neck (lateral traction). However, holding this lateral traction throughout surgery is very difficult for a tiring assistant.

We detail a previously undescribed technique of providing intra-operative lateral femoral head traction via a pelvic reduction frame, to aid fixation of difficult acetabular fractures. The first 10 consecutive cases are reviewed (Group 1) and compared with a retrospective control (Group 2, n=18) of case-matched patients, treated prior to introducing the technique. The post-operative X-rays and CT scans were assessed to identify quality of fracture reduction according to the criteria of Tornetta and Matta. Operative time, blood loss and early complication rates were also compared.

All cases in both groups were acute injuries with medial and/or superior migration of the femoral head. The majority were either associated both column or anterior column posterior hemi-transverse. There was no statistical difference between the groups in age, time to surgery, BMI or ASA grade.

Fracture reduction was assessed as excellent in seven, good in three and poor in one. This was not significantly different from the control group (p=0.093). The mean operative time was 232 minutes in Group 1 and 332.78 minutes in Group 2 (p = 0.0015). There was no difference between the groups for blood loss or complication rates.

We conclude that this new technique is at least equivalent to using manual traction and early results suggest it reduces operative time and technical difficulty in treating these complex acetabular fractures.

The purpose of this study was to evaluate the results of LISS fixation of distal femur fractures

This is a single-centre review of 64 consecutive LISS plates used for distal femoral fractures over 5.5 years. No patients were excluded and all were followed for a minimum of one year (mean 37 months). Primary outcomes were time to union, knee ROM, Knee Outcome Survey Activities of Daily Living Scale and SF-36 scores. Secondary outcomes were fracture alignment, additional surgery and complications.

Sixty-four fractures were followed in 62 patients with a bimodal distribution of age (mean 66 yrs, 14–98 years). Two major subgroups were young patients (55 and under) with high-energy fractures, most common in men (12:4) and elderly patients with insufficiency or peri-prosthetic fractures, more common in women (11:35). Twenty-two patients died prior to clinical follow-up in the study, but only eight of these died prior to radiological and clinical bony union. No other patients were lost to follow-up. Ninety-four percent of patients achieved within 10 degrees of full knee extension (mean 1.4 degrees), whilst 74% achieved knee flexion > 100 degrees and all achieved 90 degrees. Mean union time was 6.8 months and there was one infected non-union. There were 28 re-operations in 17 patients. Ten were for removal of metal-ware, four required bone grafting and two had revision of fixation.

LISS fixation is a reproducible technique, producing reliable union, low re-operation rates (other than metal-ware removal) and good restoration of knee function. LISS is good for both high and low energy injury patterns and works well in the presence of both knee and hip replacements. We recommend bi-cortical proximal fixation in osteoporotic bone.