Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019.Aims
Methods
The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day.Aims
Methods
Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment.Aims
Methods
We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable. Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners.Aims
Methods
We report our experience with glenohumeral arthrodesis
as a salvage procedure for epilepsy-related recurrent shoulder instability.
A total of six patients with epilepsy underwent shoulder fusion
for recurrent instability and were followed up for a mean of 39 months
(12 to 79). The mean age at the time of surgery was 31 years (22
to 38). Arthrodesis was performed after a mean of four previous
stabilisation attempts (0 to 11) in all but one patient in whom
the procedure was used as a primary treatment. All patients achieved
bony union, with a mean time to fusion of 2.8 months (2 to 7). There
were no cases of re-dislocation. One revision was undertaken for
loosening of the metalwork, and then healed satisfactorily. An increase
was noted in the mean subjective shoulder value, which improved
from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively
although it decreased in two patients. The mean Oxford shoulder
instability score improved from 13 pre-operatively (7 to 21) to
24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis
eliminated recurrent instability and improved functional outcome. Fusion
surgery should therefore be considered in this patient population.
However, since the majority of patients are young and active, they
should be comprehensively counselled pre-operatively given the functional
deficit that results from the procedure. Cite this article:
Drug therapy forms an integral part of the management
of many orthopaedic conditions. However, many medicines can produce
serious adverse reactions if prescribed inappropriately, either
alone or in combination with other drugs. Often these hazards are
not appreciated. In response to this, the European Union recently
issued legislation regarding safety measures which member states
must adopt to minimise the risk of errors of medication. In March 2014 the Medicines and Healthcare products Regulatory
Agency and NHS England released a Patient Safety Alert initiative
focussed on errors of medication. There have been similar initiatives
in the United States under the auspices of The National Coordinating
Council for Medication Error and The Joint Commission on the Accreditation
of Healthcare Organizations. These initiatives have highlighted
the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications
in orthopaedic practice. This is germane to safe and effective clinical
care. Cite this article:
Dislocation rates are reportedly lower in patients requiring
proximal femoral hemiarthroplasty than for patients undergoing hip
arthroplasty for neoplasia. Without acetabular replacement, pain
due to acetabular wear necessitating revision surgery has been described.
We aimed to determine whether wear of the native acetabulum following
hemiarthroplasty necessitates revision surgery with secondary replacement
of the acetabulum after proximal femoral replacement (PFR) for tumour
reconstruction. We reviewed 100 consecutive PFRs performed between January 2003
and January 2013 without acetabular resurfacing. The procedure was
undertaken in 74 patients with metastases, for a primary bone tumour
in 20 and for myeloma in six. There were 48 male and 52 female patients,
with a mean age of 61.4 years (19 to 85) and median follow-up of
two years (interquartile range (IQR) 0.5 to 3.7 years). In total,
52 patients presented with a pathological fracture and six presented
with failed fixation of a previously instrumented pathological fracture.Aims
Patients and Methods
A variety of operative techniques have been described as under
the term ‘Bristow-Latarjet’ procedure. This review aims to define
the original procedure, and compare the variation in techniques
described in the literature, assessing any effect on clinical outcomes. A systematic review of 24 studies was performed to compare specific
steps of the technique (coracoid osteotomy site, subscapularis approach,
orientation and position of coracoid graft fixation and fixation
method, additional labral and capsular repair) and detect any effect
this variability had on outcomes.Objectives
Materials and Methods
We have investigated the effect of using tranexamic
acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative
blood loss and blood transfusion requirements. In addition we analysed
whether the use of TXA was associated with an increased risk of
venous thromboembolism (VTE) following this procedure. A consecutive series of 96 PAOs, performed by a single surgeon,
were reviewed. A total of 48 patients received TXA and 48 did not.
The TXA group received a continuous infusion of TXA at a rate of
10 mg/kg/h. The primary outcome measure was the requirement for
blood transfusion. Secondary outcomes included total blood loss,
the decrease in the level of haemoglobin in the blood, the length
of hospital stay, and the complications of this treatment. The mean rate of transfusion was significantly lower in the TXA
group (62.5% The use of TXA reduced the blood loss and the rate of transfusion
after PAO significantly, without adverse effects such as an increased
rate of VTE. Cite this article:
Cerebral venous sinus thrombosis is a rare condition, which is difficult to diagnose. It has not previously been reported following surgery to the cervical spine . We report such a case in a 45-year-old man after cervical disc replacement. A high index of suspicion, with early imaging of the brain and prompt treatment, can produce a favourable outcome, albeit not in this case.
In this study we evaluated whether the Instability
Severity Index Score (ISIS) and the Western Ontario Shoulder Instability
Index (WOSI) could detect those patients at risk of failure following
arthroscopic Bankart repair. Between April 2008 and June 2010, the
ISIS and WOSI were recorded pre-operatively in 110 patients (87
male, 79%) with a mean age of 25.1 years (16 to 61) who underwent
this procedure for recurrent anterior glenohumeral instability. A telephone interview was performed two-years post-operatively
to determine whether patients had experienced a recurrent dislocation
and whether they had returned to pre-injury activity levels. In
all, six (5%) patients had an ISIS >
6 points (0 to 9). Of 100 (91%)
patients available two years post-operatively, six (6%) had a recurrent dislocation,
and 28 (28%) did not return to pre-injury activity. No patient who
dislocated had an ISIS >
6 (p = 1.0). There was no difference in
the mean pre-operative WOSI in those who had a re-dislocation and
those who did not (p = 0.99). The pre-operative WOSI was significantly
lower (p = 0.02) in those who did not return to pre-injury activity, whereas
the ISIS was not associated with return to pre-injury activity (p
= 0.13). In conclusion, neither the pre-operative ISIS nor WOSI predicted
recurrent dislocation within two years of arthroscopic Bankart repair.
Patients with a lower pre-operative WOSI were less likely to return
to pre-injury activity. Cite this article:
The treatment of a chronic posterior dislocation of the shoulder is often determined by the size of the associated impression fracture of the humeral head. Our hypothesis was that patients with a chronic unreduced posterior dislocation of the shoulder and a defect in the humeral head involving between 25% to 50% of the articular surface, would do better if reconstructed with an allograft from the femoral head rather than treated by a non-anatomical reconstruction. We reviewed ten men and three women with a mean age of 42 years (36 to 51) at a mean follow-up of 54 months (41 to 64) who had this procedure. At follow-up, nine had no pain or restriction of activities of daily living. Their mean Constant-Murley shoulder score was 86.8 (43 to 98). No patient had symptoms of instability of the shoulder. Reconstruction of the defect in the humeral head with an allograft provides good pain relief, stability and function for patients with a locked, chronic posterior dislocation where the defect involves between 25% and 50% of the circumference of the articular surface.
Blood loss during total knee replacement (TKR)
remains a significant concern. In this study, 114 patients underwent TKR,
and were divided into two groups based on whether they received
a new generation fibrin sealant intra-operatively, or a local infiltration
containing adrenaline. Groups were then compared for mean calculated
total blood volume (TBV) loss, transfusion rates, and knee range
of movement. Mean TBV loss was similar between groups: fibrin sealant
mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml
(261 to 2308) (p = 0.929). Overall, significantly fewer units of
blood were transfused in the fibrin sealant group (seven units)
compared with the local adrenaline group (15 units) (p = 0.0479).
Per patient transfused, significantly fewer units of blood were transfused
in the fibrin sealant group (1.0 units) compared with the local
adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin
sealant may reduce the need for multiple unit transfusions. Knee
range of movement was similar between groups. From our results,
it appears that application of this newer fibrin sealant results
in blood loss and transfusion rates that are low and similar to
previously applied fibrin sealants. Cite this article:
We describe a 23-year-old woman with neuritis ossificans involving the tibial, common peroneal and lateral sural nerves. She presented with chronic debilitating posterior knee pain. An MRI scan showed masses in these nerves, biopsy of which revealed a histological diagnosis of neuritis ossificans. Treatment with OxyContin and Neurotin for two years resulted in resolution of symptoms. Follow-up MRI demonstrated a resolution of two of the three masses. There was a persistent area of ossification without associated oedema in the common peroneal nerve. Neuritis ossificans has the histological appearance of myositis ossificans and follows a similar clinical course. The success of conservative treatment in this case suggests that the potential complications of surgical excision can be avoided.
To determine the morbidity and mortality outcomes of patients
presenting with a fractured neck of femur in an Australian context.
Peri-operative variables related to unfavourable outcomes were identified
to allow planning of intervention strategies for improving peri-operative
care. We performed a retrospective observational study of 185 consecutive
adult patients admitted to an Australian metropolitan teaching hospital
with fractured neck of femur between 2009 and 2010. The main outcome
measures were 30-day and one-year mortality rates, major complications
and factors influencing mortality. Objectives
Methods
The painful subluxed or dislocated hip in adults
with cerebral palsy presents a challenging problem. Prosthetic dislocation
and heterotopic ossification are particular concerns. We present
the first reported series of 19 such patients (20 hips) treated
with hip resurfacing and proximal femoral osteotomy. The pre-operative
Gross Motor Function Classification System (GMFCS) was level V in
13 (68%) patients, level IV in three (16%), level III in one (5%) and
level II in two (11%). The mean age at operation was 37 years (13
to 57). The mean follow-up was 8.0 years (2.7 to 11.6), and 16 of the
18 (89%) contactable patients or their carers felt that the surgery
had been worthwhile. Pain was relieved in 16 of the 18 surviving
hips (89%) at the last follow-up, and the GMFCS level had improved
in seven (37%) patients. There were two (10%) early dislocations;
three hips (15%) required revision of femoral fixation, and two
hips (10%) required revision, for late traumatic fracture of the
femoral neck and extra-articular impingement, respectively. Hence
there were significant surgical complications in a total of seven
hips (35%). No hips required revision for instability, and there
were no cases of heterotopic ossification. We recommend hip resurfacing with proximal femoral osteotomy
for the treatment of the painful subluxed or dislocated hip in patients
with cerebral palsy.
The aim of this study was to examine the rates
and potential risk factors for 28-day re-admission following a fracture
of the hip at a high-volume tertiary care hospital. We retrospectively
reviewed 467 consecutive patients with a fracture of the hip treated
in the course of one year. Causes and risk factors for unplanned
28-day re-admissions were examined using univariate and multivariate
analysis, including the difference in one-year mortality. A total
of 55 patients (11.8%) were re-admitted within 28 days of discharge.
The most common causes were pneumonia in 15 patients (27.3%), dehydration
and renal dysfunction in ten (18.2%) and deteriorating mobility
in ten (18.2%). A moderate correlation was found between chest infection
during the initial admission and subsequent re-admission with pneumonia
(r = 0.44, p <
0.001). A significantly higher mortality rate
at one year was seen in the re-admission group (41.8% (23 of 55)
Nutritional osteomalacia is a metabolic bone disorder common among the Asian female immigrant population in the United Kingdom. We describe the case of a female of Asian origin, who was found to have a unilateral undisplaced pseudofracture of the neck of the femur during pregnancy. Although not operated on the fracture was treated successfully with calcium and vitamin D supplement therapy. Within one month of treatment, the bone pain subsided and she was able to bear full weight. Subsequent radiological follow-up showed the pseudofracture to have healed sufficiently with no evidence of avascular necrosis. There should be a high index of suspicion of this disease, particularly among Asian patients presenting with persistent and non-specific musculoskeletal pain.
Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.
