We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in Clostridium difficile colitis (p = 0.017), deep wound infection (p = 0.043) and gastrointestinal haemorrhage (p = 0.033). There were no differences in any patient risk factors (except the prevalence of chronic obstructive pulmonary disease), cause of death and length of stay before and after intervention. The underlying mechanisms are unclear, but may include improved efficiency and medical contact time. These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect

Several experimental models have been used to produce intravascular fat embolism. We have developed a simple technique to induce fat embolism using corn oil emulsified with distilled water to form fatty micelles. Fat embolism was produced by intravenous administration of these fatty micelles in anaesthetised rats, causing alveolar oedema, haemorrhage and increased lung weight. Histopathological examination revealed fatty droplets and fibrin thrombi in the lung, kidney and brain. The arteriolar lumen was filled with fatty deposits. Following fat embolism, hypoxia and hypercapnia occurred. The plasma phospholipase A. 2. , nitrate/nitrite, methylguidanidine and proinflammatory cytokines were significantly increased. Mass spectrometry showed that the main ingredient of corn oil was oleic acid. This simple technique may be applied as a new animal model for the investigation of the mechanisms involved in the fat embolism syndrome

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection. . Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination. . While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared

A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes. The patients were categorised into three groups: non-obese (body mass index (BMI) < 30 kg/m. 2. ), obese (BMI 30 to 40 kg/m. 2. ) and morbidly obese (BMI > 40 kg/m. 2. ). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%). There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients

1. Seven cases of haemophiliac arthropathy of the hip joint are reported. 2. Attention is drawn to the different appearances in the hip when it is affected before and after puberty. Before puberty there are features similar to pseudocoxalgia. After puberty there may be cyst formation, coxa valga, or features similar to osteoarthritis. 3. It is suggested that intra-osseous haemorrhage is important in the production of these changes and that intra-epiphysial haemorrhage is responsible for the appearances seen before puberty

1. Biopsies of muscle were taken during the course of operation from sixteen patients with vascular injuries to the limbs. Three types of histological change were found. 2. In the first, there was massive necrosis of muscle fibres—a group of cases in which there had always been serious damage to the main artery of the limb or to the vessel supplying the affected muscles. 3. In the second type there was dense interstitial fibrosis, the muscle fibres sometimes being normal and sometimes showing necrosis or denervation—a group of cases in which the vascular injury varied from severance of the vessels by gunshot wounds to trivial damage, causing slow haemorrhage within fascial-bound spaces. 4. The third type showed scattered foci of necrosis together with patchy interstitial fibrosis—due to the pressure of tight plasters, crushing of the limb, fractures with arterial contusion, or slow haemorrhage or extravascular transfusion within fascial planes. The rise of tension within the muscles was probably sufficient to occlude the smaller arterioles with resultant patchy necrosis. 5. The vulnerability of certain muscles to vascular damage is partly related to the intramuscular vascular pattern, of which five types have been described. 6. In ischaemic muscles the intramuscular nerve trunks may be normal or they may show evidence of degeneration or necrosis; but in favourable circumstances there may be regeneration of axons. 7. In some cases there was evidence of regeneration of muscle fibres in man, the regeneration being dependent to some extent upon the efficiency of intramuscular anastomoses. 8. The prognosis, in cases of ischaemia of human voluntary muscle, depends upon the extent and the reversibility of damage to both muscle and nerve fibres and upon the extent of regeneration of muscle fibres

We present a case of delayed presentation of a subdural haematoma causing cauda equina syndrome which occurred 96 hours after a spinal anaesthetic had been administered for an elective total hip replacement in an 86-year-old man. The patient had received low-molecular-weight heparin anticoagulation which had been delayed until 12 hours postoperatively. No other cause of the haemorrhage could be identified

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Aims

The risk of postoperative complications after resection of soft-tissue sarcoma in the medial thigh is higher than in other locations. This study investigated whether a vessel sealing system (VSS) could help reduce the risk of postoperative complications after wide resection of soft-tissue sarcoma in the medial thigh.

1. The management of fractures in seven haemophiliacs and one patient with Christmas disease is described. 2. The problems of management are essentially those associated with haemorrhage into the soft tissues. 3. There is no delay in the healing of fractures, which usually occurs with a relative lack of periosteal callus. 4. The principles of transfusion therapy are discussed

1. Exostosis bursata in a patient with hereditary multiple exostoses is described. 2. Fracture of the tip of the exostosis had occurred causing acute pain and haemorrhage into the bursa. 3. Although it appeared that it might be a pseudo-joint cavity the histological appearance indicated that it was a bursa caused by friction between the exostosis and the surrounding soft tissue

A total of 254 cases of synovial cysts of the spine have been reported in the English literature, but only eight have been associated with haemorrhagie. We describe a 55-year-old man with acute radiculopathy resulting from haemorrhage involving a synovial cyst at a lumbar facet joint. Traumatic factors could have caused bleeding around or into the synovial cyst. Treatment by resection of the cyst and evacuation of the haematoma led to complete neurological recovery

1. Figures relating to blood loss and post-anaesthetic progress during and after 407 orthopaedic operations performed with the aid of hexamethonium bromide are presented. 2. Two deaths from circulatory failure are examined in detail. 3. The criteria that must be observed to ensure safety are discussed. 4. Measures designed to avoid reactionary haemorrhage are enumerated. 5. Observations regarding contra-indications are presented

Ultrasound examination has been recommended for the evaluation of acute haemorrhages into soft tissues or joints in haemophilic patients. We have reviewed the notes of all such patients admitted during one calendar year and find that in 47 separate admissions the ultrasound examination assisted management decisions on 27 occasions. The technique is described with an analysis of the ways in which ultrasound observations may influence the clinician

1. The case history of a haemophiliac in whom a large haematoma of the thigh was treated by amputation of the limb is described. 2. Examination of the available radiographs and of the histology led to the conclusion that the cyst was subperiosteal in origin. 3. Evidence is presented to support the hypothesis that haemophilic pseudotumours are always associated with subperiosteal haemorrhage, and that those haemophilic cysts which are confined to muscle have little or no effect on the adjacent bone

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

1. Maffucci's syndrome consists of dyschondroplasia (Ollier's disease) in association with cavernous haemangiomata and phlebectasia. Twenty-two cases have hitherto been described. 2. A further case is recorded with autopsy findings showing the characteristic features of the syndrome. Death was caused by a chondrosarcoma of the sphenoid, which led to subarachnoid haemorrhage, cranial nerve palsies, crossed hemiplegia and cavernous sinus thrombosis with almost total pituitary necrosis

Thirteen elbows affected by severe haemophilic arthropathy and treated by silastic interposition arthroplasty were followed up for at least five years. The severity of pain, the frequency and severity of spontaneous haemorrhage and the range of movement were assessed before operation and at review. All patients were much improved and needed less factor replacement. Three elbows were revised, one for infection and two because of fragmentation of the silastic sheet. They regained good function following revision

Six patients with severe haemophilic arthropathy of the elbow have been treated by limited excision arthroplasty using a sheet of silicone rubber as an interposition membrane. There were no complications. The symptoms and signs before and after operation have been assessed using the grading system advocated recently by the World Federation of Haemophilia. In all cases there was relief of pain and increased movement. Moreover, the subsequent incidence of spontaneous haemorrhage into the elbow has been reduced with considerable cost benefit

1. Four joints of three young haemophiliacs who died in traffic accidents have been examined. 2. All patients had received prompt specific treatment for intra-articular and other haemorrhages. 3. Major macroscopic and histological changes were seen in the joints, but these changes were not quite so severe as those described before the days of specific treatment. 4. The possibilities of preventing articular changes and of minimising the effect of blood in the joints are discussed