COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19.Aims
Methods
To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods.Aims
Methods
The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function.Aims
Methods
The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.
Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing. We established a custom-made chamber with airflow for rats to inhale cigarette smoke continuously, and tested our hypothesis using a femoral osteotomy model, radiograph and microCT imaging, and various biomechanical and biological tests.Aims
Methods
Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated. A total of 86 consecutive patients with a long tibial bone defect (≥ 8 cm), who were treated between January 2008 and January 2015, were retrospectively reviewed. A total of 45 were treated by BFT and 41 by TFT. The median age of the 45 patients in the BFT group was 43 years (interquartile range (IQR) 23 to 54).Aims
Patients and Methods
A possible solution for the management of proximal femoral bone
loss is a modular femoral endoprosthesis (EPR). Although the outcome
of EPRs in tumour surgery has been well described, the outcome of
their use in revision hip surgery has received less attention. The
aim of this study was to describe the outcome of using EPR for non-neoplastic
indications. A retrospective review of 79 patients who underwent 80 EPRs for
non-neoplastic indications was performed, including the rates of
complication and survival and the mean Oxford Hip Scores (OHS),
at a mean of five years post-operatively. The mean age at the time
of surgery was 69 years (28 to 93) and the mean number of previous operations
on the hip was 2.4 (0 to 17). The most common indications for EPR
implantation were periprosthetic joint infection (PJI) (n = 40),
periprosthetic fracture (n = 12) and failed osteosynthesis of a
proximal femoral fracture or complex trauma (n = 11).Objectives
Methods
The aim of this study was to investigate the outcomes of Vancouver
type B2 and B3 fractures by performing a systematic review of the
methods of surgical treatment which have been reported. A systematic search was performed in Ovid MEDLINE, Embase and
the Cochrane Central Register of Controlled Trials. For inclusion,
studies required a minimum of ten patients with a Vancouver type
B2 and/or ten patients with a Vancouver type B3 fracture, a minimum
mean follow-up of two years and outcomes which were matched to the type
of fracture. Studies were also required to report the rate of re-operation
as an outcome measure. The protocol was registered in the PROSPERO
database. Aims
Materials and Methods
Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients. A total of 32 cases of post-traumatic osteomyelitis were admitted to our department between August 2011 and October 2012. This retrospective study included 22 men and ten women, with a mean age of 40 years (19 to 70). Within this group there were 20 tibias and 12 femurs with a mean defect of 5 cm (1.5 to 12.5). Antibiotic-loaded PMMA cement was inserted into the defects after radical debridement. After approximately eight weeks, the defects were implanted with bone graft.Objectives
Methods
The aim of this study was to identify risk factors for the failure
of exchange nailing in nonunion of tibial diaphyseal fractures. A cohort of 102 tibial diaphyseal nonunions in 101 patients with
a mean age of 36.9 years (15 to 74) were treated between January
1992 and December 2012 by exchange nailing. Of which 33 (32%) were
initially open injuries. The median time from primary fixation to
exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to
9.8 months). The main outcome measures were union, number of secondary fixation
procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify
risk factors for failure to achieve union. Aims
Patients and Methods
The purpose of this prospective study was to evaluate the outcomes
of coccygectomy for patients with chronic coccydynia. Between 2007 and 2011, 98 patients underwent coccygectomy for
chronic coccydynia. The patients were aged >
18 years, had coccygeal
pain, local tenderness and a radiological abnormality, and had failed
conservative management. Outcome measures were the Short Form 36
(SF-36), the Oswestry Disability Index (ODI) and a visual analogue
scale (VAS) for pain. Secondary analysis compared the pre-operative
features and the outcomes of patients with successful and failed
treatment, two years post-operatively. The threshold for success
was based on a minimum clinically important difference (MCID) on
the ODI of 20 points. All other patients, including those lost to
follow-up, were classified as failures.Aims
Patients and Methods
Infected nonunion of a long bone continues to
present difficulties in management. In addition to treating the infection,
it is necessary to establish bony stability, encourage fracture
union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in
66 patients treated in a multidisciplinary unit. The operative treatment
of patients suitable for limb salvage was performed as a single
procedure. Antibiotic regimes were determined by the results of
microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%)
had an infection-free united fracture in a functioning limb. Seven
others required amputation (three as primary treatment, three after
late failure of limb salvage and one for recalcitrant pain after
union). The initial operation achieved union in 54 (84%) of the salvaged
limbs at a mean of nine months (three to 26), with recurrence of
infection in 9%. Further surgery in those limbs that remained ununited
increased the union rate to 62 (97%) of the 64 limbs treated by
limb salvage at final follow-up. The use of internal fixation was
associated with a higher risk of recurrent infection than external
fixation. Cite this article:
High-intensity narrow-spectrum (HINS) light is
a novel violet-blue light inactivation technology which kills bacteria through
a photodynamic process, and has been shown to have bactericidal
activity against a wide range of species. Specimens from patients
with infected hip and knee arthroplasties were collected over a
one-year period (1 May 2009 to 30 April 2010). A range of these
microbial isolates were tested for sensitivity to HINS-light. During
testing, suspensions of the pathogens were exposed to increasing
doses of HINS-light (of 123mW/cm2 irradiance). Non-light exposed
control samples were also used. The samples were then plated onto
agar plates and incubated at 37°C for 24 hours before enumeration.
Complete inactivation (greater than 4-log10 reduction)
was achieved for all of the isolates. The typical inactivation curve
showed a slow initial reaction followed by a rapid period of inactivation.
The doses of HINS-light required ranged between 118 and 2214 J/cm2.
Gram-positive bacteria were generally found to be more susceptible
than Gram-negative. As HINS-light uses visible wavelengths, it can be safely used
in the presence of patients and staff. This unique feature could
lead to its possible use in the prevention of infection during surgery
and post-operative dressing changes. Cite this article:
The December 2012 Trauma Roundup360 looks at: whether tranexamic acid stops bleeding in trauma across the board; antibiotic beads and VAC; whether anaesthetic determines the outcome in surgery for distal radial fractures; high complications in surgery on bisphosphonate-hardened bone; better outcomes but more dislocations in femoral neck fractures; the mythical hip fracture; plate augmentation in nonunion surgery; and SIGN intramedullary nailing and infections.
There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents.
While the demand for orthopaedic surgical expertise in the developing world is in critically short supply, short-term remedy from visiting doctors cannot solve this long-term healthcare problem. Capacity building by senior and training orthopaedic surgeons from established Western training programmes can offer a significant contribution to the orthopaedic patient in the developing world and the gains for those visiting are extremely valuable. We report on several visits by a UK orthopaedic team to a hospital in Kabul, Afghanistan and discuss the operative and non-operative case mix and the benefits in terms of local capacity building and the unique experience of those visiting.
All major studies have incorporated the use of prolonged courses of parenteral or oral antibiotic therapy in the management of two-stage revision of an infected total knee arthroplasty. We present a series of 59 consecutive patients, all with microbiologically-proven deep infection of a total knee arthroplasty, in whom a prolonged course of antibiotic therapy was not routinely used. The mean follow-up was 56.4 months (24 to 114). Of the 38 patients who underwent a staged exchange, infection was successfully eradicated in 34 (89%) but recurrent or persistent infection was present in four (11%). Our rate of cure for infection is similar to that reported elsewhere. We conclude that a prolonged course of antibiotic therapy seems not to alter the incidence of recurrent or persistent infection. The costs of the administration of antibiotics are high and such a regime may be unnecessary.
Between 1990 and 2001, 24 children aged between 15 months and 11 years presented with late orthopaedic sequelae after meningococcal septicaemia. The median time to presentation was 32 months (12 to 119) after the acute phase of the disease. The reasons for referral included angular deformity, limb-length discrepancy, joint contracture and problems with prosthetic fitting. Angular deformity with or without limb-length discrepancy was the most common presentation. Partial growth arrest was the cause of the angular deformity. Multiple growth-plate involvement occurred in 14 children. The lower limbs were affected much more often than the upper. Twenty-three children underwent operations for realignment of the mechanical axis and limb-length equalisation. In 15 patients with angular deformity around the knee the deformity recurred. As a result we recommend performing a realignment procedure with epiphysiodesis of the remaining growth plate when correcting angular deformities.
