Aims

The aim of this study was to report the outcomes of patients with severe open fractures of the lower limb in the five years after they took part in the Wound management for Open Lower Limb Fracture (WOLLF) trial.

We report a patient who developed an aortic pseudoaneurysm in the L3–L4 disc space after lumbar disc surgery. The diagnosis was made by MRI and aortography, and repair using a prosthetic graft and anterior fusion was successful. We discuss the predisposing factors, the clinical picture and management of vascular injuries during disc excision

Vascular injuries after total hip arthroplasty are occasionally reported, but we have found only two cases of major arterial occlusion, and none at all involving the common femoral artery. We report two cases of occlusion of the common femoral artery after Charnley arthroplasties, one of which resulted in a below-knee amputation

I. Five cases of fracture and dislocation in the lower limb complicated by vascular injury are described and discussed. 2. Suspicion of arterial injury is an urgent indication for exploration. Conservative measures must not be undertaken without radiological evidence of an undamaged main limb artery. 3. The eventual outcome of arterial reconstruction cannot be forecast, but it is always worth while attempting unless the limb is obviously beyond hope of survival

1. The history of the development of the operation of sympathetic ganglionectomy for vasospasm is related. 2. A simple classification is given of the common diseases of the peripheral arteries. 3. The symptoms of peripheral arterial disease are described. 4. The investigations are discussed. 5. The treatment, both conservative and surgical, is discussed, with comments on arterial grafts. 6. Special points are made regarding poliomyelitis, acrocyanosis, Bazin's disease, cervical rib, vascular injuries and crutch arteritis. 7. The long-term results of sympathectomy are reviewed

Eleven patients underwent disarticulation for infected arthroplasty of the hip. Exchange total hip arthroplasty or conversion to a Girdlestone excision arthroplasty had been undertaken previously an average of 2.9 times. The indications for disarticulation were as a life-saving measure, or as a result of severe infection of soft tissue and bone, loss of bone stock, or vascular injury. While the indications for this drastic operation were highly individual, there were instances where disarticulation could have been avoided if repeated exchange operations had been eschewed in deference to a Girdlestone procedure

Aims

The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring. As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases

In an eight-year period we treated 51 cases of vascular injury associated with fractures and/or dislocations or soft-tissue injuries of the limbs. We relied on a clinical diagnosis and immediate exploration of blood vessels rather than the time-consuming procedure of arteriography. All patients were operated on by the orthopaedic residents on duty and not by vascular surgeons. Only 17 (33%) were repaired within six hours of injury. Limb viability with good function was obtained in 38. Complications included six deaths, four amputations, two renal failures and delayed occlusion in one case

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions

We retrospectively reviewed 56 patients (71 hips) treated by total replacement for severe disability after pelvic irradiation. Symptoms were associated with various radiological lesions due to irradiation, including atraumatic femoral-neck fracture, osteonecrosis of the femoral head or of the acetabulum, and radiation osteitis of the whole pelvis. From 1970 to 1982 we used standard cemented components in 49 hips and had a high rate of acetabular loosening (52%) at a mean follow-up of 69 months. This was probably due to the mechanical insufficiency of irradiated periacetabular bone. From 1983 to 1990 we routinely used acetabular reinforcement rings. The rate of aseptic acetabular loosening in 22 hips at a mean follow-up of 40 months was 19%, but there were two septic loosenings emphasising the risk of infection in these patients. When total replacement is required for an irradiated hip, we recommend reinforcement of the acetabulum using a metallic ring, but there is still an increased risk of infection and in difficult cases such as severe acetabular destruction or soft-tissue or vascular injuries, a Girdlestone procedure may be indicated

We report two cases of aneurysm of the external iliac artery after arthroplasty of the hip. In each case the patients suffered from severe, seropositive, rheumatoid arthritis, had been treated with oral corticosteroids and had defects in the acetabular floor which were complicated by sepsis. In these circumstances bleeding from the wound in the hip should be investigated by immediate arteriography with anteroposterior and lateral views. Though vascular injury during operations on the hip is rare, recognition is important as safe and satisfactory treatment can be achieved. In the surgical management of these cases the following points should be noted: an alternative blood supply to the limb must be established using separate surgical incisions; to reduce the risk of sepsis these incisions should be closed and dressed before exploring the aneurysm; the aneurysmal vessel must be isolated and ligated, no attempt being made at primary repair; the aneurysm should be opened longitudinally to avoid damaging the femoral nerve which overlies it; and all foreign material should be removed from the hip

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor

Aims

Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue.

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Aims

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

Aims

The aim of this study was to define the complications and long-term outcome following adolescent mid-shaft clavicular fracture.