Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

Periprosthetic joint infection (PJI) occurs in 0.2-2% of primary hip and knee arthroplasty and is a leading cause of revision surgery, impaired function, and increased morbidity and mortality. Topical, intrawound vancomycin administration allows for high local drug concentrations at the surgical site and has demonstrated good results in prevention of surgical site infection after spinal surgery. It is a promising treatment to prevent infection following hip and knee arthroplasty. Prior studies have been limited by small sample sizes and the low incidence of PJI. This systematic review and meta-analysis was performed to determine the effectiveness of topical vancomycin for the primary prevention of PJI in hip and knee arthroplasty.

A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to PRISMA guidelines. Studies comparing topical vancomycin to standard perioperative intravenous antibiotics in primary THA and TKA with a minimum of three months follow-up were identified. The results from applicable studies were meta-analysed to determine the impact of topical vancomycin on PJI rates as well as wound-related and overall complications. Results were expressed as odds ratios (ORs) and 95% confidence intervals

Nine comparative observational studies were eligible for inclusion. 3371 patients treated with 0.5-2g of topical vancomycin were compared to 2884 patients treated with standard care. Only one of nine studies found a significantly lower rate of PJI after primary THA or TKA (OR 0.09-1.97, p=0.04 for one study, p>0.05 for eight of nine studies), though meta-analysis showed a significant benefit, with vancomycin lowering PJI rates from 1.6% in controls to 0.7% in the experimental group (OR 0.47, p=0.02, Figure 1). Individually, only one of five studies showed a significant benefit to topical vancomycin in THA, while none of seven studies investigating PJI after TKA showed a benefit to topical vancomycin. In meta-analysis of our subgroups, there was a significant reduction in PJI with vancomycin in THA (OR 0.34, p=0.04), but there was no significant difference in PJI after TKA (OR 0.60, p = 0.13). In six studies which reported complication rates other than PJI, there were no significant differences in overall complication rates with vancomycin administration for any study individually (OR 0.48-0.94, p>0.05 for all studies), but meta-analysis found a significant difference in complications, with a 6.7% overall complication rate in controls compared to 4.8% after topical vancomycin, largely driven by a lower PJI incidence (OR 0.76, p=0.04).

Topical vancomycin is protective against PJI after hip and knee arthroplasty. No increase in wound-related or overall complication rates was found with topical vancomycin. This meta-analysis is the largest to date and includes multiple recent comparative studies while excluding other confounding interventions (such as povidone-iodine irrigation). However, included studies were predominantly retrospective and no randomized-controlled trials have been published. The limited evidence summarized here indicates topical vancomycin may be a promising modality to decrease PJI, but there is insufficient evidence to conclusively show a decrease in PJI or to demonstrate safety. A prospective, randomized-controlled trial is ongoing to better answer this question.

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The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed.

We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission.

A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001).

This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI.

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness.

We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination.

In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications.

In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA.

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis.

The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts.

Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care).

General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates.

In addition to mechanical stresses, an inflammatory mediated association between obesity and knee osteoarthritis (OA) is increasingly being recognised. Adipokines, such as adiponectin and leptin, have been postulated as likely mediators. Clinical and epidemiological differences in OA by race have been reported. What contributes to these differences is not well understood. In this study, we examined the profile of adipokines in knee synovial fluid (SF) and the gene expression profile of the infra-patellar fat pad (IFP) by race among patients with end-stage knee OA scheduled for knee arthroplasty.

Age, sex, weight and height (used to derive body mass index (BMI)) and race (White, Asian and Black) were elicited through self-report questionnaire prior to surgery. SF and IFP samples were collected at the time of surgery. Adipokines (adiponectin and leptin) were examined in the SF using MAGPIX Multiplex platform. IFP was profiled using Human Adipogenesis PCRArray and genes of interest were further validated via quantitative relative RT-PCR using Student's t-test. Overall differences in adiponectin and leptin concentrations were tested across race. Linear regression modeling was used to investigate the association between adiponectin and leptin concentrations (outcomes) and race (predictor; referent group: White), adjusting for age, sex and BMI.

67 patients (18 White, 33 Asian, 16 Black) were included. Mean SF adiponectin concentration was greatest in Whites (1175.05 ng/mL), followed by Blacks (868.53 ng/mL) and Asians (702.23 ng/mL) (p=0.034). The mean SF leptin concentration was highest in Blacks (44.88 ng/mL), followed by Whites (29.86 ng/mL) and Asians (20.18 ng/mL) (p=0.021). Regression analysis showed Asians had significantly lower adiponectin concentrations compared to Whites (p<0.05). However, leptin concentrations did not differ significantly by race after adjusting for covariates. Testing of the IFP, using the Adipogenesis PCRArray, showed significant higher expression of LEP gene (leptin, p=0.03) in Asians (n=4) compared to Whites (n=4).

There appears to be important racial differences in the SF adiponectin profile among individuals with end-stage knee OA. Differential gene expression in the IFP across racial groups could be a potential contributory source for the noted SF variations. Further work to determine the source and function of adipokines in knee OA pathophysiology across racial groups is warranted.

Patients undergoing Joint Arthroplasty received a significant proportion of blood transfusions. In this study, we compared the risk of Deep Infection, and Superficial Infection post operation following Primary Total Hip or Knee replacement in blood-transfused and non-blood-transfused patients.

Cohort of patients who underwent primary total Hip or Knee Arthroplasty from April 2012 to March 2015 in Alberta. Patient characteristics, comorbidity, received blood transfusion were collected from electronic medical records, operating room information systems, discharge abstract database, provincial clinical risk grouper data. Deep Infection and Superficial Infection were captured from Provincial Surgical Site Infection Surveillance data. Deep Infection include deep incisional and organ/space infections. Logistic regression analysis were used to compare Deep Infection and Superficial Infection in blood-transfused and non-blood-transfused cohorts, and risk-adjusted for age, gender, procedure type, and co-morbidities.

Our study cohort contains 27891 patients, with mean of age at admission was 66.3±10.4, 57.5% female, 49.3% had 1 or more comorbidities. 58.8% underwent Knee Replacement. 11.1% received blood transfusion during hospital stay (Total Hip Replacement (THR) =13.1% and Total Knee Replacement (TKR) =9.7%,). 1.1% had Deep Infection (THR=1.4% and TKR=0.9%) and 0.5% had Superficial Infection (THR=0.5% and TKR=0.5%). Blood-transfused patients got 1.7% Deep Infection and 1.0% Superficial infection. Non-blood-transfused patients got 1.0% Deep Infection and 0.5% Superficial infection. Controlling for age, gender, procedure type, and co-morbidities, the odds of Deep Infection were 1.6 times higher for blood-transfused patients than for non-blood-transfused patients (adjusted odds ratio [OR]=1.6, 95% confidence interval [CI] [1.2–2.2], p=0.004). The odds of Superficial Infection were 2.0 times higher for transfused patients (adjusted OR=2.0, 95% CI [1.3–3.0], p=0.002).

Blood transfusion increases Deep Infection and Superficial Infection post-surgery following Primary Total Knee or Hip Replacement. This finding suggests to reduce the unnecessary blood transfusion for patients considering Joint Arthroplasty. Reducing the blood transfusion will save the inpatient cost and decrease the infective complications post-surgery in Hip or Knee Arthroplasty patients.

For degenerative osteoarthritis of the knees, a variety of non-surgical management options have been tried from time to time. Medical management, chondroprotective agents, disease modifying drugs, viscosupplimentation etc. to name a few. Arthroscopic knee lavage with saline also has shown good results, with the effect of cleaning the debries from the joint.

Growth Factors Rich Plasma (GFRP) or Platelet Rich Plasma (PRP) is an emerging treatment therapy called “ Orthobiologics”. Alfa granules in platelets contain numerous growth factors which enhance tissue recovery dramatically by catalyzing the body's natural healing response. PRP also attracts Mesenchymal Stem Cells, which differentiate into variety of cell types during tissue repair processes & induce the production of new collagen by the fibroblasts, osteoblasts and chondrocytes as per the need of the parent tissue.

Knee lavage is done under local anesthesia using single antero-lateral portal. Four liters of saline is used to lavage the knee and at the end of procedure 80 mg. methyl prednisolone is injected. For GFRP injection, 100 cc of patient's blood is double centrifuged in the refrigerated blood component separator centrifuge in the blood bank giving about 15 cc of buffy layer having GFRP.

Since Feb. 2010, more than 1000 knees of different grades of osteoarthritis have been injected with GFRP and the results compared with other different treatment options. Results of few different combination therapies are presented in this study. 1. Knee Lavage Vs Autologous GFRP Injection (100+100 cases) 2. Knee Lavage + Autologous GFRP Injection in 1 knee Vs GFRP Injection only in other knee (200+200 Knees) 3. Visco-supplimentation Vs Autologous GFRP Injection. (10+10cases)

Results were analyzed up to 1 year as per VAS scale. Knee Lavage clears the joint of the microscopic and macroscopic debris of the cartilage and synovium which are causing chemical and mechanical irritation resulting in the inflammatory cascade. GFRP injection tries to repair the cartilage by the efficacy of the Growth factors contained therein. It has been observed that Knee Lavage and GFRP Injection have almost similar efficacy at 1 year, though knee lavage starts showing its effects early. GFRP therapy has shown better results compared to visco supplimentation at 1 year. Combination of knee lavage with GFRP injection showed much better results than GFRP injection alone and the results are inversely related to the grade of the osteoarthritis. Viscosupplimentation has very short lived efficacy.

It's concluded that Knee Lavage followed by GFRP injection gives the best long term results and this pilot project initiated, hopefully will go a long way in future to change the course of the management for osteoarthritis knees at a minimal cost and may obviate the need for Knee arthroplasty if started in early stages of Osteoartrhritis.

Purpose

Conflict of interest reporting at annual orthopaedic surgical meetings aims to ensure transparency of surgeon-industry relationships. Increasing rigor in the reporting guidelines provides a unique opportunity to understand the impact of industry relationships in the conduct of orthopaedic research. We examined self-reported conflicts by surgeons presenting original research in arthroplasty and trauma meetings.

Introduction: Giant cell tumor (GCT) is a benign but locally aggressive tumor that primarily affects the epiphyses of long bones of young adults. Pulmonary metastases in giant cell tumor are rare. We report our experience of treating pulmonary metastatic GCT of bone over the last 24 years between 1984–2007.

Methods: A retrospective review of patients’ records and oncology database of patients with metastatic GCT

Results: We had 471 patients with GCT of bone out of which 7 patients developed pulmonary metastases (1.48%). Six patients following diagnosis and initial treatment and one with pulmonary metastases present at the diagnosis. There were 4 males and 3 females aged between 23 to 40 years (median, 27 years). All patients had GCT around the knee (distal femur/proximal tibia). All patients eventually required Endoprosthetic Replacement apart from one who was treated with curettage only. The time of pulmonary metastases from initial diagnosis was 16–92 months (median, 44.6 months). All patients who developed metastases in the postoperative period had thoracotomy for excision of the pulmonary metastases. Two patients received chemotherapy for control of the local recurrence. At an average follow up of 151 months (27–304 months), all patients were alive

Discussion: Pulmonary metastases have been reported as 1% to 9% in GCT. Because of its rarity, very little is known about the long-term outcome and the best treatment for the pulmonary lesions. The mortality rates recorded for patients with pulmonary metastatic GCT range from 0% to 37%. In our series the mortality rate was 0% and metastases 1.48%. It seems that surgical resection of pulmonary metastases gave excellent rate of survival.

The European Working Time Directive is a directive from the Council of Europe to protect the health and safety of workers in the European Union. The working time directive currently ensures a 56 working hour week and by August 2009 a 48 hour maximum working week. To accommodate such a reduction in working hours, the on call rotas for institutions have had to change. Has this had an affect on trauma exposure for current specialist registrars?

Materials and Methods: Data collection was from electronic logbooks of orthopaedic specialist registrars and locum appointment trainees on the Southwest Thames rotation. From the elogbooks indexed trauma procedures were audited, this included: dynamic hip screw, hemiarthroplasty, open reduction and internal fixation ankle, intramedullary nail femur, intramedullary nail tibia, and intramedullary nail humerus. The data was divided into year groups and then the data was subdivided into on call rotas. Obtained from the data collection was the number of indexed linked operations carried out per 6 months per year group.

Results: The data collection was over an 18 month period October 2006 – April 2008. The total number of trainee logbooks who had the complete data from the logbook available was 90. The number of trainees for each year = n, the total number of operations =x and mean number of operations for each year of training =μ. The results for year groups are as follows:Year 1 n=18, x=4897, μ= 272:Year 2 n=12, x=2853, μ= 238: Year 3 n=22, x=4106, μ= 187:Year 4 n=19, x=3176, μ= 167:Year 5 n=4, x=658, μ=165:Year 6 n=15, x=3249, μ=217.Data for on call rotas were subdivided into the following groups: 1in13, 1in9, 1in8 and 1in7. The number of trainees for each on type of on call rota =n, the total number of operations = x, the mean number of operations for each on call rota group = μ.The results were as follows:1in13 on call: n=12, x=2215, μ=185; 1in9 on call: n=11, x=3195, μ=290

1in8 on call: n=20, x=3754, μ=188; 1in7 on call: n=47, x=9775, μ=208

The results for the number of indexed linked operations carried out per 6 months per year group are as follows:YEAR 1 257.73:YEAR 2 228.24:YEAR 3 173.49: YEAR 4 173.23:YEAR 5 164.50: YEAR 6 208.49

Conclusion: The results show that year groups 1, 2 and 6 have carried out the highest number of procedures. The data also shows that trainees on the lowest frequency of on call rota call have the lowest number of indexed operations. The results for the number of indexed linked operations carried out per 6 months per year group shows that as the year groups progress the number of procedures carried out continues to decrease from year 1 to 5 and then increases again at year 6. The structure of orthopaedic training is being overhauled. The need for effective training has intensified. This audit aims to demonstrate some of the effects of the changes made in higher speciality training in orthopaedics.

Aim: We report radiological outcome following percutaneous minimally invasive corrention of Hallux Valgus using K-wire fixation.

Methods: We followed 15 patients (11 bilateral operations) who had above procedure for Hallux Valgus deformity correction. All patients had pre operative and post operative x-rays assessed for Hallux Valgus angle, 1st Intermetatarsal angle and Distal Metatarsal Articular angle. We also collected clinical data including deformity correction and complications.

Results: Mean age of the patients was 55.47(SD 14.27). Of the 15 procedures 11 had bilateral operations and 4 had only one side operated (total 14 right sided 12 left sided operations). Mean duration of follow up was 85.47 days (range 29 to 259). The pre operative mean Hallux Valgus angle was 37.05(SD 6.49, range 28 to 49) where as post operative it was 11.32(SD 9.07, range 0 to 33). The pre operative mean 1st Intermetatarsal angle was 16.46(SD 2.74, range 11 to 21) where as post operative it was 5.48(SD 3.62, range 1 to 16). The pre operative mean Distal metatarsal articular angle was 35.36(SD 8.38, range 18 to 51) where as post operative it was 8.29(SD 9.13, range 0 to 38). Clinically one great toe had infection post operatively requiring early removal of K-wires resulting in residual deformity. One had mild bilateral recurrence, two had mild unilateral recurrence. These patients did not require any further surgery.

Conclusion: Above results indicate that Percutaneous Minimally invasive Hallux Valgus correction using K-wire fixation showed good radiological correction in various angles measured to quantify Hallux Valgus deformity.

Purpose of the study: Our aim was to look at, how we are following the British Orthopaedic Association (BOA) guidelines regarding the clinic times. The decrease in doctor working hours and increase in sub-specialisation has added to the problem.

Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second by an independent observer. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded.

Results: Of total Clinic time, 45% spent for consulting follow-up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time was 75%, procedures 4%, investigations 3%, consent 4%, dictation 13%, teaching 1%. Mean time for consultation was 13 minutes 6 seconds for new and 8 minutes 43 seconds for follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up patients).

Conclusion: Since the British Orthopaedic Association (BOA) guidelines in 1990, there has been a change in patient’s expectation, responsibility of the clinician towards well informed patients, detailed investigation, consenting in clinics etc. Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise BOA guidelines regarding clinics to provide more time in clinics per patient to maintain quality of care and training.

Introduction: The use of Ilizarov frames is contraindicated in patients with psychiatric conditions, thought to be due to non compliance. We present our experience of treating five fractures with Ilizarov frame in four patients who sustained their injuries through parasuicide.

Method: Consecutive series of patients treated by a single surgeon at our institution. Five fractures in four patients, (one bilateral fracture) were treated with an Ilizarov fine wire frame. All fractures were comminuted distal tibia (pilon): one was B3.3, two C3.2 and a further two C3.3 using the AO system. Four out of five fractures were open Grade IIIA. Outcome was based on functional score (Olerud and Molander); SF 12 and radiological assessment.

Results: There were three females and the mean age was thirty-one years. Of the five fractures, three united successfully, at eight months; one achieved a malunion and one an aseptic non-union at 1 year

Discussion: Our experience suggests complex fractures can be treated favourably with circular frames in parasuicide patients. The patients were generally compliant with frame care and the outpatient monitoring was no different from any other patient with similar injuries.

Background: The British Orthopaedic Association (BOA) guidelines regarding consultation time were published in 1990. There has been a change in the expectation of the patient and the responsibilty of the clinician to provide more information to the patients and more detailed investigation and consent forms to fill with a greater emphasis on clinical governance and increasing awareness of the patients over the years. The decrease in doctor working hours and increase in sub specialisation can not be ignored.

Methods: 55 Orthopaedic clinics were observed and time mapped to the nearest second. 5 clinics observed for each of 11 clinicians (5 Consultants and 6 Registrars). From the time the clinician entered the consultation room to start the clinic till the time he left after finishing the clinic the entire span of time was mapped with a stop watch by an independent observer. The patient factors viz age, sex, mobility, BMI, site of disease were recorded. The clinician factors viz. seniority, sub-specialisation were also recorded.

Results: Of total Clinic time, 45% spent for consulting follow up cases, 26% for new cases and 29% lost in in-between patient transit time. Of the total clinic time, patient time (time spent by clinician with the patient) was 75%, 4% spent on procedures, 3% on investigations, 4% on consent, 13% on dictation, only 1% on teaching. The mean time for consultation was 13 minutes 6 seconds for New patients and 8 minutes 43 seconds for Follow up patients which was significantly less than that recommended by BOA guidelines (15 – 20 minutes for new and 10 –15 minutes for follow up pateints in Orthopaedic clinics).

Conclusion: Despite the clinics over running in time the BOA guidelines are not being adhered to potentially compromising quality consultation and training at the cost of pressures to see the recommended 22 unit patients per clinic. There is a need to revise guidelines to provide for more time in clinics per patient to maintain quality of care and training.

Aim: To assess pain control, functional outcome and patient satisfaction following day surgery ACL reconstruction.

We report the results of 60 consecutive primary anterior cruciate ligament (ACL) reconstructions performed by a single operator at King’s College Hospital Day surgery unit. A “3 in 1” nerve block was used after general anaesthesia. Semitendinosis and gracilis were harvested from the ipsilateral side, doubled and implanted arthroscopically. Patients were discharged the same day with oral analgesia. The mean age was 34.7 years old (range 18–58). Mean period between injury and reconstruction was 26.9 months (range 6–63 months). Mean follow-up was 38 months (range 7–86 months). Average post operative pain score was 3.86 with an average analgesic requirement of 11.2 days (range 0–50 days) Mean Modified Lysholm score was 85.63 (range 31–100) and mean IKDC score was 79.83 (range 37–100).

In conclusion we found that following day surgery ACL reconstruction, pain relief was adequate in most cases, functional outcome was rated good or excellent by 78% of patients and 91% were satisfied with the overall service.

We have reviewed the management and outcome of ununited fractures of the humerus in a specialist limb reconstruction unit. A retrospective study conducted at Kings College Hospital, including referrals during the period September 1994 to present. There were 47 cases of humeral non-union, (14 proximal, 25 diaphyseal and eight distal). The time of referral from injury ranged from two months to eight years, with one patient referred after 37 years. 38 of the 47 patients had undergone an average of 1.08 operations prior to referral. Treatment aimed to achieve alignment, stability and stimulation. Methods were as follows: Proximal fractures [14]: nine Locked Compression Plate (LCP), five Dynamic Compression Plate (DCP). Autologous bone graft alone [eight], Bone Morphogenic Protein (BMP – Osigraft) alone [three], both bone graft and BMP [three]. 13 have united. One is under treatment. Mean time to union was six months. Diaphyseal fractures [25]: 12 LCP, four DCP, five Intramedullary (IM) nail, one Ilizarov frame and one required observation only. Autologous bone graft alone [17], BMP alone [two], both bone graft and BMP [three]. 23 have united. One patient awaits surgery. One patient declined surgery. Mean time to union was four months. Distal fractures [eight]: four LCP, two DCP, two Ilizarov frames. Autologous bone graft alone [seven], both bone graft and BMP [one]. Seven have united. One is under treatment. Mean time to union was seven months. Open reduction and appropriate stabilisation, together with the stimulus of autologus bone graft and/or BMP consistently resulted in healing of ununited fracture of the humerus. Many treatment methods were employed. It is not clear whether it was the treatment method or the accumulated experience of the Limb Reconstruction Unit, which was responsible for a high success rate comparable to, or better than, published results.

Cryopreserving agents (CPAs) can cryopreserve articular cartilage (AC) but their use is limited due to cellular toxicity. This study examined the time-dependent penetration of multiple CPAs into intact porcine AC. Porcine AC was immersed in CPAs for various amounts of time at three temperatures (4°C, 22°C, and 37°C). The results demonstrated an initial sharp rise in CPA concentration within the matrix for dimethyl sulfoxide and propylene glycol with maximum concentration after three to six hours. The trehalose and glucose concentration increased minimally even after twenty-four hours of exposure. The information from this study provides insight into the penetration kinetics of cryoprotectant agents into AC.

This study examined the time-dependent penetration of cryoprotectant agents (CPAs) [dimethyl sulfoxide (DMSO), propylene glycol (PG), trehalose and glucose] into intact porcine articular cartilage (AC).

Penetration of DMSO and PG into AC was rapid but time and temperature dependent while trehalose and glucose had poor penetration.

The information gathered from this study can determine concentrations of CPAs within the cartilage matrix to create cryopreservation/vitrification solutions while minimizing toxicity.

The results demonstrated there was a sharp rise in the CPA concentration within 15–30min exposure to DMSO and PG and the concentration peaked after three to six hours exposure at a concentration approximately 90% of the original concentration (6.5 molar). This was temperature dependent with slower penetration at lower temperatures. The trehalose and glucose had very poor penetration into the matrix at all temperatures, with a maximum penetration of 2% of the original concentration.

Dowels of porcine AC (10mm diameter) were immersed in high concentration of each CPA for various amounts of time (0min, 15min, 30min, 60min, 3hr, 6hr, and 24hr) at three temperatures (4°C, 22°C, and 37°C). The cartilage was excised and the amount of cryoprotectant within the matrix determined.

Successful cryopreservation of AC could improve clinical results of osteochondral allografting and provide a useful treatment alternative for large cartilage defects. However, successful cartilage cryopreservation is limited by chondrocyte death and matrix disruption due to inadequate CPA penetration.

To evaluate the mechanism of dislocation of the navicular in complex foot trauma; we hypothesize this is similar to lunate/perilunate dislocations.

Our experience with 6 cases of total dislocation of navicular without fracture, and an analysis of 7 similar cases reported world-wide was used as the basis for this hypothesis. Radiographs of our patients and the published cases were analyzed in detail, and associated injuries/instablilities were assessed. The position of the dislocated navicular and the mechanism of trauma was considered and correlated, and this hypothesis was propounded.

When the navicular dislocates without fracture, it most frequently comes to lie medially, with superior or inferior displacement, depending upon the foot position at injury. It is hypothesized that the forefoot first dislocates laterally (perhaps transiently) at the naviculocunieform joint by an abduction injury; in all cases we recorded significant lateral injury (either cuboid fracture, or lateral midfoot dislocation). The relocating forefoot subsequently pushes the unstable navicular from the talonavicular joint, and depending upon the residual attachments of soft tissues, this bone comes to lie at different places medially. This is a similar mechanism to the lunate dislocation in the wrist, where the relocating carpus push the lunate volarly. Our clinical experience with these complex injuries has shown that the whole foot is extremely unstable. For reduction, the talonavicular joint has to be reduced first, and then the rest of the forefoot easily reduces on to the navicular. An understanding of injury mechanics allows us to primarily stabilize both the columns of the foot, and subsequent subluxation and associated residual pain are avoided.

Pure navicular dislocations are not isolated injuries, but are complex midfoot instabilities, and are similar to perilunate injuries of the wrist.