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This paper explores the disease COVID-19 caused by the SARS-CoV-2 virus. This disease has caused a global pandemic affecting the way society both works and lives. COVID-19 is spread through droplets from the mouth and nose, which has implications for how we practice orthodontics. Our clinical practice will therefore need to be adapted to keep both patients and staff safe. This paper addresses the adaptations that should be considered. We also address what the future of orthodontics may look like in light of the issues with cross infection that COVID-19 has raised. CPD/Clinical Relevance: How to adapt our clinical practice to keep both staff and patients safe.

External fixators (EF) are not commonly used for patients with haemophilia. We describe the use of EF (Ilizarov, AO- uni- and bi-planar fixators and Charnley clamp) in nine patients (mean age: 19.2 years; range: 9-37) with haemophilia for the following indications - arthrodesis of infected joints, treatment of open fractures and osteoclasis. EF required an average of nine skin punctures [range: 4-17 were maintained for a period of 15 weeks (range: 8-29.5), without regular factor replacement, till bone healing was adequate and were removed with a single dose of factor infusion]. The mean preoperative factor level achieved was 85% (range: 64-102%). Much lower levels were subsequently maintained till wound healing. The average total factor consumption was 430 IU kg(-1) (range: 240-870), administered over a period of 17 days (range: 9-44). There were no major complications related to EF except in a patient who developed inhibitors. In conclusion, EF can be used safely in haemophilic patients who do not have inhibitors and does not require prolonged factor replacement.

Purpose. To evaluate the time required for effective action of phenol against the giant cell tumour (GCT) cells. Methods. Fresh GCT cells were harvested from 9 patients with primary GCT of the distal femur (n=4), proximal tibia (n=4), and proximal humerus (n=1), with the Campanacci tumour grades 3 (n=6), 2 (n=2), and 1 (n=1). Specimens were immersed in 80 % phenol for one, 3, 6, and 10 minutes, and were assessed by a single pathologist for irreversible cell death and the depth of phenol penetration. Results. Phenol caused consistent GCT cell death in 6 of the 9 specimens after 3 minutes and in all 9 specimens after 6 minutes, compared to none in controls (pConclusion. GCT cells immersed in 80% phenol for 6 minutes resulted in consistent cell death.

Purpose. To review outcomes of 7 patients who underwent revision surgery for infected non-union of the humerus using a fibular graft as an intramedullary strut. Methods. Records of 7 men aged 29 to 59 (mean, 40) years with humeral diaphyseal infected nonunion who underwent fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut were reviewed. The mean number of previous surgeries was 2.7 (range, 2–4). Three of the patients had active draining sinuses previously. Their C-reactive protein levels were normal and tissue cultures negative. The remaining 4 patients had active draining sinuses. They first underwent implant removal and debridement. Tissue cultures confirmed infection in 3 of them. The mean duration between debridement and the index surgery was 5 (range, 3–10) months. Results. The mean length of the fibulae harvested was 13 (range, 12–15) cm. All 7 non-unions healed. The mean time to healing was 5.4 (range, 4–8) months. The mean follow-up period was 15 (range, 13–24) months. All patients had weakness of the extensor hallucis longus, which improved to near normal at month 3. There was no donor-site morbidity. Three patients with active infection at presentation underwent repeat surgery. Two of them had wound washouts, and their non-unions went on to heal successfully; one underwent implant removal after union due to an active sinus. Six of the patients returned to their pre-injury activity level, and one endured a brachial plexus injury. Conclusion. Fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut achieved good outcome for infected non-union of the humerus despite prior multiple failed surgeries.

Purpose.To assess the role of preoperative embolisation in benign bone tumour excision.Methods.3 men and 3 women aged 19 to 35 (mean 23) years with either a giant cell tumour or an aneurysmal bone cyst in limb girdle sites underwent preoperative embolisation a day prior to wide local excision by the same surgeon. Tumour size, blood loss, wound healing, infection, and tumour recurrence were assessed.Results.The mean total blood loss was 391 (range, 100–980) ml. No blood transfusion was needed. No patient had any surgery- or embolisation-associated complication. No tumour recurred within a minimum 5-year follow-up. All patients had satisfactory limb function.Conclusion.Preoperative embolisation is useful in the management of vascular and aggressive bone tumours located at limb girdle sites where a tourniquet cannot be used.

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab’s criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

We describe here the management of eleven patients with fracture neck of femur. Excepting one patient all had severe haemophilia A. Nine patients were less than 50 years of age. Eight out of eleven patients had fracture after trivial trauma. Nine patients had closed reduction and one patient open reduction. The patient with non union had a Valgus osteotomy. All fractures united. The average time to union was 11 weeks (range:8-16). We followed either a low dose intermittent or a low dose continuous infusion factor support protocol for the management of these patients. The median dose of factor support was 252 u/kg (range: 136-580). The average duration of factor support was 9 days (range: 7-10). Two patients had aggravation of pre existing knee stiffness following post operative immobilisation. No other major complication was observed in this cohort of patients. To conclude, management of fracture neck of femur in patients with haemophilia is no different from general population if an adequate haemostasis is achieved.

We describe an adult patient with traumatic, nonunion of ulna sustained at 11 years of age who presented with wrist deformity. The possible pathogenesis, differential diagnoses and its successful management are described. A 23-year- old right hand dominant male presented with a progressive wrist deformity of his right upper limb. At 11 years of age, he sustained an isolated open fracture of the right forearm. He had nonoperative treatment. He had 60 degrees of ulnar deviation at wrist. He had no pain in the wrist or elbow. He was able to do all activities using his right upper limb. Radiograph revealed a nonunion of ulna in mid-shaft. The radius was bowed. Radiographs at the time of injury revealed a displaced both bones forearm fracture in mid-shaft. He underwent open reduction, internal fixation of ulna with bone grafting and a corrective osteotomy of the radius. The contracted Extensor carpi ulnaris was Z lengthened. Seven months postoperative, both the nonunion of ulna and radius osteotomy were consolidated. The wrist had no deformity. He had returned to preoperative activity level. Though nonunion is rare in pediatric forearm fractures, asymmetric bone and soft tissue growth can lead to deformities even in the absence of physeal injury. In addition to the standard treatment of nonunion, maintenance of the relative lengths of radius and ulna is essential, to obtain optimum function.

Recommendations for factor replacement therapy for postoperative haemostasis in haemophilia are often empirical and based on the physiological understanding of haemostatic requirements. This report describes the haemostatic management of patients with severe haemophilia undergoing major surgery using lower than usually recommended levels of factor replacement therapy. Eighteen adults (11 with FVIII and seven with FIX deficiency) with an average weight of 52 kg (range: 27-69) underwent 20 major surgical procedures. Factor concentrates were administered by intermittent bolus infusions. The dose of FVIII infused before surgery was 76 mu kg-1 (range: 51-113) and that of FIX was 77 mu kg-1 (range: 50-104). The preoperative levels achieved were 107% (range: 80-180) and 73% (range: 60-90), respectively. Between days 1 and 3 after surgery, an average of 29 mu kg-1 day-1 (range: 20-46) of FVIII and 23 mu kg-1 day-1 (range: 12-42) of FIX was used resulting in mean trough levels of 36% (range: 12-62) and 34% (range: 11-52), respectively. After day 4, an average of 19 mu kg-1 day-1 (range: 15-25) of FVIII and 18 mu kg-1 day-1 (range: 10-37) of FIX was administered until wound healing. The average duration of factor replacement was 11 days (range: 8-16). The mean dose of factor concentrate per patient was 260 mu kg-1 (range: 179-338) of FVIII and 300 mu kg-1 (range: 183-524) of FIX. The total amount of factor used per patient ranged from 12,380 to 19,980 units of FVIII and 8000 to 23,600 units of FIX. Only one patient had post-operative bleeding which was due to a surgical cause. It is concluded that it may be possible to use much lower than recommended levels of factor replacement therapy for postoperative haemostasis in severe haemophilia.

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8°. Loss of correction was maximal in the lumbosacral spine at 13.7°. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.