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Background Despite interest among North American orthopaedic residents to pursue rotations in resource-limited settings, little is known regarding resident motivations and impact on host surgeons. Methods Surveys were distributed to North American orthopaedic surgeons and trainees who participated in international rotations during residency to assess motivations for participation and to orthopaedic surgeons at partnering low- and middle-income country (LMIC) institutions to assess impact of visiting trainees. Results Responses were received from 136 North American resident rotators and 51 LMIC host surgeons and trainees. North American respondents were motivated by a desire to increase surgical capacity at the LMIC while host surgeons reported a greater impact from learning from residents than on surgical capacity. Negative aspects reported by hosts included selfishness, lack of reciprocity, racial discrimination, competition for surgical experience, and resource burdens. Conclusions The motivations and impact of orthopaedic resident rotations in LMICs need to be aligned. Host perceptions and bidirectional educational exchange should be incorporated into partnership guidelines.

AimsThe primary aim of this study was to assess the effect of time to surgery on fracture reduction, assessed as residual articular step, in cases of tibial plateau fracture (TPF). The secondary aim was to assess the effect of pre-operative demographics and residual articular step on patient reported outcomes (PROMs) following TPF.MethodBetween 2006 and 2017 all surgically treated TPF patients managed by a single surgeon at our institution were prospectively consented for the study of fracture outcomes. Timing to surgical intervention, reduction of articular step, age, gender, medical background, fracture classification, mechanism of injury and PROMs (Lysholm Scores and Knee Injury and Osteoarthritis Outcome Scores (KOOS)) were recorded and analysed. Reduction of articular step, defined as ResultsOne hundred seventeen patients were enrolled, 52 with Schatzker II, four with Schatzker IV and 61 with Schatzker VI fractures. Patients were followed-up to a mean time of 3.9 years. The ability to achieve fracture reduction was negatively influenced by time to theatre with the odds of achieving reduction decreasing 17% each day post-injury (p = 0.002). An increased time to theatre was associated with reduced Lysholm scores at the one-year mark (p = 0.01). The ability to achieve fracture reduction did not influence PROMs within the study period.ConclusionDelay in surgical fixation negatively affects fracture reduction in TPF and may delay recovery. However, residual articular step did not influence the investigated PROMs in the cohort investigated over the mid-term (mean of 3.9 years).

Introduction Clinical studies in orthopedics are using patient-reported outcome measures (PROMs) increasingly. PROMs are often being designed for a specific disease or an area of the body with the aim of being patient centered. As yet, none exists specifically for treatment with circular ring external fixation devices. Aim The purpose of this study is to provide a comprehensive systematic review of the published literature related to the use of PROMs in patients that underwent treatment with circular frames (Ilizarov or Hexapod Type Fixators). Methods An online literature search was conducted for English language articles using the Scopus. Results There were 534 published articles identified. After initial filtering for relevance and duplication, this figure reduced to 17, with no further articles identified through searching the bibliographies. Exclusion criteria removed two articles resulting in 15 articles included in the final review. Out of the 15 studies identified, a total of 10 different scoring measures where used. The majority of studies used a combination of joint/limb-specific and generic health PROMs with an average of 2.5 per study. No paper specifically discussed all eight PROMs criteria when justifying which PROMs they used. Conclusion Our findings indicate that none of the PROMs analyzed in this systematic review are truly representative of the health outcomes specific to this patient group and, therefore, propose that a PROM specific to this patient group needs to be developed. How to cite this article Antonios T, Barker A, Ibrahim I, et al. A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation. Strategies Trauma Limb Reconstr 2019;14(1):34-44.

Long-stemmed uncemented implants are commonly used during revision hip arthroplasty but may be difficult to re-revise. Impaction bone grafting allows for the use of a shorter cemented stem during revision hip arthroplasty and may restore bone stock in patients with substantial femoral defects. Femoral impaction bone grafting is particularly beneficial in younger patients, who are more likely to require additional revision procedures in the future. The surgical technique used at our institution includes improvements to previous methods including the use of modular tamps and nonirradiated, size-profiled bone graft.

Cases We describe 2 cases of nonagenarians with periprosthetic knee fractures that were not amenable to either standard internal fixation nor prosthesis revision because of infected leg ulcers in the same limb. The fractures were internally fixed by percutaneous insertion of medial and lateral plates that spanned the knee. Both patients returned to their baseline level of activity without developing surgical site infections. Conclusions Percutaneous bridging plates that span the knee are a useful option for treating these difficult cases.

Background The aim of this study is to assess the outcomes of 52 consecutive Vancouver B2 peri-prosthetic fractures around cemented polished double-tapered stems treated by open reduction and internal fixation in 2 trauma centers in 2 countries. Methods Outcomes included modified Harris Hip Score (mHHS), Harris Pain Score, and return to pre-injury mobility. Fracture healing was assessed; implant subsidence measured and complications including re-operations reported. Results No patient was lost to follow-up. Median patient age at operation was 82 years (range 43-98); Harris pain scores showed minimal pain (median 42, range 10-44) at latest follow-up. Median total subsidence at 1 year was 1.1 mm (range 0-5.4), the majority of which occurred within the cement mantle. No subsequent femoral stem revision was required (median 2.9 years, 0-10); however, there were 3 re-operations: 1 re-operation for pre-existing recurrent dislocation involving head liner exchange and 2 for repeat fixation due to metal fatigue. Two additional fractures occurred below the new plating, requiring further plating whilst still retaining the original stems. Conclusion Anatomical reduction and open reduction and internal fixation of Vancouver B2 peri-prosthetic fractures should be considered as an appropriate treatment solution for frail elderly patients with a peri-prosthetic fracture around cemented polished double-tapered stems.

According to the National Hip Fracture Database, over 64,000 patients were admitted with a hip fracture across England, Wales, and Northern Ireland in 2013, but very few are bilateral, and there are no current cases in the literature of bilateral neck of femur fractures in a patient with bilateral below-knee amputations. We present a case of a 69-year-old bilateral below-knee amputee male admitted to the emergency department with bilateral hip pain and radiological evidence of bilateral displaced neck of femur fractures. The patient subsequently underwent synchronous bilateral total hip replacements under general anaesthetic and an epidural and then went on to make a full recovery. He was discharged 27 days after arrival in hospital. Outpatient follow-up at 3 months has shown that the patient has returned to a similar level of preinjury function and is still able to carry out his daily activities with walking aids and bilateral leg prostheses.

BackgroundThere are concerns regarding early years' training for junior doctors in Trauma & Orthopaedic Surgery (T&O) in the United Kingdom. Our primary objective was to audit the clinical activities undertaken by junior doctors working in Trauma & Orthopaedic (T&O) surgery in the National Health Service (NHS) in a typical workweek. A secondary objective was to audit the clinical exposure of junior surgeons in training to the Joint Committee on Surgical Training (JCST) standards for minimum weekly clinical exposure in T&O surgery.MethodsWe recruited collaborators in 101 T&O surgery departments in NHS hospitals to participate in this study. Clinical activity diaries from 935 doctors working in T&O surgery in the 101 participating NHS hospitals were involved. All junior doctors covering the junior on call tier were included. Collaborators collected clinical activity data from 08:00 18/01/2015 to 20:00 22/01/2015. Clinical activities recorded in sessions (morning, afternoon, evening) depending on what activity that doctor undertook for the majority of that session. Clinical activities were grouped into operating theatre/room, outpatient clinic, on call, "not in work" (i.e. leave, sickness), teaching, and ward cover sessions. The weekly clinical activity of Core Surgical Trainees (CSTs) were analyzed in accordance to two JCST standards for minimum weekly clinical exposure.ResultsOverall, junior doctors working in T&O surgery attended a theatre list session 8.5% of the time, an outpatient clinic 3.2%, were on call 14.8%, a teaching session 1.7%, providing ward cover 34.6%, and on a zero session 20.7% of the time. Only 5% of core surgical trainees (n = 200) met both the JCST standards for minimum weekly clinical exposure in the specialty.ConclusionsJunior surgeons in training, working in Trauma & Orthopaedic surgery in the United Kingdom are not meeting the minimum weekly clinical sessions laid out by the JCST. Further work to develop models allowing for enhanced training experiences and improved clinical exposure to operating lists and outpatient clinics would be beneficial.

The posterior approach to the hip is the most common extensile approach used, however exposure is limited superiorly by the superior gluteal neurovascular bundle (SGNB). The extra-pelvic course of the SGNB demonstrates variability between individuals, occasionally located only 1 cm from the acetabular rim. In complex acetabular reconstructions where the application of a reinforcement cage maybe required protecting the SGNB is challenging. The flanges of these cages are designed to sit on the ilium superior to the acetabular rim and to receive screws for fixation. The application of such cages may result in iatrogenic injury to the SGNB by way of forceful retraction or entrapment. We describe a technique that involves exposure and release of the SGNB such that the flanges of cage constructs may be safely applied.

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm2 (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm2 (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm2 (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region. Cite this article: Bone Joint J 2013;95-B:1662–6.

Clinicians are often asked by patients, “When can I drive again?” after lower limb injury or surgery. This question is difficult to answer in the absence of any guidelines. This review aims to collate the currently available evidence and discuss the factors that influence the decision to allow a patient to return to driving. Medline, Web of Science, Scopus, and EMBASE were searched using the following terms: ‘brake reaction time’, ‘brake response time’, ‘braking force’, ‘brake pedal force’, ‘resume driving’, ‘rate of application of force’, ‘driving after injury’, ‘joint replacement and driving’, and ‘fracture and driving’. Of the relevant literature identified, most studies used the brake reaction time and total brake time as the outcome measures. Varying recovery periods were proposed based on the type and severity of injury or surgery. Surveys of the Driver and Vehicle Licensing Agency, the Police, insurance companies in the United Kingdom and Orthopaedic Surgeons offered a variety of opinions. There is currently insufficient evidence for any authoritative body to determine fitness to drive. The lack of guidance could result in patients being withheld from driving for longer than is necessary, or returning to driving while still unsafe. Cite this article: Bone Joint J 2013;95-B:290–4.

Objective To retrospectively assess the clinical and functional outcomes of a group of patients receiving Charite lumbar disc replacement and to compare those outcomes to the corresponding surgical technical accuracy. Methods A retrospective study of all patients treated over a 3-year period was undertaken. Objective pain scores were quantified from 1 to 10. Short Form 36-Health Survey (SF-36v2) scores were compared to Australian population norms. Surgical placements were radiographically classified. Heterotopic ossification, disc height restoration and angle-defined instability were assessed using established protocols. Results Twenty-five patients were identified with three patients lost to follow-up. Average follow-up was 34 months. Ideal surgical placement was achieved in five (33%) single-level and three (37.5%) dual-level disc replacements. Sub-optimal surgical placement was seen in nine (60%) single-level and five (62.5%) dual-level disc replacements. Poor surgical placement was observed in a single-level disc replacement. All patients demonstrated a reduction in objective pain score (P < 0.05). SF-36v2 outcomes were superior in single-level compared to dual-level and ideal compared to sub-optimal replacements (P < 0.05). Conclusion The hypothesis that ideal surgical placements are associated with improved clinical and functional outcomes in total lumbar disc replacement was confirmed.

Methicillin resistant Staphylococcus aureus (MRSA) is defined as any strain of Staphylococcus aureus resistant to beta-lactam antibiotics, including the penicillins and cephalosporins. Over the past ten years the UK has seen a dramatic increase in MRSA prevalence in healthcare facilities and the community, with an estimated 30–50% of healthy adults thought to be colonised with MRSA. Surgical patients are among those at highest risk. With potential sequelae including septicaemia, septic shock, septic arthritis, osteomyelitis, meningitis, pneumonia or endocarditis, it is vital that all care facilities have up to date evidence-based guidelines to tackle this problem. The purpose of this review is to highlight the current evidence supporting some of the key perioperative measures which may be implemented in preventing MRSA.

Hip fracture is a major cause of morbidity, mortality and loss of independence for the elderly. Surgical fixation of the fractured hip remains the standard of care to allow for early mobilisation and a return to independence. Operative management in this population carries its own set of problems. The altered physiological state of the older person, often coupled with significant co-morbidity, can present challenges for the anaesthetist, the surgeon and the rest of the perioperative team. This article provides an evidence-based review of the important perioperative factors associated with hip fractures in the older person and their management.

Fractures of the phalangeal joints of the hand present a challenging problem because of the small size of the fracture fragments, limiting internal fixation, and their articular nature necessitating early mobilisation to ensure good results. We present a case of a patient presenting with an open displaced intraarticular fracture of the metacarpophalangeal joint that was managed with limited internal fixation with a Kirschner wire along with the S-Quattro. The fracture united and the patient returned to his previous occupation with no limitations in his activities of daily living. This is the first instance of S-Quattro being described for the management of an open fracture with the additional use of limited internal fixation. The additional use of limited internal fixation ensured adequate fracture reduction and stabilisation. The S-Quattro application does not require significant soft tissue dissection, making it particularly suited to open fractures.

The addition of large amounts of antibiotics to bone cement provides a convenient local delivery, but may influence the compressive properties of the cement. Flucloxacillin and vancomycin were added to Simplex P (Stryker, Limerick, Ireland) and VersaBond (Smith & Nephew) cements. Tripling the antibiotic dose from 2 to 6 g had little effect on the static compressive properties 24 hours after curing. After 4 weeks in phosphate-buffered saline, there was marked decrease in properties with the addition of antibiotics. Compressive strength of cements with 6 g of antibiotic was reduced to near or below the ASTM and ISO minimum of 70 MPa after 4 weeks in phosphate-buffered saline. Microcomputer tomography revealed increased porosity and clumping of the radiopacifier with the addition of antibiotics.

Purpose The vincula are specialized mesotendinous structures attaching to the flexor tendons of the hand. In addition to providing vascular supply to the tendons, the vincula can be mechanically important. The purpose of this study was to quantify the influence of intact vincula on digital flexion after flexor tendon laceration and to assess the ultimate strength and stiffness of the vincula. Methods The index, middle, and ring fingers of 12 fresh-frozen cadaveric fingers were dissected free at the level of the metacarpophalangeal joint, preserving at least 10 cm of the flexor and extensor tendons. A 9.8-N load was applied to each flexor tendon, and using digital photography and image analysis software, the degree of flexion at the proximal and distal interphalangeal joints and excursion of tendons proximal to the metacarpophalangeal joint was recorded before and after division of the flexor digitorum profundus and flexor digitorum superficialis tendons at their insertions. Load to failure and stiffness of the vincula were measured via a uniaxial material testing apparatus. Analysis of means was performed with a paired t -test. Results After division of the flexor digitorum superficialis tendon, proximal interphalangeal joint flexion secondary to the influence of the intact vincula was 93% of that compared with the uninjured digit. Distal interphalangeal joint flexion after flexor digitorum profundus transection was 69% of normal. The increased excursion of transected tendons compared with testing before division was 4 mm for flexor digitorum superficialis and 2 mm for flexor digitorum profundus. Load to failure was 27 N, and stiffness was 6 N/mm. Conclusions The vincula breve can facilitate digital flexion after distal tendon transection, allowing tendons to act indirectly across the interphalangeal joints. The intact vincula breve can facilitate an almost normal range of motion across the interphalangeal joints, making the diagnosis of a flexor tendon injury difficult. In the immediate postinjury period, the vincula breve can hold a divided tendon within a few millimeters of its insertion. Testing against resistance is important to avoid missing the diagnosis of a tendon injury.

Cartilage has an extremely poor capacity to heal, which has lead to intensive research into biomaterials and tissue engineering for the purpose of regenerating cartilage in vivo. Many of these techniques have shown great promise in vitro; however, the results do not always carry across to the in-vivo scenario. Healthy cartilage autografts often do not integrate with the adjacent cartilage, suggesting that cartilage is rarely capable of healing even under ideal conditions. It is hypothesized in this study that the surgical creation of defects in cartilage causes significant damage to the adjacent tissues, leading to further degradation of the cartilage and poor outcome for the repair in general. This study compares the healing response of osteochondral defects created with either a punch or a drill in the weight-bearing region of the sheep knee at 4 and 26 weeks following surgery. The use of a drill to create the defect creates a more aggressive inflammatory response at 4 weeks compared with a punch. However, by 26 weeks, defects created with a punch scored higher on the O'Driscoll cartilage grading scale. Tissue damage at the time of surgery plays an important part in the sequence of events for healing of cartilage defects. This knowledge will help to characterize and refine the ovine model for cartilage regeneration and may have an influence on surgical technique and instrumentation for clinical cartilage repair.

Objectives Generational changes in lifestyle expectations, working environments and the feminisation of the medical workforce have seen an increased demand in postgraduate less than full-time training (LTFT). Despite this, concerns remain regarding access to, and information about, flexible training for surgeons. This study aimed to assess the opinions and experiences of LTFT for surgical trainees. Design Prospective, questionnaire-based cross-sectional study. Setting/participants An electronic, self-administered questionnaire was distributed in the UK and Republic of Ireland through mailing lists via the Association of Surgeons in Training and British Orthopedic Trainee Association. Results Overall, 876 completed responses were received, representing all grades of trainee across all 10 surgical specialties. Median age was 33 years and 63.4% were female. Of those who had undertaken LTFT, 92.5% (148/160) were female. Most worked 60% of a full-time post (86/160, 53.8%). The reasons for either choosing or considering LTFT were childrearing (82.7%), caring for a dependent (12.6%) and sporting commitments (6.8%). Males were less likely to list childrearing than females (64.9% vs 87.6%; p

Third generation cementing technique is now commonly used for total hip arthroplasty. The aim of this technique is to sufficiently pressurise the cement and allow maximal penetration of the cement into any remaining trabecular bone to provide a stable fixation of the prosthesis. We report a case where this pressurisation resulted in Polymethylmethacrylate retrograde filling of the nutrient vessel and we discuss the controversial diagnosis and current literature surrounding this rare phenomenon.

BACKGROUND: Functional outcome after reconstruction of open ankle injuries has not been well presented in the literature. The authors present the functional results of 24 patients who sustained complex ankle injuries. METHODS: Patients were assessed using three scoring systems (a modified A/O score, the Enneking score, and the AOFAS) and subdivided into two groups: those primarily treated at Charing Cross Hospital according to strict protocols combining orthopedic and plastic surgical techniques (group P) and those secondarily treated who were transferred to Charing Cross Hospital after initial management at a remote unit (group S). RESULTS: There were nine patients (37.5 percent) in group P and 15 (62.5 percent) in group S. Eighteen patients (75 percent) underwent free-tissue transfer. Sixteen patients (67 percent) were assessed (group P, n = 7; group S, n = 9) for return of function using the Enneking score. Mean time to assessment was 10.5 months for group P and 11.4 months for group S. Mean Enneking percentage score was 75 for group P and 72.2 for group S. There were no significant differences (p > 0.05) between these scores. The mean time to union was 19 weeks (n = 5) for group P and 24 weeks (n = 7) for group S. The mean AOFAS Ankle-Hindfoot Scores were comparable to the Enneking scores when independent observers undertook this assessment. Most patients in both groups reported difficulty with descent of stairs. CONCLUSIONS: Although the authors were able to achieve a similar return of function for both groups, group S patients needed at least one more operation. In cases of ankle fracture where there is significant soft-tissue injury (either closed or open), representing a complex injury, the authors recommend making no attempt to internally fix the fracture and instead referring the patient to a specialist center for combined orthoplastic attention. If this is not immediately at hand, screw fixation of the medial malleolus should be undertaken after open reduction. The lateral malleolus should not be internally fixed, but should it require control, external fixation is the preferred method of skeletal stabilization.

Carpal Tunnel Syndrome (CTS) is normally diagnosed via its sensory and motor manifestations. The associated autonomic dysfunction has not been exploited to its full potential as a diagnostic tool due to the difficulties in quantifying it. We aim to demonstrate that autonomic dysfunction of CTS can be quantified by measuring skin capacitance. Fifty-one patients with clinical signs and electrophysiological evidence of CTS in 89 hands were recruited. Skin capacitance was measured using Corneometer CM825 (C&K Electronic, GmbH) from the palmar aspect of the distal phalanx of the index and little finger of the affected hand. Healthy gender- and age-matched individuals were recruited as controls. The mean ratio of hydration of the index to the little finger was 0.82. The mean difference was 10.98 arbitrary units. The control group consisted of 151 subjects (80 Male & 71 Female) and 302 hands with an average age of 40.1 years (18-81 years). The mean ratio of hydration of the index to the little finger was 0.87. The mean difference was 8.67 arbitrary units. The measurement ratios (index to little finger skin hydration) between the two groups was compared directly and gave a significant mean difference of 0.05 arbitrary units. Statistically significant differences in skin capacitance between CTS patients and controls have been demonstrated and quantified using a rapid and simple method. This can be used in clinic to reduce the reliance on Nerve Conduction Studies for diagnosing CTS.