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Value driven outcome (VDO) initiative is a value-based, patient-focused tool which utilizes a clinical outcome-based approach to optimize value of care based on clinically relevant quality indicators and costs required to achieve the care. In this study, we evaluate the impact of a VDO initiative on groin hernia repair, a commonly performed elective surgery in our hospital.A VDO initiative was implemented in 2019 to encourage elective inguinal hernia repair to be performed at a day surgery setting. A comparison of outcomes was made between hernia surgeries performed in 2019 with those in 2020 and 2021. Pre-defined criteria were used to select patients that can be operated at a day surgery setting. Patients' expectations were addressed preoperatively about day surgery procedure and postoperative recovery. Day surgery bundles were used to standardize pre- and post-surgery protocols. Pain control was optimized using a specialized local anesthesia regime.A total of 263 laparoscopic hernia surgeries were performed between May 2019 and December 2021. After implementation of VDO initiative, the percentage of patients discharged within 24 h increased from 78% in year 2019 to 97% in year 2020 and 99% in year 2021. Conversion rate for day surgery to short stay decreased from 9% in year 2019 to 1% in year 2020 and 2% in year 2021. In 2019 to 2021, there were no 30-day readmission, no hernia recurrence in 90 days, no conversion to open surgery.VDO initiative is a promising tool to deliver better value-based care for patients undergoing endo-laparoscopic inguinal hernia repair.

Objectives We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures; early (within 4 days) definitive stabilization (EDS) can be performed without an increase in post-operative ventilation and post-operative complications. Design Retrospective Cohort Study SETTING:: Level 1 Trauma Centre PATIENTS:: In total 103 patients were included in this study of which 18 (17.5%) were female and 85(82.5%) were male. These patients were borderline trauma patients who had the following parameters prior to definitive surgery, normal coagulation profile, lactate Intervention These patients were treated either according to Early Total Care (ETC), definitive surgery on day of admission, or Damage Control Orthopaedics (DCO) principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (LDS) (>4 days). Main outcome measurements Primary outcome measured was duration of ventilation more than 3 days post definitive surgery and presence of post-operative complications. Results 35 (34.0%) patients received ETC, while 68 (66.0%) patients were treated with DCO. In total 51 (49.5%) of all patients had LDS while 52 (50.5%) patients had EDS. On Logistic Regression the following factors were found to be predictive of higher rates of post -operative ventilation ≥ 3 days, Units of Blood Transfused and time to definitive surgery>4 days. Increased age, Head AIS 3 or more and Time to definitive surgery were found to be associated with an increased risk of post-operative complications. Conclusions Borderline polytrauma patients with no severe soft tissue injuries such as chest or head injuries may be treated with EDS if adequately resuscitated with no increase in need for post-operative ventilation and complications. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose The review aims to provide a summary of the current literature regarding common medications prescribed in orthopaedic surgery and their potential implications in COVID-19 patients. Methods A systematic review was performed using the PRISMA guidelines. All clinical studies, reviews, consensus and guidelines related to the above medications and COVID-19 were included. Results A total of 18 articles were included. The use of analgesia, anti-inflammatories, steroids, anticoagulants, antibiotics, vitamin B, vitamin C and vitamin D and their potential impact on COVID-19 patients were reported. Conclusion Eight main recommendations were derived from the review. Firstly, paracetamol remains the first line of analgesia and antipyretic. Secondly, there is no need to avoid NSAIDs for COVID-19 patients. Thirdly, opioids have the potential for immunosuppression in addition to respiratory depression and, therefore, should be prescribed with care in COVID-19 patients. Fourthly, patients with conditions where steroids are proven to be efficacious can continue to receive their steroids; otherwise, systemic steroids are not recommended for COVID-19 patients. Fifthly, orthopaedic surgeons following up on COVID-19 patients who are using steroids should continue to follow them up for possible avascular necrosis. Sixthly, whenever possible, oral anticoagulation should be converted to parental heparin. Seventhly, common orthopaedic antibiotics including penicillin and clindamycin are safe to continue for COVID-19 patients. However, for COVID-19 patients, the antibiotics can potentially be switched to macrolides and tetracyclines if the organisms are sensitive. Lastly, prescription for vitamins B, C and D should continue as per usual clinical practice.

A hip fracture causes high morbidity and mortality. Frailty is associated with adverse outcomes and increased costs. Frailty measured using the Hospital Frailty Risk Score (HFRS) is associated with higher costs and adverse outcomes. HFRS is useful as a fuss-free frailty measurement in the management of older adults with hip fractures.Hip fractures account for an increasing number of hospital admissions around the world and are associated with high rates of morbidity and mortality. Frailty is increasingly recognized to be associated with adverse outcomes and increased costs. The purpose of this study is to determine the association of the Hospital Frailty Risk Score (HFRS) with the healthcare cost and outcomes in older adults who present with a hip fracture.A retrospective analysis was performed on 1014 patients ≥ 60 years who presented with a hip fracture between January 2016 to June 2020. Each patient was classified into HFRS low, intermediate or high frailty cohorts. Demographics, hip fracture type, comorbidities, Charlson Comorbidity Index (CCI), American Society of Anesthesiologist score (ASA), costs, length of stay, time to surgery, complications, readmission rate and mortality were compared between the cohorts.Median total hospitalization costs were significantly higher in the highest HFRS (SGD$22,432) patients as compared to intermediate (SGD$18,759) and low HFRS (SGD$15,671) patients. The difference between the high and low groups remains significant after adjusting for covariates using quantile regression. Similar results were shown for median length of stay (14 vs 10 vs 8 days), total number of complications (2 vs 1 vs 0) and adjusted time to surgery (p 0.05). HFRS was not associated with 30-day readmission or 30-day or 1-year mortality.Frailty is associated with a marked increase in total costs in hip fracture patients. HFRS proved useful in estimating LOS and outcomes for older patients with hip fractures.

Objective To evaluate the utility of 3-D printed models of acetabular fractures as a teaching and assessment tool compared to conventional lecture based teaching among orthopaedic trainees. MethodsThis was randomised prospective study conducted in a tertiary hospital setting which was consisted of 16 Orthopaedic residents. Ten different cases of acetabular fracture patterns were identified and printed as 3-D models. Baseline knowledge of acetabular fracture classification and surgical approach was determined by an x-ray based pre-test. Trainees were then randomly assigned into two groups. Group I received only lectures. Group II were additionally provided with 3-D printed models during the lecture. Participants then received a post-test and were assessed for comprehension and retention of teaching. ResultsSixteen trainees participated in the trial. Both Group 1 and Group 2 improved post teaching with mean score of 2.5 and 1.9 to 4.4 and 6 out of 10 respectively. Post test score for fracture classification and surgical approach were significantly higher for 3-D model group (pConclusion3-D printed model of real clinical cases have significant educational impact compared to lecture based learning in improving young trainees understanding of complex acetabular fractures.

Operative treatment of tibial pilon fracture is challenging. There is a lack of consensus and only one clinical study on the optimal location of distal tibial plating for fixation of pilon fractures based on varus or valgus fracture patterns. We hypothesize that complications rates, specifically mechanical complications, are not influenced by the location of the tibial plating in the fixation of pilon fractures with respect to varus or valgus fracture patterns. Sixty-nine patients who had single plating for tibial pilon from 2007 to 2017 were recruited. They were divided into two groups, transverse fibular fracture (varus fracture pattern) and comminuted fibular fracture (valgus fracture pattern). Our primary outcome measure was any mechanical complications as a result of the location of plating (medial vs lateral) on varus or valgus fracture patterns. There were 38 (55.1%) patients with varus fracture pattern and 31 (44.9%) patients with valgus fracture pattern tibial pilon fractures. In the varus fracture pattern group, mechanical complications were not significantly different between the two plating locations (27.3 vs 33.3%, p > 0.05). Notably, there were more fibula fixations performed in patients with medial plating (74.1 vs 45.5%, p = 0.092) when compared those with lateral plating in the varus fracture pattern group. There were also no statistically significant differences found although 10 (40%) out of 25 patients had mechanical complications in the medial plating group compared to 1 (16.7%) out of 6 patients with lateral plating (p = 0.383) in the valgus fracture pattern group. There were no differences in mechanical complications for medial vs lateral plating in tibial pilon fracture based on varus or valgus deforming forces. As much as we should consider the fracture patterns and deforming forces when deciding on plating location, other factors such as careful soft tissue management and fragment-specific fixation should be prioritized.

Background: Gustilo IIIB tibial fractures are associated with high rates of infection and nonunion. This study evaluates the impact of factors such as patient demographics, mechanism of injury, time to the first debridement, and time to flap coverage on the union and infection rates. Materials and Methods: A retrospective analysis was performed on all patients with open tibial fractures who presented to our tertiary trauma center over 13 years from April 2000 to August 2013. All patients were followed for at least 6 months and continued till radiographic evidence of union (maximum 72 months). Time to fracture union was based on radiological evidence of callus bridging at least three cortices. Information on infection rates and the presence of microbes were evaluated. Results: A total of 120 patients were analyzed. The mean time to fracture union was 33.8 weeks. Younger age was associated with a lower risk of nonunion with the mean age being 30.4 years in union group compared to 38.2 in the delayed-union group. Smoking was associated with an increased risk of delayed union with revision surgery being needed in 61.5% of smokers compared to 36.4% in nonsmokers. Rates of infection were high at 30.3%. Smoking was associated with an increased risk of infection (65.4% vs. 24.7%). Conclusion: High-energy open tibia fractures required an average of 8.5 months to heal and delayed or nonunion at an earlier juncture cannot be assumed.

Introduction Percutaneously-placed sacroiliac (SI) screws are currently the gold-standard fixation technique for fixation of the posterior pelvic ring. The relatively high prevalence of sacral dysmorphism in the general population introduces a high risk of cortical breach with resultant neurovascular damage. This study was performed to compare the accuracy of SI screw placement with and without the use of intraoperative navigation, as well as to externally validate the sacral dysmorphism score in a trauma patient cohort. Patients and methods All trauma patients who underwent sacroiliac screw fixation for pelvic fractures at a level 1 trauma centre over a 6 year period were identified. True axial and coronal sacral reconstructions were obtained from their pre-operative CT scans and assessed qualitatively and quantitatively for sacral dysmorphism – a sacral dysmorphism score was calculated by two independent assessors. Post-operative CT scans were then analysed for breaches and correlated with the hospital medical records to check for any clinical sequelae. Results 68 screws were inserted in 36 patients, most sustaining injuries from road traffic accidents (50%) or falls from height (36.1%). There was a male preponderance (83.3%) with the majority of the screws inserted percutaneously (86.1%). Intraoperative navigation was used in 47.2% of the patient cohort. 30.6% of the cohort were found to have dysmorphic sacra. The mean sacral dysmorphism scores were not significantly different between navigated and non-navigated groups. Three cortical breaches occurred, two in patients with sacral dysmorphism scores >70 and occurring despite the use of intraoperative navigation. There was no significant difference in the rates of breach between navigated and non-navigated groups. None of the breaches resulted in any clinically observable neurovascular deficit. Conclusion The sacral dysmorphism score can be clinically applied to a cohort of trauma patients with pelvic fractures. In patients with highly dysmorphic sacra, reflected by high sacral dysmorphism scores, intraoperative navigation is not in itself sufficient to prevent cortical breaches. In such patients it would be prudent to consider instrumentation of the lower sacral corridors instead.

We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted. 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically. There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65–10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47–8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction. The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications.

Purpose To compare clinical outcomes of anterior cruciate ligament (ACL) reconstruction and investigate whether the clinical results of 4-strand hamstring tendon (HT) reconstruction are still inferior to that of the patellar tendon (PT). Methods We performed a comprehensive systematic review and meta-analysis of the English literature on PubMed, Scopus, Web of Science, and the Cochrane register for papers that compared clinical outcomes of PT versus HT for ACL reconstruction. Outcome measures analyzed included rate of rerupture, KT-1000, International Knee Documentation Committee grade, Lachman, pivot shift, Lysholm score, Tegner Activity Scale, anterior knee pain, and discomfort on kneeling. Results We included 19 studies from an initial 1,168 abstracts for the systematic review, and, eventually, 19 studies were included in the meta-analysis. The study population consisted of a total of 1784 patients. The average follow-up duration was 58.8 months. We found significant differences in favor of the HT technique in the domains of anterior knee pain, kneeling pain, and restriction in the range of active extension ("extension deficit"). We found no differences between the PT and HT technique in terms of rerupture rate. There were no clinically significant differences for the outcomes of Lysholm score and Tegner Activity Scale as well as the KT-1000 side-to-side at maximum manual force. Conclusions Contemporary 4-strand HT ACL reconstruction is comparable with the PT technique in terms of clinical stability and postoperative functional status across most parameters studied. The HT technique carries lower risk of postoperative complications such as anterior knee pain, kneeling discomfort, and extension deficit. Primary ACL reconstruction using the 4-strand HT technique achieves clinical results that are comparable with the PT technique with significantly less postoperative complications. Level of Evidence Level I, systemic review and meta-analysis of Level I studies.

INTRODUCTION How many orthopods does it take to change a light bulb? One - to refer to the medics for 'Darkness ?Cause'. Additionally, anaesthetists and surgeons often disagree on the estimated blood loss during surgery and the estimated procedure duration. We designed this study to compare the ability of orthopaedic surgeons and anaesthetists in: (a) estimating fluid volumes; (b) estimating procedure durations; and (c) changing light bulbs. METHODS Participants had to either be a specialist in anaesthesia or orthopaedic surgery, or a trainee in that specialty for at least two years. Three different fluid specimens were used for volume estimation (44 mL, 88 mL and 144 mL). Two videos of different lengths (140 seconds and 170 seconds), showing the suturing of a banana skin, were used for procedure duration estimation. To determine the ability at changing light bulbs, the participants had to match eight different light sockets to their respective bulbs. RESULTS 30 male anaesthetists and trainees and 31 male orthopaedic surgeons and trainees participated in this study. Orthopaedic surgeons underestimated the three fluid volumes by 3.9% and anaesthetists overestimated by 5.1% (p = 0.925). Anaesthetists and orthopaedic surgeons overestimated the duration of the two procedures by 21.2% and 43.1%, respectively (p = 0.006). Anaesthetists had a faster mean time in changing light bulbs (70.1 seconds vs. 74.1 seconds, p = 0.319). CONCLUSION In an experimental environment, male orthopaedic surgeons are as good as male anaesthetists in estimating fluid volumes (in commonly seen surgical specimens) and in changing light bulbs. Both groups are poor at estimating procedure durations.

Proximal ulna fractures account for 20% of all proximal forearm fractures. Many treatment options are available for such fractures, such as cast immobilisation, plate and screw fixation, tension band wiring and intramedullary screw fixation, depending on the fracture pattern. Due to the subcutaneous nature of the proximal forearm, it is vulnerable to open injuries over the dorsal aspect of the proximal ulna. This may in turn prove challenging, as it is critical to obtain adequate soft tissue coverage to reduce the risk of implant exposure and bony infections. We herein describe a patient with a Gustillo III-B open fracture of the proximal ulna, treated with minimally invasive intramedullary screw fixation using a 6.0-mm cannulated headless titanium compression screw (FusiFIX™, Péronnas, France).

The present cadaveric study was designed to measure the flexor hallucis longus (FHL) tendon length and obtain anatomic data regarding the graft-to-tunnel length ratio in an interference screw fixation model for the FHL short-harvest single-incision technique to the calcaneus. Ten fresh-frozen paired cadaveric specimens were used for the FHL short-harvest technique. The length of the osseous tunnel in the calcaneus was measured. At harvesting of the FHL tendon, the length of the tendon that traverses the osseous tunnel was measured with the ankle in neutral and maximal plantarflexion from the tip of the osseous tunnel to the transected end of the tendon within the bone tunnel. The mean length of the osseous tunnel was 42.7 ± 2.3 (range 38 to 46) mm. With the ankle in neutral position, the mean length of the FHL tendon traversing the bone tunnel was 31 ± 1.7 (range 29 to 34) mm. This mean length increased to 38.8 ± 1.6 (range 36 to 41) mm with the ankle placed in maximal plantarflexion. The ratio of the mean length of the tendon graft to the mean length of the osseous tunnel with the ankle in neutral was 0.727 ± 0.046 (range 0.667 to 0.81), and the ratio was 0.91 ± 0.042 (range 0.864 to 0.976) when the ankle was maximally plantarflexed. To the best of our knowledge, we report for the first time that the short-harvest technique provides >70% (ratio 0.727) of the FHL tendon graft in the osseous tunnel at all times, even when then ankle is in neutral, resulting in sufficient tendon length for FHL tendon transfer to the calcaneus for chronic Achilles tendon rupture.

INTRODUCTION New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures. METHODS Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications. RESULTS In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001). CONCLUSION Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

The world’s population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture. 56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year. Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery. Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.

This paper considers the central bank mandate with respect to financial stability and identifies the links to the functioning of securities markets. It argues that while emergency support to securities markets is an important part of the crisis management response, a high bar should be set for its use. Importantly, it should be used only as part of a comprehensive policy package. The paper considers what types of securities markets may be important for financial stability, what market conditions could trigger emergency support measures, and how programs can be designed to restore market functioning while minimizing moral hazard.

Introduction Tension-band wire fixation of patellar fractures is associated with significant hardware-related complications and infection. Braided polyester suture fixation is an alternative option. However, these suture fixations have higher failure rates due to the difficulty in achieving rigid suture knot fixation. The Arthrex syndesmotic TightRope, which is a double-button adjustable loop fixation device utilizing a 4-point locking system using FibreWire, may not only offer stiff rigid fixation using a knotless system, but may also obviate the need for implant removal due to hardware related problems. The aim of our study is to compare the fixation rigidity of patella fractures using Tightrope versus conventional tension-band wiring (TBW) in a cadaveric model. Materials and methods TBW fixation was compared to TightRope fixation of transverse patella fractures in 5 matched pairs of cadaveric knees. The knees were cyclically brought through 0–90° of motion for a total of 500 cycles. Fracture gapping was measured before the start of the cycling, and at 50, 100, 200 and 500 cycles using an extensometer. The mean maximum fracture gapping was derived. Failure of the construct was defined as a displacement of more than 3 mm, patella fracture or implant breakage. Results All but one knee from each group survived 500 cycles. The two failures were due to a fracture gap of more than 3 mm during cycling. There was no significant difference in the mean number of cycles tolerated. There was no implant breakage. There was no statistical significant difference in mean maximum fracture gap between the TBW and TightRope group at all cyclical milestones after 500 cycles (0.3026 ± 0.4091 mm vs 0.3558 ± 0.7173 mm, p = 0.388). Conclusions We found no difference between the TBW and Tightrope fixation in terms of fracture gapping and failure. With possible lower risk of complications such as implant migration and soft tissue irritation, we believe tightrope fixation is a feasible alternative in fracture management of transverse patella fractures.

Introduction Pertrochanteric fractures after low-energy trauma are common among osteoporotic patients. Although the use of intramedullary devices to treat such fractures is becoming increasingly popular, there is a paucity of data comparing the outcomes of the use of short cephalomedullary nails (SCN) with the use of long cephalomedullary nails (LCN). This study aimed to compare the outcomes of treatment using LCN with treatment using SCN for patients with osteoporotic pertrochanteric fractures. Methods A retrospective review of 64 patients with osteoporotic pertrochanteric fractures who were treated with either LCN or SCN and had a minimum follow-up of one year was performed. Primary outcome measures include complications, revision surgeries and union rates. Secondary outcome measures include duration of surgery, estimated blood loss, length of hospital stay, and ambulatory and mortality status at one year. Results There was no significant difference in the clinical and functional outcomes of the patients who were treated with LCN and those who were treated with SCN. However, there was a higher incidence of heterotopic ossification in the latter group, and a slightly greater average estimated blood loss and duration of surgery in the former group. Patients treated with LCN tended to be more osteoporotic. Conclusion Our study found no significant difference in terms of complications, revision surgeries, union rates and ambulatory status between the patients who were treated with LCN and those who were treated with SCN. Both LCN and SCN provided safe and reliable outcomes in the treatment of osteoporotic pertrochanteric fractures.

Introduction: The humerus is subjected to substantial amount of torsional stress. Conventional plating may not address this sufficiently and may lead to fixation failure or non-union. A helical plate may offer the solution. We present the surgical technique and functional outcome of 5 cases of humeral shaft fractures treated with this technique in a minimally invasive way. Materials and Methods: The operations were performed between 2004 and 2010, by three surgeons. All the patients had closed humeral shaft fractures, either simple transverse or with mild comminution. Two small incisions were made. The proximal incision was placed along the deltopectoral groove over the shaft, and the distal incision was placed as in an antero-lateral approach. The radial nerve was identified and protected. A pre-selected plate was contoured and introduced in the submuscular plane. The plate was placed in a proximal-lateral and distal-anterior position. Screws were inserted through stab incisions. The patients were followed for an average of 6 months. Functional recovery of the shoulder and elbow was assessed using the Constant and Mayo elbow performance score systems. Results: All incisions healed by first intention without complications and all the fractures went on to unite. All patients achieved good to excellent shoulder and elbow function. Conclusion: The helical plate technique is a safe and effective method of treating humeral shaft fractures and has good functional outcome.

Problem statement: Numerous animal studies have shown that administration of Parathyroid Hormone (PTH) or a related analogue promotes callus formation and bone union. However, there has yet to be sufficient evidence in human subjects to justify the use of PTH or related analogues in promoting fracture healing. The purpose of this paper is to (1) review all literature involving the use of PTH analogues in humans (2) compare the clinical efficacy of PTH analogues to conventional management of fracture healing and (3) evaluate the safety profile and potential side-effects of PTH analogues administered in humans. Approach: We conducted a systematic review of multiple databases analysing papers within the last 10 years. All studies involving the use of PTH analogues in humans were included. All animal studies were excluded. Appropriate statistics regarding patient’s age, gender, site of fracture, teriparatide treatment regime, clinical outcomes and imaging outcomes were extracted, analysed and summarized. Results: A total of 10 observational studies and 2 randomized controlled trials were evaluated in this study. With administration of teriparatide (PTH1-34), the mean time to 100% disappearance of fracture site pain was 3.1 months ±0.7 months. Delayed or non-union fractures achieved bony bridging in 4.3 months. For new fractures treated non-surgically, there have been reports of shorter time to cortical bridging in the treatment group (7.4 weeks, n = 34, p = 0.006) as compared to the control group (9.1 weeks, n = 34). Lastly, a total of 8 out of 254 patients (3.1%) experienced mild side effect from teriparatide administration. Conclusion: Teriparatide shows promise to be a viable option for the treatment of fractures. Although initial studies do prove encouraging, greater evidence is needed to evaluate the optimal dosing regimen and the patient and fracture types that would achieve the best response.

Hip fractures are on the rise globally. With increased life expectancy, many will be in their nineties. These nonagenarians may require particular attention because of their age and comorbidities, the former long accepted to be strongly associated with mortality 1 . Unlike many parts of the world where surgery is almost always advocated, this is often not the case for elderly Singaporeans, especially nonagenarians. We analyzed and compared the mobility, morbidity and mortality in nonagenarians with hip fractures treated both conservatively and surgically in recent years.

Objective The aim of this study was to identify pitfalls in the acute management of ankle fractures which were referred to a regional orthopaedic unit. This unit provides orthopaedic services for the catchment area of the Waterford Emergency Department together with three additional emergency units in the south-eastern region of Ireland. Methods This is a retrospective study of all patients referred to the Waterford Regional Orthopaedic service from 1 January 2001 to 31 December 2001 for management of acute ankle fractures. Results A total of 236 patients were identified during the study period. Open reduction and internal fixation were performed in 200 cases. In all, 52% of patients had definitive surgery within 24 h of their injury. These patients were evenly distributed between regional (64%) and peripheral (60%) emergency unit referrals. 24% of patients required essential manipulation prior to surgery. This had been performed in only 34% of cases prior to transfer. Two patients were transferred with a pulseless foot. Conclusions Ankle fractures are a common musculoskeletal injury seen in emergency departments and minor injury units. Long-term disability resulting from ankle fractures can be reduced by optimal early management procedures. This is an important area for consideration in education programmes in emergency medicine.

The introduction of locking plate devices have increased the number of viable options for fracture fixation. An understanding of the indications and contraindications and technique limitations are important to minimise associated adverse events. We report the case of a patient who presented with a single broken screw head four years following fixation of a supracondylar femur fracture, resulting in symptoms of migratory knee pain and locking. He underwent implant and foreign body removal and made an unremarkable recovery postoperatively. With the increasing use of locking plate devices, we are likely to see more such complications. Key Words bone plates, bone screws, fractures

Introduction Autologous bone grafting has been accepted as the gold standard in the treatment of non-unions and in definitive filling of segmental bone defects. However, there have been well-recognised complications associated with their harvest. The Reamer Irrigator Aspirator (RIA) system is an alternative technique of autologous bone graft harvesting. Studies have been published in the Western population showing the efficacy and outcome of this technique. No prior studies were done in the Asian population, who has smaller average canals, different femoral geometry as compared to Caucasians and weaker bone density in both genders. We aim to present the findings and discuss its suitability in the Asian population when dealing with segmental bone loss and non-unions requiring reconstruction. Methods We conducted a retrospective analysis of all trauma patients with segmental bone loss and non-unions treated with RIA bone grafting over a 4.5 year period. A total of 57 cases of RIA bone grafting were conducted on 53 patients. The amount of bone graft harvested, blood loss and post-operative pain were measured. Patients were followed up for union rate as well as complications of the procedure. Results Union was achieved in 86.8% of patients. The mean time to union was 17.64 weeks. Seven patients did not achieve union after the first RIA surgery, in which six of seven were open fractures initially and six were smokers. One major intra-operative complication was recorded, that being a fractured femoral shaft due to thinning of the cortex by the RIA harvester. There were two patients who developed donor site superficial soft tissue infection that resolved after a course of antibiotics. There were no long-term complications seen in all patients. Conclusions The safety and efficacy of RIA bone graft harvesting for the management of non-union in the Asian population is promising, with adequate graft quantities, high success and low complication rates that are comparable to the Caucasian population. The diameter of the medullary canal in our population is suitable for this procedure. We believe that RIA bone graft harvesting provides a reliable and safe alternative source of autologous bone grafts for bone grafting of non-union sites.

Purpose.To compare early versus late flap coverage for open tibial fractures.Methods.Medical records of 83 men and 6 women (mean age, 38 years) who underwent fixation for open tibial fractures (Gustilo grades IIIB and IIIC) followed by flap coverage within (n=30) or after (n=59) 72 hours were reviewed. All fractures were treated within 24 hours. Outcome measures included bone union, infection, flap failure, the need for secondary procedures to achieve union, and eventual amputation. The early and late flap coverage groups were compared.Results.Early flap coverage was associated with shorter length of hospitalisation (31.4 vs. 55.8 days, pConclusion.In severe open tibial fractures, early soft-tissue coverage (within 72 hours) was associated with more favourable outcomes in terms of length of hospitalisation and infection.

Purpose. To review short-term outcomes of proximal femoral locking compression plate (PF-LCP) fixation for proximal femoral fractures in terms of postoperative complications and failure rates. Methods. Medical records of 21 men and 5 women aged 22 to 85 (mean, 49.7) years who underwent internal fixation with the PF-LCP for proximal femoral fractures were reviewed. Younger patients (mean age, 38.7 years) were more commonly involved in high-energy trauma with multiple musculoskeletal injuries, whereas older patients (mean age, 67.7 years) were more commonly involved in low-energy trauma. Fractures were classified into: multi-fragmentary pertrochanteric fractures (n=13), transtrochanteric fractures (n=6), and subtrochanteric/proximal diaphyseal fractures (n=7). Results. Patients were followed up for a mean of 14.7 months. Seven patients developed complications including loosening of locking screws (n=4), delayed union (n=2), and infection (n=1); 4 of them required additional surgeries. Conclusion. The PF-LCP is appropriate for complex proximal femoral fractures with poor bone quality, revision surgeries, and multi-fragmentary subtrochanteric/proximal diaphyseal fractures. For intertrochanteric fractures, the sliding hip screw system should be used to avoid failure.

It seems as if someone from the ‘industry’ knocks on our doors every week to tell us about ‘the next best prosthesis for joint replacement or implant for fracture surgery’ in orthopaedic surgery. How do we objectively evaluate the performance of these new implants while practising evidence-based medicine? It is important to remember that those who do not know the history of these new protheses are doomed to repeat it. Obviously, by recording all the events, mishaps and incidences of complications following the use of these prostheses or implants by various surgeons, and making that information readily available to other like-minded orthopaedic surgeons, will help them to be judicious in their selection of patients and prosthesis or implants. It is in this context that the value of a National Joint Registry (NJR) and Hip Fracture Registry (HFR) cannot be overstated. Not only does it assist in the short- and long-term follow-up of patients, it also “helps to monitor the performance of implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians and the orthopaedic industry”, as stated by the United Kingdom (UK) NJR.(1) Data collection and registries are already established in several advanced Wvestern countries. Their value has been demonstrated by the early recognition of accelerated failure rate of the metal-on-metal Articular Surface Replacement (ASR) hip arthroplasty implant.(2) Data collection and analysis from these different NJRs have raised concerns regarding metal-on- metal surface replacement and ensured that this information was publicised expeditiously throughout the orthopaedic community, thus ensuring patient safety and reducing risk to more patients.(3-6) This in turn has improved clinical standards and reduced liability litigation, benefiting the industry. Joint registries not only play a role, but have also “demonstrated value as a resource for the study of large numbers of patients, providing the opportunity to study rare occurrences and identify early failures of surgical procedures”.(7) So why should we not develop our own national registries? It could be argued that it would be difficult to collate the required information. However, in 1998, National University Hospital (NUH) in Singapore introduced the use of electronic patient records in the form of the Computerized Patient Support System (CPSS). This was a significant milestone. Patient information, including patient history, previous admissions, current and past medications, as well as prior procedures and/or operations could be retrieved at the touch of a button. Shortly after CPSS went online, the Picture Archiving System (PACS) was introduced, complementing the former by making available all radiology images. Whilst these new technologies allowed rapid access to data, sped up clerical processes and improved overall patient care, as management decisions could be made in a timelier manner, they also contain the basic information required for National Joint and Hip Fracture Registries. Furthermore, by having expanded and integrating CPSS and PACS to involve all hospitals and polyclinics across Singapore, this ensured that any complication following arthroplasty or hip fracture surgery could be captured. With so many registries worldwide, does Singapore really need one of its own? Can we not infer patient outcome by studying the existing registries from other countries? The United States of America has regional databases and registries. Australia, Norway, Iceland, Sweden and the UK all have NJRs, with Norway also having an HFR. However, they contain information predominantly on Caucasian patients. We have seen that these registries, particularly those for trauma implants, are designed for northern European patients and often do not suit the morphology of Asian bones. Thus, fracture implants have recently been redesigned to suit Asian patients. Having our own NJR and HFR would thus allow us to see how our population fares following surgery, and can be useful for future research and development of orthopaedic implants. Currently, we already have tools available to develop our own registries, i.e. the CPSS and PACS. The UK, which only begun implementing electronic patient records last year, is experiencing teething problems, even though the country has had an NJR since 2002. We know that many hospitals in Singapore have ‘stand-alone’ registries of their own patients who have undergone arthroplasty or hip fracture fixation, using CPSS and PACS as the primary data source. NUH has developed the InterTrochanteric and electronic Neck Of Femur Fracture (IT eNOFF) database, where we can review our patient population admitted after sustaining a hip fracture from 2010 to 2012 inclusive. We identified 624 patients and reviewed 22 parameters, including patient demographics, mechanism of injury, type of injury and treatment. This information is readily accessible from the digitalised patient information systems. Within a short few weeks, we were able to achieve complete data acquisition for all parameters with perfect intra- and inter-observer reliability. Before the installation of integrated computer systems, data collection would have taken many months to complete. Such databases are useful research tools. However, even though we can extrapolate some parameters for our hospital population, we are unable to draw conclusions or identify trends on a national basis, as the patient population varies from hospital to hospital. Furthermore, national planning in terms of health budgets and future resource requirements have become paramount during these times of fiscal restraint, and will become even more important with the expected increase in the aged population over the next couple of decades. According to the recently published Population White Paper, Singapore’s total population could fall between 6.5 and 6.9 million by 2030.(8) Whilst this figure has caused much concern, as highlighted in the Singapore media, more alarming is the fact that by 2030, 19% of Singapore’s population will be persons aged 65 years and above.(9) The World Health Organization states that “approximately 1.66 million hip fractures occur each year worldwide” and “the incidence is set to increase four-fold by 2050 because of the increasing number of older people”.(10) We feel that the potential for improving resource planning by having a much larger pool of patients in a National Joint and Hip Fracture Registry is self-evident. At present, several hospitals in the country already have individual databases. It would be more useful if these databases were interconnected and allowed sharing of information among various users, namely orthopaedic surgeons, hospitals, government departments, and perhaps, even the industry. Are we prepared for the Singapore of the future? Can we accurately determine our needs? How good are we at identifying reasons for poor patient outcomes and failing implants? By building a National Registry now, we can plan and finance our future healthcare, and more importantly, meet the needs and demands of a growing, ageing population while continually striving to improve patient care. Therefore, we suggest culminating individual hospital data into a single National Joint and Hip Fracture Registry. Of course, there is a need to protect patients’ privacy, especially with the introduction of the Personal Data Protection Act this year. This can be assured if a single, non-profit professional organisation, such as a national orthopaedic society, takes responsibility and control over access to the database. This will enable us to take advantage of the invaluable electronic data we possess, as well as assist in short- and long-term patient follow-up. In addition, it will allow us to infer patient outcomes for our own local population by studying our local registry rather than extrapolating data from other countries based on an incomparable patient population. As mentioned earlier, the potential for improving resource planning and patient care through the establishment of a large, single National Joint and Hip Fracture Registry is self-evident and warrants serious consideration. Yours sincerely

Positioning existing humeral implants into Asian patients poses significant challenges due to the inconsistent statistical shapes between Western population and Asian population. Current humeral orthopedic fixation devices and implants have a generic shape and are not designed for Asian patients who exhibit different sizes and shapes compared to their Western counterparts for which present day designs have been based on. To address this problem, it is necessary to develop Asian-specific implants that accommodate the morphology of Asian humeri. Existing morphological studies of humeri in Asian populations are rare and most previous analyses are either based on the manual measurement of dry bones or the use of dual energy X-ray absorptiometry scans. The purpose of this pilot morphological study is to explore the characteristics of Asian humeri using statistical atlas-based analysis. Forty-four CT scans of normal upper limbs were obtained from the National University Hospital, Singapore and used to construct statistical humerus atlases. The atlases were subsequently used to study the morphology of the humeri in an Asian population. Humeral shapes of different patient clusters were analyzed based on statistical shape models. Comparison between different clusters was conducted with regard to centerline, length, width and surface curvature. The statistical humerus atlases reflected the mean shape and modes of variation of humeri in an Asian population. Analyses based on these atlases indicated that curvature and shape of the internal humeral canal were similar in males and females while humeral length and width were greater in males. Most importantly, surface curvatures were explicitly different between clusters. Morphologic analysis based on statistical atlases is novel and useful to characterize the Asian humerus. The humerus demonstrates gender-specific morphology. This unique approach provides information that is useful to the clinician and biomedical engineer, not only in the modification of current or design of future humeral implants, but also in the precise dynamic positioning of Asian-specific humeral implants to Asian patients. Our findings support the need for further development of humeral implants, curvilinear robotics, and the questioning of whether gender-specific devices are necessary.

The statistical shape analysis of population-specific anatomical structures plays a pivotal role in both implant design and associated dedicated surgical robotic instruments. The sizes of current off-the-shelf humerus implants are unable to accommodate Asian patients since they are mainly produced for the American and European countries based on locally collected data. In this paper, an algorithm to construct a statistical humerus model is proposed so as to create a reference model for the development of humerus implants that conforms to the Asian population, and for the related design of snake-like robot for intramedullary procedures. The statistical humerus model is constructed from 14 CT datasets of male patients by implementing a three-step simplified method with improved alignment process. We have further constructed the statistical atlas showing the internal anatomy of humerus by adopting a spherical harmonics based method for the aim of developing intramedullary based implants used for humerus fixation. The validation results demonstrate that the proposed method significantly improves the efficiency of alignment without compromising the accuracy of the atlas. A comparison between the atlas constructed using the proposed method and that constructed utilizing the framework of spherical harmonics is further illustrated.

To determine the prevalence of carpal fracture in Singapore, to compare demographic differences between isolated scaphoid and other carpal fractures, and to identify parameters associated with multiple carpal fractures.A total of 149 patients with 162 carpal fractures seen at the National University Hospital in 2009 were enrolled into the study. We retrospectively reviewed their case records and radiographic studies. Pertinent demographic data including patient age, gender, occupation, injured wrist, dominant hand, mechanism of injury, and type of carpal fracture were then recorded and statistically analyzed. We also performed a separate analysis of isolated scaphoid versus other carpal fractures and single versus multiple carpal fractures.Patients with carpal fracture were predominantly male (132), below 40 years of age (116), and usually right hand dominant (136). The more common occupations were students (30), full-time military national servicemen (24), and construction workers (14). Most presented after a fall on an outstretched hand from standing height (81). The scaphoid was the most common single carpal fracture (99). This was followed by triquetrum (27), hamate (5), pisiform (4), lunate (2), capitate (1), and trapezium (1). No fracture of the trapezoid was encountered. Ten patients had multiple carpal fractures, of which 4 were perilunate fracture dislocations. The mean age and male/female ratio for isolated scaphoid and other carpal fractures was 26 years versus 41 years (p.001) and 13:1 versus 4:1 (p=.036), respectively. A high-energy mechanism of injury was the only parameter associated with multiple carpal fractures (p=.009).The prevalence of carpal fracture in our population was consistent with studies performed in other countries. Military conscription was identified as an at-risk activity predisposing to carpal fracture. Isolated scaphoid and other carpal fractures exhibit different demographics in terms of age and gender, which may be related to differences in the mechanism of injury. A high-energy mechanism of injury was associated with multiple carpal fractures.

The global financial crisis (GFC) has renewed interest in emergency liquidity support (sometimes referred to as “Lender of Last Resort”) provided by central banks to financial institutions and challenged the traditional way of conducting these operations. Despite a vast literature on the topic, central bank approaches and practices vary considerably. In this paper we focus on, for the most part, the provision of idiosyncratic support, approaching it from an operational perspective; highlighting different approaches adopted by central banks; and also identifying some of the issues that arose during the GFC.

Simultaneous bilateral neck of femur fracture is a rare injury and poses a diagnostic challenge. This uncommon pattern of injury has been associated with high-energy trauma and seizure disorders. Proper clinical examination of both hip and knee joint should be performed in patients presenting with bilateral knee pain. Clinical suspicion and detailed radiologic evaluation of both hip and knee joint is essential for diagnosis of uncommon injury around hip joint. A battery of metabolic tests to assess vitamin D deficiency and histology study of the specimen should be performed. Patients with simultaneous bilateral fracture neck femur can be treated well and perform activities of daily living with good outcomes with prompt surgical intervention and medical treatment. We report the case of asymptomatic simultaneous bilateral neck of femur fracture following vitamin D deficiency which was missed and was misdiagnosed and treated for severe bilateral osteoarthritis knee.

The electromagnetic eigenvibrations of a dielectric sphere, which manifest themselves e.g. in the form of resonances appearing in the radar cross section of the sphere, can be explained in terms of surface (creeping, circumferential) waves generated in the scattering process, or by more general means. The phase match which occurs at any one of the eigenfrequencies leads to constructive interference in the amplitudes of the circumferential waves, and hence to a resonant build-up, in the course of their repeated circumnavigations of the sphere. Evidence is presented to show that in each partial wave (normal mode), these resonances are superimposed on a non-resonant background which can be described by the perfectly conducting-sphere scattering amplitude.