Search

Introduction During Covid-19 pandemic, operation theatres limit the number of staff during each session, which causes a decrease in training opportunity. To counteract this lapse, the Orthopaedic Research Institute (ORI) designs an innovative training session. During the nationwide lockdown, the closure of the Institute allowed for the transfer of the VirtaMed ArthrosTM (VA), to our NHS facility. VA is a surgical simulator which enables the participant to practise knee arthroscopy. Method Participants with little arthroscopic experience were included in the study. Three fellowship-trained surgeons conducted daily teaching sessions. Participants were taught necessary arthroscopic skills before undertaking training modules on diagnostic arthroscopy. 90% of the participants attended the session at least three times. At the end of every module, VA generates a score based on parameters which include procedure duration, visualisation of key structures and iatrogenic chondral damage. Structure questionnaires were also used to analyse feedback. Results The overall confidence and module scores progress with each subsequent session. A keystone of success is the location and ease of access to the simulator. Conclusions Surgical simulators are a useful tool for surgical education and training. We should encourage their use in the future, especially in the UK surgical training programme.

BackgroundPelvic fractures (PFX) reflect high-energy trauma with high mortality and morbidity.AimWe attempted to determine: whether there is a decrease in levels of sporting and physical activity in patients with operatively-treated PFX; risk factors for decreased sporting activity; any correlation between sporting activity and quality of life in this group.MethodsRetrospective demographics on mechanism of injury, fracture type, associated injury and injury severity score, as well as prospective documentation of the level and frequency of sporting activity, were collected from adult patients treated operatively for a PFX between 2007 and 2010, using a specifically designed questionnaire. Quality of life before and after injury was also recorded using the EuroQol-5D health-outcome tool.Results80 patients without pre-existing musculoskeletal disability were enrolled. The mean age was 44.9 years (18-65). The mean follow-up was 30.5 months (12-39). A decrease in level and frequency of sporting activity was observed. It was associated with lower-extremity associated injuries, but not with injury severity score, PFX severity, PFX type, age, or timing of follow-up. Sporting activity before injury predicted higher levels of sporting participation after injury. Decreased sporting activity after injury was associated with decreased EuroQol-5D score.ConclusionsPatients should be counselled on the likelihood of a reduction in sporting activities after surgically treated PFX. A larger multi-centre study is needed to further expand on the evidence of the true impact of PFX and its associated injuries on sporting activity.

Fractures of the distal femur are relatively uncommon, accounting for only 6% of femoral fractures, occurring approximately 10 times less frequently than proximal femoral fractures. They afflict two distinct patient groups; low-energy injuries are most often seen in elderly osteoporotic patients and high-energy injuries, are commoner in younger patients, often in the context of polytrauma. Severe functional impairment and permanent disability may result from such injuries, with mal-union and limb shortening compromising functional outcome. The management of patients with distal femoral fractures, regardless of which patient group they belong to, should be standard and adherent to ATLS principles. The treatment options for distal femoral fractures are operative and non-operative. Extra-articular, simple pattern and non-displaced fractures may be treated non-operatively, as well as fractures in patients that carry a significant anaesthetic risk or those with low functional demands. Ultimately, this decision must be weighed against the risks of prolonged immobilization and its complications. Operative fixation for displaced, high-energy, open or intra-articular fractures may utilize intramedullary nailing, plate osteosynthesis or circular external fixators depending on the fracture configuration and other patient related factors. The majority of cases will make an uneventful recovery but severe functional impairment and permanent disability may result from the more severe injuries, with mal-union and limb shortening compromising functional outcome. Hence, specialist care for these patients should always be considered, if this service is available.

Traumatic dislocations of the native hip are a relatively rare injuries resulting from high-energy mechanisms producing grossly abnormal force vectors acting across the hip joint. Road-traffic collisions are the main cause and the affected patients have a high incidence of associated injuries. A thorough trauma assessment should be undertaken and, in simple dislocations, immediate reduction should be attempted before considering operative measures. An optimal outcome is achieved when reduction is achieved within 6 h, which has been shown to minimize the incidence of ensuing avascular necrosis. Open reduction is necessary when concentric reduction is not achieved by closed manipulation due to the interposition of soft tissue, cartilage or bone. Surgical fixation of the acetabulum and femoral head, in complex cases, is necessary to maintain joint congruity and reduce the risk of late post-traumatic arthrosis. The management of patient expectations and adequate surveillance for avascular necrosis is necessary in treating these relatively rare injuries.

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

The introduction of laparoscopic nephroureterectomy highlights the need for the critical appraisal of approaches to the distal ureter at surgery for upper tract transitional cell carcinoma. We compared differences after endoscopic ureteral detachment and open bladder cuff excision in nephroureterectomy.A total of 138 patients underwent open nephroureterectomy for upper urinary tract transitional cell carcinoma from 1982 to 2005 with a median followup of 43 months. Of these patients 90 underwent endoscopic ureteral detachment and 48 underwent bladder cuff excision. Demographic, perioperative and oncological outcome data were collected in all cases. Statistical analyses were performed using the Student t test, chi-square and log rank tests, and logistic and Cox regression.Mean operative duration was significantly lower in the endoscopic detachment group than in the bladder cuff group (p0.01). There were 49 (54.4%) bladder recurrences in the endoscopic detachment group, of which 8 (16.3%) were muscle invasive and 3 (3.3%) developed at the resection site. There were 23 (47.9%) bladder recurrences in the bladder cuff group, of which 3 (13.0%) were muscle invasive and 2 (4.2%) developed at the resection site. All 5 resection site tumors occurred after excision of muscle invasive distal ureteral tumors and 4 of these had positive margins. There were no differences in recurrence-free survival or disease specific survival between the groups. Operation subtype did not predict oncological outcome on univariate or multivariate analysis.Endoscopic ureteral detachment reduces operative duration and is associated with equivalent oncological outcomes compared with open bladder cuff excision in nephroureterectomy. Caution should be exercised in patients with low ureteral tumors.

Pelvic fractures (PFX) reflect high-energy trauma with high mortality and morbidity.We attempted to determine: whether there is a decrease in levels of sporting and physical activity in patients with operatively-treated PFX; risk factors for decreased sporting activity; any correlation between sporting activity and quality of life in this group.Retrospective demographics on mechanism of injury, fracture type, associated injury and injury severity score, as well as prospective documentation of the level and frequency of sporting activity, were collected from adult patients treated operatively for a PFX between 2007 and 2010, using a specifically designed questionnaire. Quality of life before and after injury was also recorded using the EuroQol-5D health-outcome tool.80 patients without pre-existing musculoskeletal disability were enrolled. The mean age was 44.9 years (18-65). The mean follow-up was 30.5 months (12-39). A decrease in level and frequency of sporting activity was observed. It was associated with lower-extremity associated injuries, but not with injury severity score, PFX severity, PFX type, age, or timing of follow-up. Sporting activity before injury predicted higher levels of sporting participation after injury. Decreased sporting activity after injury was associated with decreased EuroQol-SD score.Patients should be counselled on the likelihood of a reduction in sporting activities after surgically treated PFX. A larger multi-centre study is needed to further expand on the evidence of the true impact of PFX and its associated injuries on sporting activity.

Introduction: Aim of this study is to present the clinical profile and outcomeof complexmultifragmented/segmental femoral fractures, comparing their outcome following different management strategies. Materials and methods: Retrospective single centre cohort study of complex femoral fractures classified as AO types 32-C.1/2/3. Pathologic, paediatric fractures were excluded. Demographics, mechanism of injury, type of fracture, associated injuries (AIS05), ISS and NISS, treatment method, secondary procedures, complications and final clinical outcome were recorded. Descriptive statistical methods were utilised comparing early-total-care (ETC) protocols versus damage-control-orthopaedics (DCO). Results: 22-patients (24-fractures) were identified over a 4year period. Young males represented the majority (75%), with median age 32 years (18–71). Road-traffic-accidents were responsible for all of these injuries. Therewere 12 32-C.2 (segmental), and 12 32-C.3 (multifragmented) fractures (4 open grades 3A/B). The median length of the segment or, of the comminution was 13.1 cm (3.9–26.6).There was bone loss in 5cases (ranging 7.8–13.6 cm). Median ISS was 22 (9–41), median NISS was 27 (13–43). Half were managed according to ETC and half in stages (DCO). Deep local sepsis complicated 6 cases, 1 thromboembolism, 1 femoral head AVN, and 2 systemic complications. Three months post-injury mortality was 18%. The rest 9/19 fractures united after median period of 8 months (6–9). There were 2delayed-unions (healed at 11 and 12months) and 8 nonunions. Secondary interventions were necessary for 9 cases (6 healed, 3 still under treatment). DCO was associated with higher ISS/NISS, mortality, while the clinical outcome of either treatment protocol was comparable. Discussion: Severe femoral fractures represent an index injury of severe trauma, are associated with multiple other injuries. Their mortality, complication rate and final clinical outcome remain suboptimal irrespective of different management strategies.

Bone infection in adults is a potentially devastating complication following trauma or surgery. The clinician should diagnose osteomyelitis based on certain clinical manifestations and on laboratory and imaging findings. For pathogen identification, the treating surgeon should take appropriate tissue samples. Close collaboration with microbiologists is of paramount importance to dictate the appropriate duration and type of antibiotics to be administered. Treatment of acute osteomyelitis requires surgical debridement and prolonged course of antibiotics. Debate exists regarding the maintenance or the removal of any internal fixation device. Treatment of chronic osteomyelitis is more complicated. For its eradication the treatment course is often prolonged and frustrating. Based on the current literature an algorithm of treatment for both acute and chronic bone infections is recommended.