Introduction to the Masterclass Series.

How to cite this article: Harwood P, Mader K, Nayagam S. Introduction to the Masterclass Series. Strategies Trauma Limb Reconstr 2023;18(1):1.

The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature.

Introduction: Knee joint distraction (KJD) is a potential technique for cartilage regeneration in young patients with osteoarthritis of the knee. Static distraction has been utilised typically; however, a significant proportion of patients complain of knee stiffness post-distractor removal. The use of a hinged distractor may reduce the duration and severity of post-treatment knee stiffness by maintaining the range of motion during distraction. Furthermore, improved cartilage regeneration has been demonstrated in hinged ankle joint distraction as compared to static, and this may also be demonstrated at the knee. An evidence review was undertaken to inform further research and a potential change in practice. Aim: A systematic review of all primary research on hinged knee joint distraction for cartilage regeneration. Methods: An online systematic search of citation databases was conducted. Quality assessment and data extraction were undertaken by two separate researchers. Results: The literature search returned a small number of relevant studies, of which 7 were included. Three of these were animal studies, two cadaveric and two case series. The study quality was low or very low. There was significant methodological heterogeneity with difficulties encountered in the transfer of constructs from animal and cadaveric studies to humans. Issues faced included difficulties with hinge placement and pin site pain in motion. Conclusion: The feasibility of hinged knee joint distraction has yet to be proven. Any further research attempting to establish the benefits of hinged-over static knee distraction will have to take construct design considerations into account. How to cite this article: Lineham B, van Duren B, Harwood P, et al. The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature. Strategies Trauma Limb Reconstr 2023;18(1):37-43.

Volunteering for Infection: Participant Perspectives on a Hepatitis C Virus Controlled Human Infection Model.

Ethical human subjects research requires participants to be treated safely and respectfully, yet much bioethical debate takes place without participants. We aim to address this gap in the context of controlled human infection model (CHIM) research. Based upon our own experience as study participants, and bolstered by a survey of 117 potential hepatitis C virus CHIM participants, we present ideas to inform efficient, ethical, and scientifically useful study design. We advocate for full protocol transparency, higher compensation, commitment to the rapid dissemination of study results, and proactive efforts to detail risk-minimization efforts as early as possible in the recruitment process, among other measures. We encourage researchers to proactively partner with volunteer advocacy organizations that promote collective representation of volunteers to maximize their agency, and guard against ethical issues arising from healthy human subjects research.

The Posttaumatic Adjustment Scale (PAS) is an effective measure in predicting psychological distress in patients following major trauma.

AIMS: To determine whether a psychological screening tool - the Posttraumatic Adjustment Scale (PAS), predicts later psychological distress for admissions to a Major Trauma Centre (MTC) and to identify whether there was an unmet need in relation to the psychological support offered. METHODS: Patient demographics and details of their injuries were retrieved from the Trauma Audit & Research Network (TARN) database. All patients admitted to Leeds General Infirmary MTC were approached for inclusion in the study over a three-month period. The PAS was administered to all participants at baseline. Following discharge, patients were sent two validated psychological measures via post, the Impact of Events Scale - Revised (IES-R) and the Clinical Outcomes in Routine Evaluation System (CORE-10). Relationships between continuous variables were examined using a Spearman's rank test (SR). The diagnostic accuracy of the different psychological screening systems was examined and compared using Receiver Operator Characteristic (ROC) analysis. RESULTS: Eighty-two patients completed the PAS, 26 of whom had been referred to clinical psychology and 56 who were not. Fifty-seven of these patients (70%) returned follow-up IES-R and CORE-10 data, 20 who had been referred to psychology and 37 who had not. The PAS-P score recorded shortly after admission correlated strongly with the CORE-10 (SR rs 0.54, p<0.0001) and IES-R (SR rs 0.63, p<0.0001) scores recorded at early follow up. A PAS-P of more than 10 predicted the development of PTSD symptoms (IES-R 33 or more) or moderate global psychological distress (CORE-10 15 or more) with 72% sensitivity and 71% specificity. To identify patients who went on to develop psychological symptoms according to either measure (IES-R 33 or more or CORE-10 15 or more), the PAS-P was more sensitive than clinician referral (71% vs 52%, p<0.05) with similar specificity (72% vs 75%, p=0.78). CONCLUSIONS: In an unselected group of trauma inpatients treated in a MTC, the PAS is an effective means of identifying those who are likely to go on to suffer PTSD symptoms or psychological distress. It may useful to use the PAS as a measure to formalise psychology referrals.

Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique.

PURPOSE: The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis-Ilizarov method (ILF), or with Masquelet technique (MIF). METHODS: Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF). RESULTS: The average defect length was 5.6 cm (2.6-9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459-£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9. CONCLUSIONS: The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

Long-term outcomes of lower limb post-traumatic osteomyelitis.

PURPOSE: Whilst recurrence and amputation rates in post-traumatic osteomyelitis (PTOM) are described, limb specific functional outcomes are not, leading to a knowledge gap when counselling patients prior to management. We aim to investigate the patient reported outcomes (PROMS) of this patient group to provide reference for discussions with patients prior to embarking on treatment. METHODS: Single institution cross-sectional retrospective study of all patients presenting with PTOM of the tibia/femur over a 7-year period. Alongside recurrence and amputation rates, patient reported outcomes were recorded including the lower extremity functional scale (LEFS), EQ-5D-3L and EQ-VAS. RESULTS: Seventy-two patients (59 male; median age 46 years) were identified. Treatment was principle-based and included debridement (with Reamer-Irrigator-Aspirator (RIA) in 31/72), local antibiotics (52/72), soft tissue reconstruction (21/72) and systemic antibiotic therapy in all cases. PROMS were collected in 84% of all eligible patients at a median of 112-month post-treatment. Twelve patients experienced recurrence, whilst nine underwent amputation. The median LEFS was 60, the EQ-5D-3L index score was 0.760, and the EQ-VAS was 80. These scores are substantially lower than those seen in the general population (77, 0.856 and 82.2, respectively). LEFS was significantly higher, where RIA was utilised (69.6 vs 52.8; p = 0.02), and in those classified as BACH uncomplicated (74.4 vs 58.4; p = 0.02). EQ-5D-3L was also higher when RIA was utilised (0.883 vs 0.604; p = 0.04), with no difference in EQ-VAS scores. CONCLUSIONS: Patients with PTOM report functional outcomes below that of the general population, even when in remission. Improved outcomes were associated with uncomplicated disease and the use of RIA.

Lower limb post-traumatic osteomyelitis: a systematic review of clinical outcomes.

PURPOSE: The aim of this study was to examine the patient-reported outcomes of patients presenting with post-traumatic osteomyelitis (PTOM) of the lower limb over the past 15 years. This period was chosen to reflect modern treatment principles and increased centralisation of care. METHODS: An electronic literature search of the relevant databases (PubMed, Ovid Medline, Embase, and the Cochrane library) was conducted to identify studies published between January 2006 and July 2021 reporting series of greater than 10 patients with PTOM of the tibia or femur at the site of a previous fracture. Studies reporting septic non-union were excluded. RESULTS: Sixteen eligible studies were identified and included in the final report. Remission of infection was achieved in 93.2% of cases (range 70-100%), whilst amputation was reported in 1-7% of cases. A variety of patient-reported outcome measures were utilised including the lower extremity functional scale, short musculoskeletal functional assessment, Enneking score, and EQ-5D-3L. Limb-specific functional outcomes returned to levels similar to that of the general population although poorer outcomes were noted in specific cohorts including those with complex anatomic disease and active medical comorbidities. CONCLUSION: Infection following fracture fixation remains a difficult problem to treat. Regardless, using modern treatments and techniques patients can have comparable functional outcomes to that of the general population. High-quality studies are required to advance our knowledge into which types of treatments offer a benefit and how to further improve outcomes.

Integration of somatosensory and motor-related information in the auditory system.

An ability to integrate information provided by different sensory modalities is a fundamental feature of neurons in many brain areas. Because visual and auditory inputs often originate from the same external object, which may be located some distance away from the observer, the synthesis of these cues can improve localization accuracy and speed up behavioral responses. By contrast, multisensory interactions occurring close to the body typically involve a combination of tactile stimuli with other sensory modalities. Moreover, most activities involving active touch generate sound, indicating that stimuli in these modalities are frequently experienced together. In this review, we examine the basis for determining sound-source distance and the contribution of auditory inputs to the neural encoding of space around the body. We then consider the perceptual consequences of combining auditory and tactile inputs in humans and discuss recent evidence from animal studies demonstrating how cortical and subcortical areas work together to mediate communication between these senses. This research has shown that somatosensory inputs interface with and modulate sound processing at multiple levels of the auditory pathway, from the cochlear nucleus in the brainstem to the cortex. Circuits involving inputs from the primary somatosensory cortex to the auditory midbrain have been identified that mediate suppressive effects of whisker stimulation on auditory thalamocortical processing, providing a possible basis for prioritizing the processing of tactile cues from nearby objects. Close links also exist between audition and movement, and auditory responses are typically suppressed by locomotion and other actions. These movement-related signals are thought to cancel out self-generated sounds, but they may also affect auditory responses via the associated somatosensory stimulation or as a result of changes in brain state. Together, these studies highlight the importance of considering both multisensory context and movement-related activity in order to understand how the auditory cortex operates during natural behaviors, paving the way for future work to investigate auditory-somatosensory interactions in more ecological situations.

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures-A cost analysis and description of the surgical technique.

INTRODUCTION: Current surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. METHODS: All open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. RESULTS: Nine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. CONCLUSION: In suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Induced membrane technique for acute bone loss and nonunion management of the tibia.

Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects. Design: Retrospective study of prospectively collected data (Level IV). Setting: Level I trauma center in the UK. Patients/Participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss.Intervention: Two-stage Masquelet Procedure for the tibia. Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union. Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4-8 cm) and an 88.2% union rate at a mean of 8 months (range 5-18 months). Mean range of motion was 95 degrees of knee flexion (range 80°-130°). All patients but 2 returned to their previous occupation. Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.

Clinical and cost-effectiveness of Knee Arthroplasty versus Joint Distraction for Osteoarthritis (KARDS): protocol for a multicentre, phase III, randomised control trial.

INTRODUCTION: Knee replacement (KR) is a clinically proven procedure typically offered to patients with severe knee osteoarthritis (OA) to relieve pain and improve quality of life. However, artificial joints fail over time, requiring revision associated with higher mortality and inferior outcomes. With more young people presenting with knee OA and increasing life expectancy, there is an unmet need to postpone time to first KR. Knee joint distraction (KJD), the practice of using external fixators to open up knee joint space, is proposed as potentially effective to preserve the joint following initial studies in the Netherlands, however, has not been researched within an NHS setting. The KARDS trial will investigate whether KJD is non-inferior to KR in terms of patient-reported postoperative pain 12 months post-surgery. METHODS AND ANALYSIS: KARDS is a phase III, multicentre, pragmatic, open-label, individually randomised controlled non-inferiority trial comparing KJD with KR in patients with severe knee OA, employing a hybrid-expertise design, with internal pilot phase and process evaluation. 344 participants will be randomised (1:1) to KJD or KR. The primary outcome measure is the Knee Injury and Osteoarthritis Outcomes Score (KOOS) pain domain score at 12 months post-operation. Secondary outcome measures include patient-reported overall KOOS, Pain Visual Analogue Scale and Oxford Knee Scores, knee function assessments, joint space width, complications and further interventions over 24 months post-operation. Per patient cost difference between KR and KJD and cost per quality-adjusted life year (QALY) gained over 24 months will be estimated within trial, and incremental cost per QALY gained over 20 years by KJD relative to KR predicted using decision analytic modelling. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Research Ethics Committee (REC) and Health Research Authority (HRA). Trial results will be disseminated at clinical conferences, through relevant patient groups and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN14879004; recruitment opened April 2021.

Wrist fusion using an induced membrane technique for forearm salvage in a patient with an infected open injury with segmental bone loss: A case report.

This case report describes the management of a 27-year-old male who, after a quadbike accident, presented with an open, infected, segmental both bone forearm injury with significant bone and soft tissue loss including the radio-carpal joint. Limb salvage was accomplished in the form of a single bone forearm fusion utilising Masquelet's two-stage induced membrane technique to reconstruct the segmental bone defect. The patient proceeded to uneventful bony union by 6 months and returned to driving and riding a quadbike. Despite significant deep infection, successful salvage was achieved using the induced membrane technique. Critical to success was aggressive, repeated debridement alongside restoration of vascular supply and reconstruction of soft tissue defects. We highlight the multidisciplinary approach to management including relevant specialists with a particular interest in limb reconstruction.

Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction.

AIM AND OBJECTIVE: This study was designed to test and compare the mechanical performance of the biplanar ArthroSave KneeReviver and a circular frame construct with the intended use of providing a mechanically favourable environment for cartilage regeneration across a knee joint. MATERIALS AND METHODS: Three similar constructs of the two devices were applied to biomechanical testing sawbones, with the knee distracted by 8 mm. The constructs were vertically loaded to 800 N in an Instron testing machine at 20 mm/minute. Tests were conducted in neutral hip flexion and at 12° of hip flexion and extension, to mimic leg position in gait. Displacement measurements were taken from the Instron machine, and three-dimensional joint motion was recorded using an Optotrak Certus motion capture system. RESULTS: Overall axial rigidity was similar between the two devices (circular frame, 81.6 N/mm ± 5.9; and KneeReviver, 79.5 N/mm ± 25.1 with hip neutral) and similar in different hip positions. At the point of joint contact, the overall rigidity of the circular frame increased significantly more than the KneeReviver (491 N/mm ± 27 and 93 N/mm ± 32, respectively, p <0.001). There was more variability between models in the KneeReviver. There was more off-axis motion in the KneeReviver, mainly due to increasing knee flexion on loading. This was exacerbated with the hip in flexion and extension but remained small, with the maximal off-axis displacement being 7 mm/3°. CONCLUSION: The circular frame provides a similar mechanical environment to the novel KneeReviver device, for which most clinical data are available. These findings suggest that both devices appear a viable option for knee joint distraction (KJD). Further clinical data will help inform mode of application. CLINICAL SIGNIFICANCE: KJD is a relatively novel technique for use in osteoarthritis (OA), and it remains unclear which distraction devices provide appropriate mechanics. Our testing gives evidence to support either option for further use. HOW TO CITE THIS ARTICLE: Chowdhury JMY, Lineham B, Pallett M, et al. Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction. Strategies Trauma Limb Reconstr 2021;16(2):71-77.

Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study.

AIMS AND OBJECTIVES: To examine clinical and functional outcomes in patients with intra- and extra-articular distal tibial fractures treated definitively by Ilizarov fixation. MATERIALS AND METHODS: Patients with tibial fractures extending within 1 Müller square of the ankle joint were identified from our Ilizarov database over a 5-year period. Data on treatment and outcome were assembled from this database and supplemented by a review of patient records. General measures of health-related quality of life and limb-specific functional outcome scores were recorded. Adverse events were documented according to Paley's classification. RESULTS: One hundred and sixty-eight patients with 169 fractures were identified, 28% were open and 63% intra-articular. One hundred and sixty-five (98%) of the fractures united, two following bone grafting in their original frames, at a median of 166.5 days (range 104-537). Three patients with nonunions united with further treatment. One patient (an end-stage diabetic) elected to undergo amputation following multiple early complications during treatment. Closed fractures united more rapidly than open (median 157 vs 183 days; p = 0.005) and true Pilon (43C3) fractures took longer to unite than other fractures (median 157 vs 177 days; p = 0.01).Sixty-seven percent of patients completed functional outcome scores. Sixty-two percent reported good or excellent ankle scores at more than 6 months post frame removal, 38% fair and 10% poor. Patients with intra-articular fractures reported significantly worse ankle scores than those with extra-articular injuries. General measures of health-related quality of life (EuroQol-5D) revealed significant ongoing effects despite good clinical outcomes. CONCLUSION: This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries. HOW TO CITE THIS ARTICLE: Giannoudis VP, Ewins E, Taylor DM, et al. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strategies Trauma Limb Reconstr 2021;16(2):86-95.

Simultaneous induced membrane technique to reconstruct an obliterated floating knee.

The induced membrane technique, first described by Masquelet, is a powerful surgical approach that can be used to address segmental bone loss of various aetiologies. Despite ongoing debate regarding optimal delivery, the indications and limits of its application have been tested in increasingly complex situations, highlighting its considerable potential. We present a case of a devastating open lower limb injury with simultaneous femoral and ipsilateral tibial bone loss including articular injury on both sides of the joint. The Masquelet technique was used to successfully address both segments of bone loss within the same limb.

Ilizarov Method for Acute Paediatric Tibial Fractures.

AIM AND BACKGROUND: A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit's practice in adult patients. The indications, underlying principles and rationale for the method are also discussed. TECHNIQUE: The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing. CONCLUSION AND CLINICAL SIGNIFICANCE: Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve. HOW TO CITE THIS ARTICLE: Messner J, Prior CP, Pincher B et al. Ilizarov Method for Acute Paediatric Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):46-52.

Real-Time Closed-Loop Feedback in Behavioral Time Scales Using DeepLabCut.

Computer vision approaches have made significant inroads into offline tracking of behavior and estimating animal poses. In particular, because of their versatility, deep-learning approaches have been gaining attention in behavioral tracking without any markers. Here, we developed an approach using DeepLabCut for real-time estimation of movement. We trained a deep-neural network (DNN) offline with high-speed video data of a mouse whisking, then transferred the trained network to work with the same mouse, whisking in real-time. With this approach, we tracked the tips of three whiskers in an arc and converted positions into a TTL output within behavioral time scales, i.e., 10.5 ms. With this approach, it is possible to trigger output based on movement of individual whiskers, or on the distance between adjacent whiskers. Flexible closed-loop systems like the one we have deployed here can complement optogenetic approaches and can be used to directly manipulate the relationship between movement and neural activity.

The PINS Trial: a prospective randomized clinical trial comparing a traditional versus an emollient skincare regimen for the care of pin-sites in patients with circular frames.

AIMS: Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame. METHODS: Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system. RESULTS: Out of 116 patients who were enrolled in the study, 23 patients (40%) in the CHX group and 26 (44%) in the DML group had at least one bad or ugly pin-site infection. This difference was not statistically significant (p = 0.71). There was no significant relationship between pH or hydration of the skin and pin-site infection. The epidermal thickness was found to be significantly greater in patients who had a pin-site infection compared with those who did not (p = 0.01). Skin irritation requiring a change of treatment occurred in four patients (7%) using CHX, and none using DML. CONCLUSION: We found no significant difference in the incidence of pin-site infection between the CHX and DML treatment groups. Dermol appeared to offer a small but significant advantage in terms of tolerability. We did not find a significant association between patient or treatment related factors and pin-site infection. It is therefore difficult to make specific recommendations based upon these results. The use of either cleaning agent appears to be appropriate. Cite this article: Bone Joint J 2021;103-B(2):279-285.

What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

INTRODUCTION: The Trauma network was established in April 2012 in England to improve the care of patients with trauma. The care of major trauma was centralised to major trauma centres. This article aims to survey trauma team members (TTM) to compare perceptions of trauma care delivery in major trauma centres (MTC) and trauma units (TU) from where major trauma care has been diverted. METHODS: Trauma team members (TTM) from six hospitals were interviewed between June and July 2016. This included three MTCs and their neighbouring TU. Data were also gathered to determine appropriate trauma qualifications of TTMs. RESULTS: TTMs in MTCs perceived the standard of trauma service improved (90% increased, 10% same) since April 2012 in comparison to TUs (10% increased, 63% same, 27% decreased) (p ≤ 0.001). In MTCs, TTMs felt their skills improved more (66% improved, 34% unchanged) compared to TU's (24% improved, 64% unchanged, 12% regressed) (p ≤ 0.001). TTM's in MTCs were more satisfied with their trauma teams training (p ≤ 0.001), leader's communication (p ≤ 0.001) and handover process (p ≤ 0.01) in comparison to TTMs in TUs. 69% of doctors in MTCs held valid trauma qualifications as compared to only 37% in TUs (p ≤ 0.001). CONCLUSION: The centralisation of major trauma care to MTCs allows care for severely injured patients in specialised hospitals with allocated resources. This survey shows the effect of this reorganisation where diversion of major trauma from TUs may have led to their TTMs perceiving their standard of care to be less than TTMs in MTCs. This study recommends training support for TUs using modalities such as simulation-based training and regular audits to ensure improved perceptions and adequate qualifications. Multidisciplinary meetings between MTCs and TUs can allow information to be exchanged and shared to ensure reciprocal support and engagement to improve perception of trauma care delivery.

Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle.

Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available. HOW TO CITE THIS ARTICLE: Irvine E, Cochrane E, Harwood P, et al. Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle. Strategies Trauma Limb Reconstr 2021;16(3):176-178.