The rising burden of penetrating knife injuries.

INTRODUCTION: Knife crime remains an area of public health concern. In order to tackle this problem and reduce its burden, the epidemiology of penetrating knife injuries needs to be understood. The aim of this study is to analyse the pattern of knife injuries at a major trauma centre (MTC) in London. METHODS: An analysis of cases from the prospectively collected Trauma Audit and Research Network database of patients attending the emergency department with violent intentional knife injuries from January 2014 to December 2018 was performed. Registry data were analysed for mechanism of injury, number of stabbings, month/date/time of admission, patient demographics, anatomical pattern of injury, hospital length of stay, intervention, ethnicity, repeat victims and fatality. RESULTS: 1373 penetrating knife injuries activated the major trauma call representing 11.7% of all major trauma alerts. 44% occurred in the 16-25 years age group and 85.6% were male. 67.2% required hospital admission. 14.1% required surgery. 50.3% required intervention from multiple specialities. 39.4% had thoracic injuries and 25.8% abdominal injuries. Fatality rate was 0.9% (n=12). 3.6% were repeat victims. 26.8% were multiple stabbings. 5.2% were deliberate self-harm. 23.2% were of white ethnic background. Injury incidence peaked on a Saturday. A significant peak in injuries occurred between 22:00 and 00:00. CONCLUSION: This study shows an increase in the incidence of knife crime per year. These cases contribute approximately 12% of major trauma calls. Female assaults increased from 8.4% to 14.3%. Approximately 2/3 injuries occur in the thorax and abdomen with high frequencies at weekends and evenings. These facts can help allocate resources more efficiently.

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review.

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.

Eliminating the use of allogeneic blood products in adolescent idiopathic scoliosis surgery.

PURPOSE: The aim of this study was to compare transfusion requirements in patients before and after the introduction of tranexamic acid as standard in patients undergoing spinal surgery for idiopathic scoliosis in a national orthopaedic hospital. METHODS: A retrospective chart review of 56 idiopathic scoliosis patients who underwent posterior spinal instrumentation and fusion between 2009 and 2013 at our institution. Preoperative, intraoperative, and postoperative data were measured. RESULTS: Patients who received tranexamic acid as standard (n = 31) showed a trend towards a decrease in transfusion requirements compared with those who received no tranexamic acid (n = 25). These patients had a statistically significant decrease in operative time (223 vs 188 min, p = 0.005), and estimated intraoperative blood loss was reduced by nearly 50% in the tranexamic acid group. They also had an associated reduced decrease in haemoglobin between preoperative and postoperative levels (4 vs 5 g/dL, p = 0.01). CONCLUSIONS: Since February 2012, no patient has required intraoperative or postoperative allogeneic blood product transfusion in this hospital. The routine use of antifibrinolytic medications in patients undergoing surgery for adolescent idiopathic scoliosis has effectively eliminated the need for allogeneic blood products.

Acute nontraumatic spinal intradural hematoma in a patient on warfarin.

BACKGROUND: Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences. OBJECTIVE: The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas. CASE REPORT: We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively. CONCLUSIONS: Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.

Preoperative comorbidity and modes of failure in revision hip arthroplasty: a single-surgeon series in a tertiary referral centre.

Revision hip arthroplasty is associated with higher morbidity post-operatively than primary surgery. We reviewed data on 102 consecutive patients (124 procedures) undergoing revision hip arthroplasty by a single surgeon from January 2005 to June 2009 in 2 institutions. Indications of failure: 62% aseptic loosening, 15% infection, 11.5% fracture, 10.6% dislocation or instability and 0.9% implant failure. Preoperative comorbidities: 28.4% cardiac, 4% respiratory and 6.8% diabetic. Morbidity: 3.9% complication rate (5 of 124 procedures). 73.5 median age and 46% over 75 years old. Modes of failure in our population leading to revision hip arthroplasty are similar to other studies. We showed a low morbidity following revision hip arthroplasty despite significant preoperative comorbidities and a high proportion of elderly patients. In conclusion, gender, age (>75) and preoperative comorbidities should not deter from revision surgery.

A narrative exploration of identity in adults with de novo scoliosis.

Adult de novo scoliosis is a chronic health condition characterised by a curvature in the ageing spine. It can cause debilitating back pain and significant visible differences. Yet there has been very limited research on the psychological effects of this condition, particularly around identity. Therefore, we undertook semi-structured interviews to explore the ways in which individuals with scoliosis understood their identity. Findings from narrative analysis highlight the ways in which individuals negotiate their identity in relation to their social roles, their ability to control their condition and things around them, the extent to which their condition is visible and the extent to which they experienced physical pain from their condition. This article concludes by highlighting the relationship between identity and scoliosis and offers practical implications and suggestions for future research.

Anterior spinal separation surgery to allow for stereotactic body radiotherapy: a novel approach permitting radical oncological treatment of oligometastatic disease.

The treatment of spinal cancers has rapidly evolved in the past decade. Often the treatment for spinal metastases required highly morbid surgeries and with palliative outcomes. However, a paradigm shift in surgical oncology has allowed spinal metastases treatment to have curative results. In the state of oligometastatic disease (OMD), the accompaniment of Stereotactic Body Radiotherapy (SBRT) as a primary modality or adjuvant treatment to surgery has been shown to excellent survival outcomes, lower morbidities and better pain management. This case report illustrates a novel approach to the treatment of spinal OMD utilizing anterior spinal separation surgery with a custom carbon fibre vertebral body replacement cage followed by postoperative SBRT with excellent radio-oncological outcomes over 30-month follow-up.

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy.

Introduction: Tomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery. Methods: First-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4-S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Results: Patient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op. Conclusion: These are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study.

BACKGROUND: Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate. METHODS: We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores. RESULTS: We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate. CONCLUSION: Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.

Total joint arthroplasty in nonagenarians--a retrospective review of complications and resource use.

Increased age brings with it the potential for increased surgical risk. Assessment of specific age cohorts is necessary to plan future service provision and this is the case in hip and knee arthroplasty as the demand for these procedures is anticipated to increase. We retrospectively reviewed the outcomes, including complications, length of stay and blood transfusion rate, in a cohort of 35 nonagenarians undergoing primary or revision total hip and knee arthroplasty. All patients were pre-assessed by anaesthetists before being deemed suitable to undergo surgery in the unit. The mean length of hospital stay was 13.7 +/- 10 days (range 2-56). Thirty-one percent of patients required a blood transfusion. Patients who underwent primary total hip arthroplasty reported improved joint specific functional scores. In this appropriately selected group of nonagenarians, we found no evidence to suggest surgery be withheld on the basis of age alone. However, patients with multiple medical comorbidities warrant appropriate assessment and surgical intervention in an institution with appropriate support. Future planning needs to take into account the predicted increase in demand for arthroplasty surgery in this age group.

Hand dominance in orthopaedic surgeons.

Handedness is perhaps the most studied human asymmetry. Laterality is the preference shown for one side and it has been studied in many aspects of medicine. Studies have shown that some orthopaedic procedures had poorer outcomes and identified laterality as a contributing factor. We developed a questionnaire to assess laterality in orthopaedic surgery and compared this to an established scoring system. Sixty-two orthopaedic surgeons surveyed with the validated Waterloo Handedness Questionnaire (WHQ) were compared with the self developed Orthopaedic Handedness Questionnaire (OHQ). Fifty-eight were found to be right hand dominant (RHD) and 4 left hand dominant (LHD). In RHD surgeons, the average WHQ score was 44.9% and OHQ 15%. For LHD surgeons the WHQ score was 30.2% and OHQ 9.4%. This represents a significant amount of time using the non dominant hand but does not necessarily determine satisfactory or successful dexterity transferable to the operating room. Training may be required for the non dominant side.

Dual modality of vertebral body tethering : anterior scoliosis correction versus growth modulation with mean follow-up of five years.

AIMS: Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. METHODS: We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). RESULTS: There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) with a mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years' follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. This one patient alone had a over-correction, a second-stage tether release, and final conversion to fusion. CONCLUSION: We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC. Cite this article: Bone Jt Open 2022;3(2):123-129.

Integrated Custom Composite Polyetheretherketone/Carbon fiber (PEEK/CF) Vertebral Body Replacement (VBR) in the Treatment of Bone Tumors of the Spine: A Preliminary Report From a Multicenter Study.

STUDY DESIGN: Retrospective, multicenter chart, and radiologic review. OBJECTIVE: To present the first case series of bone tumors of the spine surgically reconstructed with a new custom, fully radiolucent, polyetheretherketone/carbon fiber (PEEK/CF) vertebral body replacement (VBR) integrated system. SUMMARY OF BACKGROUND DATA: Surgical resections of spinal tumors result in large defects and local recurrence remains a concern. Current titanium-based implants adversely affects postoperative imaging, directly affects ability to identify tumor recurrence, and for delivery of radiotherapy treatments. PEEK/CF spinal implants allows for improved tumor surveillance, precise pre-radiation Computed Tomography planning, and reduces interference with post-reconstructive adjuvant radiotherapy. METHOD: Thirteen patients with spinal tumors underwent vertebral body resection and reconstruction with an integrated, fully radiolucent, custom PEEK/CF vertebral body replacement, and radiolucent posterior PEEK/CF screw-rod system and/or radiolucent anterior PEEK/CF plate system. Clinical and radiographic data were tabulated. Need for adjuvant radiotherapy determined based on final tissue histology and extent of surgical margins. Postoperative surveillance imaging were reviewed for local tumor recurrence. RESULTS: The ability to integrate the PEEK/CF VBR connected to either the posterior screw-rod system, or anterior plate system provided immediate stability. The VBR was placed directly on cancellous vertebral body surface in 46.2% of cases. Loosening of the distal, or proximal, aspect of posterior system was seen in 15.4% of cases. There was no clinical or radiographic evidence of VBR migration and subsidence at latest follow up. Local recurrence occurred in one (7.7%) patient. CONCLUSION: This is the first series to describe the use of a fully-radiolucent, integrated, PEEK/CF implant system for spinal tumor reconstruction. The use of a PEEK/CF VBR system integrated to either the anterior plate, or posterior screw-rod system is feasible and allows for superior postoperative surveillance imaging and effective delivery of postoperative adjuvant radiotherapy.Level of Evidence: 4.

Dynamic Radiographs in Assessing Stability of Cervical Spine Fractures: A Multicentre Study.

BACKGROUND: In the management of a trauma patient with cervical spine injury, the need for accurate diagnostic imaging is key to ensure correct management. Different classification systems have been developed including the Subaxial Injury Classification (SLIC) system and AO cervical spine fracture classification. Through a multicentre study, we have identified a group of cases where the use of CT alone to classify fractures by either SLIC or AO score may be deficient and the use of dynamic cervical spine radiographs could help identify instability. METHODS: Three level 1 trauma centers retrospectively reviewed patients with cervical spine injuries. Cervical spine radiographs (AP and lateral) were undertaken in collar, in all patients with suspected cervical spine injury within 2 weeks, followed by reanalysis of scoring systems. RESULTS: Eleven cases were identified in total, and 72% were male with a mean age of 65 years, with approximately 54% being older than 70 years. All patients reported their pain as severe using the Visual Analogue Scale scale. The predynamic radiograph mean SLIC score was 0.73, which is in contrast to the postdynamic radiograph mean SLIC score of 6. The statistical significance (P = 0.004) was found using the Wilcoxon signed-rank test. CONCLUSION: Supine imaging eliminates the gravitational loads normally exerted on the c-spine. The cases show assumed cervical stability based on CT, but dynamic c-spine radiographs subsequently demonstrated instability. Therefore, we suggest a combination of SLIC and AO classification using radiologic imaging to classify fracture and correlate clinical symptoms with persistent neck pain, which warrants a Miami-J collar and dynamic c-spine radiograph to assess stability with re-evaluation of scoring.

In Scheuermann's kyphosis, a proximal UIV and postop kyphosis value close to patients' PI decreases the risk of PJK.

PURPOSE: Prevalence of proximal junctional kyphosis (PJK) in Scheuermann's kyphosis (SK) varies between 24 and 40%. Multiple factors have been implicated, including kyphosis overcorrection, failure to include proximal end vertebra, and implant choice. This study aimed to determine the goal correction parameters based upon patients' pelvic incidence, and UIV to decrease PJK in Scheuermann's kyphosis. METHODS: X-ray and chart review of SK patients operated with all pedicle screw (PS), hybrid fixation (HF), and anterior/posterior fusions with hybrid fixation (AP). T1/T2 were grouped together as proximal fusion groups compared to T3 and distal groups. RESULTS: 96 total patients: PS (n = 41), HF (n = 24), and AP (n = 31). Overall, at early postop 12 (12.5%) patients had PJK. At final follow-up, 33 (34.4%) had PJK. There was no significant difference between groups at early postop (p = 0.86) or final follow-up (p = 0.67). When correcting kyphosis-PI to > - 10.0° and UIV was chosen to be T1 or T2, PJK developed in 6.1% of patients at final follow-up; when fusing to T1/T2 but with kyphosis-PI < - 10.0°, 38.9% of patients developed PJK. With kyphosis-PI > - 10.0° and UIV at T3 or below, 37.0% of patients developed PJK at final follow-up. When fusing to T3 or below but failing to correct kyphosis-PI to > - 10.0°, 77.8% of patients developed PJK. CONCLUSION: Selecting proximal UIV and avoiding kyphosis-PI mismatch can significantly decrease the prevalence of PJK rather than surgical technique or implant choice. Surgeons treating SK should, therefore, aim to correct kyphosis closer to the patient's pelvic incidence and choose T2/T1 as UIV.

Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises.

A 15-year-old female with 2-year post-menarchal adolescent idiopathic scoliosis and sickle cell disease (SCD) underwent posterior scoliosis correction surgery. SCD is associated with higher rates of surgical complications, and these patients require careful management to prevent vaso-occlusive sickle cell crises (VOSCC); scoliosis correction surgery can be associated with high morbidity and mortality, including significant blood loss. Multiple techniques were employed to successfully prevent VOSCC in this patient including a preoperative transfusion, meticulous haemostasis at osteotomy sites, not performing a costoplasty despite presence of a rib hump, maintenance of intraoperative mean arterial pressure below 70 mmHg, aggressive postoperative hydration and the use of intraoperative tranexamic acid (TXA). This is the first reported case of the use of TXA in a patient with SCD and scoliosis correction surgery. A satisfactory correction was achieved with a longer than average inpatient stay due to non-sickle cell pain and protracted wound ooze.

Catching the second wave: clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients during the COVID-19 pandemic.

AIMS: The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. METHODS: A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). RESULTS: From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. CONCLUSION: During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661-670.

Reproducibility and reliability analysis of the Luk Distal Radius and Ulna Classification for European patients with adolescent idiopathic scoliosis.

PURPOSE: Current clinical and radiological methods of predicting a patient's growth potential are limited in terms of practicality, accuracy and known to differ in different races. This information influences optimal timing of bracing and surgical intervention in adolescent idiopathic scoliosis (AIS). The Luk classification was developed to mitigate limitations of existing tools. Few reliability studies are available and are limited to certain geographical regions with varying results. This study was performed to analyze reproducibility and reliability of the Luk Distal Radius and Ulna Classification in European patients. METHODS: This is a radiological study of 50 randomly selected left hand and wrist radiographs of patients with AIS referred to a tertiary referral centre. They were assessed for bone maturity using the Luk Distal Radius and Ulna Classification. Assessment was performed twice by four examiners at an interval of one month. Statistical analysis was performed using the intraclass correlation (ICC) method to determine the reliabilities within and between the examiners. RESULTS: In total, 50 radiographs (M:F = 13:37) with a mean age of 13.7 years (10 to 18) were assessed for reliability. The inter-rater ICC value was 0.918 for radius assessment and 0.939 for ulna assessment. The intra-rater ICC values for radius assessment ranged between 0.897 and 0.769 and between 0.948 and 0.786 for ulna assessment. There was near perfect correlation for both assessments. CONCLUSION: This study provides independent evidence that the Luk Distal Radius and Ulna Classification is a reliable tool for assessment of skeletal maturity for European patients. Minimal clinical experience is required to reliably utilize it. LEVEL OF EVIDENCE: IV.

Corrigendum to: Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises.

[This corrects the article DOI: 10.1093/jscr/rjaa559.].

A Hybrid Virtual Fracture Clinic is Safe and Efficacious in the COVID-19 Era: Stay at Home and Save Lives.

Introduction The coronavirus disease 2019 (COVID-19) pandemic necessitated a change in the manner outpatient fracture clinics are conducted due to the need to reduce footfall in hospitals. While studies regarding virtual fracture clinics have shown these to be useful and effective, they focus exclusively on remote consultations. However, our service was bespoke to the patient - either a face-to-face, a telephone consultation or both, depending on patient need - a 'hybrid virtual fracture clinic' (HVFC). We report patient satisfaction and outcomes with this service from the first wave of the pandemic. Methods We retrospectively interviewed patients who availed of the HVFC service at our institution during the first two weeks of national lockdown in England from March 23 to April 5, 2020. The number and type of consultations, patient vulnerability to COVID-19, and type of management (surgical vs non-surgical) were among the factors taken into consideration. Patient experience was assessed using the Net Promoter Score (NPS), Customer Effort Score (CES), and Customer Satisfaction Score (CSS) on a scale of 0-10. Patient-reported outcomes were assessed using the EuroQol-5D-5L score (including EQ Visual Analogue Scale {EQ-VAS} scoring on a scale of 0-100). Results The mean overall NPS, CES, and CSS for the service were 7.32, 7.24, and 7.49, respectively. The mean self-reported EQ-VAS rating was 77.5. Of 442 consultations, 246 were conducted virtually; 10% were face-to-face, 29% virtual, and 61% were hybrid consultations. The HVFC resulted in a 55.65% reduction in footfall. Statistical analysis showed no significant difference across any outcome measure when compared between hybrid, virtual, and face-to-face consultations. Patients vulnerable to COVID-19 and those who did not require surgery tended to report better overall scores. Conclusion Our study indicates that the HVFC format can reduce patient footfall significantly (>50%) while providing effective and satisfactory outpatient care. There appears to be no difference in patient-reported outcomes between face-to-face consultations and hybrid or virtual consultations. Patients would recommend HVFC to family and friends, found it was easy to use, and reported good satisfaction with the service.