Fracture related infection in open tibial fractures.

Open tibia fractures frequently occur following high-energy trauma. Contamination of the fracture site combined with limited soft tissue coverage and blood supply means that these open fractures are associated with a high rate of complications, including fracture related infection (FRI). FRI is associated with lowered patient outcomes and requires early recognition and appropriate surgical and medical management. The current evidence on FRI after open tibial fractures largely is limited to case series, small retrospective cohort studies and expert opinion. Recent expert consensus has produced guidelines with the aim of standardising care for these patients. This review summarises the current management strategies employed in treating FRI following open tibial fractures and where possible the evidence behind them.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes.

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design: Case series; Level of evidence, 4. Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Temporary circular external fixation for spanning the traumatised ankle joint: A cohort comparison study.

BACKGROUND: Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of the traumatised soft-tissue envelope. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame monolateral external fixators to ankle spanning circular fixators. METHODS: Two cohorts were matched for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications. RESULTS: Fifty-five delta-frames and 51 circular fixators were statistically matched for demographics and fracture pattern. "Excellent" and "Good" initial reduction was achieved in 50 (91%) delta-frames and 51 (100%) circular fixators (p = 0.027). Deterioration of initial reduction quality was seen in 12 (22%) delta-frames and two (4%) circular fixators (p < 0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p = 0.147). Median duration in spanned fixation was 11 days in both groups (p = 0.114). Three (5%) delta-frames and 13 (25%) circular fixators were used as definitive fixation. The mean implant cost was 4,307 USD for delta-frames and 3747 USD for circular fixators. CONCLUSION: Temporary spanning circular fixation offers superior intra-operative reduction and maintenance of reduction and provides more opportunity to be used as definitive fixation. Circular fixation implants also proved to be less expensive and protected against further scheduled or unscheduled returns to theatre. LEVEL OF EVIDENCE: IV, retrospective cohort study.

The management of segmental femur fractures: the radiographic 'cover-up' test to guide decision making.

BACKGROUND: Segmental femur fractures often pose management challenges regarding the optimal fixation choice and sequence of surgical events. METHODS: Retrospective review of clinical records and radiographic data of adult patients with segmental femur fractures treated by a conceptual radiographic cover-up test to determine the ideal fixation method between January 2019 and December 2020. RESULTS: Forty patients with 84 individual fractures underwent fracture fixation. The most consistent fracture combinations were intertrochanter-diaphysis (AO31A-AO32) fractures (25%, n = 10) and femur neck-diaphysis (AO31B-AO32) fractures (20%, n = 8). Compared to evidence-based fracture management, the gold standard treatment was used for the fixation of 78 fractures (93%). One patient required revision for fixation failure of a diaphyseal fracture, and two fractures, both open diaphysis injuries, developed fracture-related infections. CONCLUSION: Anatomical alignment and high union rates are possible for segmental femur fractures treated by evidence-based fracture fixation principles. A conceptual radiographic cover-up test assists in matching the best possible implant for each fracture.

Do we achieve the Montgomery standard for consent in orthopaedic surgery?

AIMS/BACKGROUND: The Montgomery v Lanarkshire Health Board (2015) case set a precedent that has driven the modernisation of consenting practice. Failure to demonstrate informed consent is a common source of litigation. This quality improvement project aimed to provide pragmatic guidance for surgeons on consent and to improve the patient experience during decision making. METHODS: Elective orthopaedic patients were assessed and the quality of documented consent was recorded. Data were collected over two discrete cycles, with cycle 1 used as a baseline in practice. The following criteria were reviewed: grade of consenting clinician, alternative treatment options, description of specific risks, place and timing of consent and whether the patient received written information or a copied clinic letter. Cycle 1 results were presented to clinicians; a teaching session was provided for clinicians on the standard of consent expected and implementation of a change in practice was established with a re-audit in cycle 2. RESULTS: There were 111 patients included in cycle 1, and 96 patients in cycle 2. Consent was undertaken mostly by consultants (54%). Specific patient risks were documented in 50% of patients in cycle 1 and 60% in cycle 2. Risks associated with a specific procedure were documented in 42% in cycle 1 and 76% in cycle 2, alternative options in 48% (cycle 1) and 66% (cycle 2). A total of 14% of patients in cycle 1 and 8% in cycle 2 had documented written information provision. Copied letters to patients was only seen in 12% of all cycles. Documentation from dedicated consenting clinics outperformed standard clinics. CONCLUSIONS: Highlighting poor documentation habits and refining departmental education can lead to improvements in practice. The use of consenting clinics should be considered and clinicians should individually reflect on how to address their own shortcomings. Other units should strongly consider a similar audit. This article provides stepwise advice to improve consent and specifics from which to audit.

Fever in a patient with osteomyelitis: the diagnosis could be serotonin syndrome.

Awareness of rare differential diagnoses of common clinical presentations helps promote early detection and prompt management of serious conditions. A 54-year-old man, with an infected non-union following a high tibial osteotomy, presented with an acutely discharging abscess to his proximal tibia. He was generally unwell with a Staphylococcus aureus bacteraemia. The tibia was debrided, CERAMENT G used as dead space management and a spanning external fixator applied. Postoperatively, pregabalin and tapentadol were commenced in addition to amitriptyline and sertraline, which the patient was taking regularly. Overnight, the patient developed hyperthermia, inducible clonus, hyperreflexia, agitation, confusion and rigors. Prompt recognition of the possibility of serotonin syndrome resulted in early cessation of serotonergic medications and a positive outcome. From this case an important message is that fever in a patient taking serotonergic medications should prompt a screening neurological examination. Clinicians should also be wary when patients are commenced on multimodal analgesia, including tapentadol.

The association of socioeconomic deprivation and paediatric open tibia fractures.

The primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children's hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0-16 years). The median age at injury was 11 years (range 2-16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.

Controversies and Trends in United Kingdom Bunion Surgery.

Current practice and controversies in UK bunion surgery are discussed. Patients tend to be offered a distally based metatarsal osteotomy, such as a chevron or scarf osteotomy, for mild to moderate symptomatic bunions. Greater deformities are managed with a more extreme scarf, supplemented with a proximal phalangeal osteotomy. A proximal fusion in the form of the Lapidus-type procedure is still reserved for the most severe, hypermobile, or arthritic cases. Minimally invasive techniques for bunions have failed to disseminate into common UK practice. The trends in the United Kingdom regarding litigation, venous thromboembolism, and osteodesis for bunion surgery are also discussed.

Delayed diagnosis in primary care-The main cause of sarcoma litigation in the United Kingdom.

BACKGROUND: Poor awareness and knowledge of lumps and bumps can impact on patient outcomes and survival. Late referrals or false reassurance may lead to litigation proceedings. The aim of this study was to identify the litigation cost in sarcoma care and identify areas for improvement. METHOD: Orthopaedic litigation between 1995-2010 in England and Wales was obtained from the National Health Service Litigation Authority. Litigation specifically relating to sarcoma in the extremities was identified. Causation, compensation fee, cost of legal defense, and compensation were analyzed. RESULTS: There were 52 litigation claims. Negligence was proven in 71% (n = 37) of cases. The total cost was £4.4 million (mean of £84,000/case). The mean compensation award was £92,000 (range £650-£978,000) and the mean defense cost was £22,000 (range £0-£102,000). Delayed diagnosis accounted for 89% of cases (n = 48). Negligence following diagnosis was infrequent; inappropriate treatment (n = 2), failure to recognize complications of surgery (n = 2), intra-operative problems (n = 1), failure to refer to a specialist unit after a "whoops procedure" (n = 1). CONCLUSIONS: Once the patient is within the specialist sarcoma unit, there is a very low rate of litigation. Efforts to reduce litigation in sarcoma treatment should focus on early diagnosis and raising awareness of sarcomas. J. Surg. Oncol. 2016;113:361-363. © 2016 Wiley Periodicals, Inc.

Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.

OBJECTIVE: Fascia iliaca compartment block (FICB) administered through the loss of resistance technique effectively reduces pain and opiate requirement in elderly patients with hip fractures. FICB is a simple technique and is easily taught. This paper plots the implementation of FICB in two hospitals. METHODS: A continuous audit process of two separate sites recorded the uptake of the FICB on an organizational level. An additional control group (CG) of 100 patients were analysed to compare pain scores (using the Numerical Rating Scale) and opiate requirements between groups of patients receiving fascia iliaca block and those receiving standard care. Documentation habits and adverse drug reactions were monitored over the audit process. RESULTS: There were 434 patients audited, with 326 (75.1%) receiving the FICB. The uptake of the FICB and documentation improved over time. The FICB significantly reduced pain scores (P<0.001) and also opiate requirement (P<0.0001) compared with those in the CG. Acute length of stay reduced to 9.9 days (FICB group) from 15 days (CG). Inpatient mortality was 5.5% in the FICB group and 15% in the CG (P=0.0024). CONCLUSION: Organizational learning of this simple procedure can be achieved through a multidisciplinary approach, and committed departmental education and feedback. The impact on length of stay and mortality were striking; however, there may be other confounding factors. Only two cases of true anaesthetic toxicity occurred in 1586 patients. The authors conclude that FICB is a safe procedure and a useful adjunct for preoperative pain control in patients with hip fractures.

Local Anaesthetic Infiltration and Indwelling Postoperative Wound Catheters for Patients with Hip Fracture Reduce Death Rates and Length of Stay.

Background. An analgesic enhanced recovery (ER) protocol for patients with a hip fracture was introduced. It was hypothesised that the ER would reduce pain, length of stay and improve clinical outcomes. The protocol used intraoperative infiltration of levobupivacaine followed by ongoing wound infusions. Methods. Consecutive patients admitted to two hospitals were eligible for the ER protocol. Numerical Reporting Scale pain scores (0-10) were recorded alongside opiate requirements. 434 patients in the ER group (316 full ER, 90 partial ER, and 28 no ER) were compared to a control group (CG) of 100 consecutive patients managed with traditional opiate analgesia. Results. Mean opiate requirement was 49.2 mg (CG) versus 32.5 mg (ER). Pain scores were significantly reduced in the full ER group, p < 0.0001. Direct discharge home and mean acute inpatient stay were significantly reduced (p = 0.0031 and p < 0.0001, resp.). 30-day mortality was 15% (CG) versus 5.5% (ER), p = 0.0024. Conclusions. This analgesic ER protocol for patients with a hip fracture was safe and effective and was associated with reduced inpatient stay and mortality.

The epidemiology of transient synovitis in Liverpool, UK.

BACKGROUND: The epidemiology of transient synovitis is poorly understood, and the aetiology is unknown, although a suggestion of a viral association predominates. PURPOSE: This population-based study investigated the epidemiology in order to formulate aetiological theories of pathogenesis. PATIENT AND METHODS: Cases in Merseyside were identified between 2004 and 2009. Incidence rates were determined and analysed by age, sex, season and region of residence. Socioeconomic deprivation scores were generated using the Index of Multiple Deprivation, allocated by postcode. Poisson confidence intervals were calculated and Poisson regression was used to check for trends. RESULTS: Two hundred and fifty-nine cases were identified over 5.5 years. The annual incidence was 25.1 (95 % CI 22.1-28.5) per 100,000 0-14 year-olds. Male to female ratio was 3.2:1 (p < 0.001). Mean age at presentation was 5.4 years (95 % CI 5.0-5.8), which demonstrated a near-normal distribution. No relationship was identified between seasonality and incidence (p = 0.64). A correlation was identified with socioeconomic deprivation in Merseyside: incidence rate ratio 1.16 (95 % CI 1.06-1.26, p < 0.001), although further analysis within the subregion of Liverpool did not confirm this finding (p = 0.35). CONCLUSIONS: The normal distribution for age at disease presentation suggests a specific disease entity. The absence of seasonality casts some doubt on the popular theory of a viral aetiology. The absence of a consistent socioeconomic gradient in both Merseyside and Liverpool challenges a previous suggestion of an association with Perthes' disease. This paper provides ecological evidence that may challenge existing aetiological theories, though transient synovitis remains an enigma.

The use of percutaneous lumbar fixation screws for bilateral pedicle fractures with an associated dislocation of a lumbar disc prosthesis.

Study Design. Case report. Objective. To identify a safe technique for salvage surgery following complications of total disc replacement. Summary of Background Data. Lumbar total disc replacement (TDR) is considered by some as the gold standard for discogenic back pain. Revision techniques for TDR and their complications are in their infancy. This case describes a successful method of fixation for this complex presentation. Methods and Results. A 48-year-old male with lumbar degenerative disc disease and no comorbidities. Approximately two weeks postoperatively for a TDR, the patient represented with acute severe back pain and the TDR polyethylene inlay was identified as dislocated anteriorly. Subsequent revision surgery failed immediately as the polyethylene inlay redislocated intraoperatively. Further radiology identified bilateral pedicle fractures, previously unseen on the plain films. The salvage fusion of L5/S1 reutilized the anterior approach with an interbody fusion cage and bone graft. The patient was then turned intraoperatively and redraped. The percutaneous pedicle screws were used to fix L5 to the sacral body via the paracoccygeal corridor. Conclusion. The robust locking screw in the percutaneous screw allowed a complete fixation of the pedicle fractures. At 3-year followup, the patient has an excellent result and has returned to playing golf.

Rapid wastage of Alaska glaciers and their contribution to rising sea level.

We have used airborne laser altimetry to estimate volume changes of 67 glaciers in Alaska from the mid-1950s to the mid-1990s. The average rate of thickness change of these glaciers was -0.52 m/year. Extrapolation to all glaciers in Alaska yields an estimated total annual volume change of -52 +/- 15 km3/year (water equivalent), equivalent to a rise in sea level (SLE) of 0.14 +/- 0.04 mm/year. Repeat measurements of 28 glaciers from the mid-1990s to 2000-2001 suggest an increased average rate of thinning, -1.8 m/year. This leads to an extrapolated annual volume loss from Alaska glaciers equal to -96 +/- 35 km3/year, or 0.27 +/- 0.10 mm/year SLE, during the past decade. These recent losses are nearly double the estimated annual loss from the entire Greenland Ice Sheet during the same time period and are much higher than previously published loss estimates for Alaska glaciers. They form the largest glaciological contribution to rising sea level yet measured.