Perioperative management of adults with traumatic brain injury.

Despite advances in management strategy, traumatic brain injury remains strongly associated with neurological impairment and mortality. Management of traumatic brain injury requires careful and targeted management of the physiological consequences which extend beyond the scope of the primary impact to the cranium. Here, we present a review of the principles of its acute management in adults. We outline the procedure which patients are assessed and the critical physiological variables which must be monitored to prevent further neurological damage. We describe current interventional strategies from the context of the underlying physiological mechanisms and recent clinical data and identify persisting challenges in traumatic brain injury management and potential avenues of future progress.

Principles of management of hand fractures.

The optimal management of hand fractures requires a multidisciplinary approach. Initial assessment should include a thorough medical history and clinical examination, followed by appropriate radiological imaging. These are crucial in determining the appropriate management. Following joint stabilisation to allow fractures to unite, early mobilisation is needed to maximise the functional restoration of the hand. In this review, the principles of operative and non-operative management of these injuries are discussed.

Evaluating the Effect of Hypoxia on Human Adult Mesenchymal Stromal Cell Chondrogenesis In Vitro: A Systematic Review.

Human adult mesenchymal stromal cells (MSCs) from a variety of sources may be used to repair defects in articular cartilage by inducing them into chondrogenic differentiation. The conditions in which optimal chondrogenic differentiation takes place are an area of interest in the field of tissue engineering. Chondrocytes exist in vivo in a normally hypoxic environment and thus it has been suggested that exposing MSCs to hypoxia may also contribute to a beneficial effect on their differentiation. There are two main stages in which MSCs can be exposed to hypoxia, the expansion phase when cells are cultured, and the differentiation phase when cells are induced with a chondrogenic medium. This systematic review sought to explore the effect of hypoxia at these two stages on human adult MSC chondrogenesis in vitro. A literature search was performed on PubMed, EMBASE, Medline via Ovid, and Cochrane, and 24 studies were ultimately included. The majority of these studies showed that hypoxia during the expansion phase or the differentiation phase enhances at least some markers of chondrogenic differentiation in adult MSCs. These results were not always demonstrated at the protein level and there were also conflicting reports. Studies evaluating continuous exposure to hypoxia during the expansion and differentiation phases also had mixed results. These inconsistent results can be explained by the heterogeneity of studies, including factors such as different sources of MSCs used, donor variability, level of hypoxia used in each study, time exposed to hypoxia, and differences in culture methodology.

Endoprosthetic Reconstruction in Ewing's Sarcoma Patients: A Systematic Review of Postoperative Complications and Functional Outcomes.

Ewing's sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing's patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing's sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing's patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson's failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of 'good' functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES.

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma.

INTRODUCTION: Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. MATERIALS AND METHODS: All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. RESULTS: The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. CONCLUSION: Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

Perioperative management of open fractures in the lower limb.

An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient's postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.

Innovation Pathways in the NHS: An Introductory Review.

Healthcare as an industry is recognised as one of the most innovative. Despite heavy regulation, there is substantial scope for new technologies and care models to not only boost patient outcomes but to do so at reduced cost to healthcare systems and consumers. Promoting innovation within national health systems such as the National Health Service (NHS) in the United Kingdom (UK) has been set as a key target for health care professionals and policy makers. However, while the UK has a world-class biomedical research industry, several reports in the last twenty years have highlighted the difficulties faced by the NHS in encouraging and adopting innovations, with the journey from idea to implementation of health technology often taking years and being very expensive, with a high failure rate. This has led to the establishment of several innovation pathways within and around the NHS, to encourage the invention, development and implementation of cost-effective technologies that improve health care delivery. These pathways span local, regional and national health infrastructure. They operate at different stages of the innovation pipeline, with their scope and work defined by location, technology area or industry sector, based on the specific problem identified when they were set up. In this introductory review, we outline each of the major innovation pathways operating at local, regional and national levels across the NHS, including their history, governance, operating procedures and areas of expertise. The extent to which innovation pathways address current challenges faced by innovators is discussed, as well as areas for improvement and future study.

Insights into patient preferences for elective surgery during the COVID-19 pandemic.

AIMS: To investigate factors that contribute to patient decisions regarding attendance for arthroplasty during the COVID-19 pandemic. METHODS: A postal questionnaire was distributed to patients on the waiting list for hip or knee arthroplasty in a single tertiary centre within the UK. Patient factors that may have influenced the decision to attend for arthroplasty, global quality of life (QoL) (EuroQol five-dimension three-level (EQ-5D-3L)), and joint-specific QoL (Oxford Hip or Knee Score) were assessed. Patients were asked at which 'COVID-alert' level they would be willing to attend an NHS and a "COVID-light" hospital for arthroplasty. Independent predictors were assessed using multivariate logistic regression. RESULTS: Of 540 distributed questionnaires, 400 (74.1%; 236 awaiting hip arthroplasty, 164 awaiting knee arthroplasty) complete responses were received and included. Less than half (48.2%) were willing to attend for hip or knee arthroplasty while a UK COVID-19 epidemic was in circulation (COVID-alert levels 3 to 5). Patients with worse joint-specific QoL had a preference to proceed with surgery at COVID-alert levels 3 to 5 compared to levels 1 and 2 (hip arthroplasty odds ratio (OR) 1.54 (95% confidence interval (CI) 1.45 to 1.63); knee arthroplasty OR 1.16 (1.07 to 1.26)). The odds of patients with worse joint-specific QoL being willing to attend for surgery at COVID-alert levels 3 to 5 increased further if surgery in a private, "COVID-light" hospital was available (hip arthroplasty OR 3.50 (95% CI 3.26 to 3.71); knee arthroplasty OR 1.41 (95% CI 1.29 to 1.53). CONCLUSION: Patient decisions surrounding elective surgery have been influenced by the global COVID-19 pandemic, highlighting the importance of patient involvement in ensuring optimized provision of elective surgery during these challenging times. Cite this article: Bone Jt Open 2021;2(4):261-270.

Systematic review on the use of autologous matrix-induced chondrogenesis for the repair of articular cartilage defects in patients.

AIM: To systematically review the results of studies looking at autologous matrix-induced chondrogenesis (AMIC) in humans. METHODS: A literature search was performed, adhering to the PRISMA guidelines, to review any studies using such techniques in humans. Our initial search retrieved 297 articles listed on MEDLINE, Google Scholar, CINHal and EMBASE. From these studies, 15 studies meeting the eligibility criteria were selected and formed the basis of our systematic review. RESULTS: The study designs, surgical techniques and outcome measures varied between the studies. Although all studies reported improvements in patient outcome measures, this was not necessarily correlated with magnetic resonance imaging findings. Although there were many additional procedures performed, when AMIC was performed in isolation, the results tended to peak at 24 mo before declining. CONCLUSION: Although short-term studies suggest improved patient reported outcomes with a variety of scaffolds, surgical techniques and rehabilitation regimes, the literature remains equivocal on whether the defect size and location, and patient factors affect the outcome. Patient benefit appears to be maintained in the short-to-medium term but more high level studies with extensive and robust validated outcome measures should be conducted to evaluate the medium- and long-term effect of the AMIC procedure.

Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre.

INTRODUCTION: The use of total-body computed tomography (CT) scanning in the evaluation of multiply injured patients is increasing, and their liberal use has stirred debate as to the added benefit relative to the risk of radiation exposure and inappropriate use of limited healthcare resources. Findings unrelated to the clinician's reasons for requesting the radiological examination are often uncovered due to the comprehensive nature of the evaluation at a trauma centre. However, some of these findings are outside the expertise of the trauma team who initially organised the scan and this may lead to uncertainty over who is best qualified to follow-up the incidental finding. We aim to evaluate the frequency of incidental findings on whole body trauma CT scans in a consecutive series of trauma admissions to our unit. MATERIALS AND METHODS: We identified 104 consecutive major trauma patients who received a whole-body trauma CT (head, cervical spine, chest, abdomen and pelvis) from Jan 2013 to Dec 2013 in our unit (out of a total of 976 trauma admissions in the same year). Patient-specific information was extracted from computerised hospital databases containing admission and progress notes, radiological reports, operation notes and pathology reports. RESULTS: 57 patients (54.8%) had incidental findings identified on the radiologist report, with a total of 114 individual incidental findings. 6 (5.8%) patients had potentially severe findings that required further diagnostic work up; 65 (62.5%) patients had diagnostic workup dependant on their symptoms, and 43 (41.3%) patients had incidental findings of minor concern which required no follow up. DISCUSSION AND CONCLUSIONS: Our findings reflect the literature noting that incidental findings are increasingly common due to the central diagnostic role of CT imaging in trauma care, but also due to advances in imaging techniques and quality. In keeping with published literature, we note that increased age is associated with an increased incidence of "incidental findings" and this will continue to rise with the ageing population and the mandatory nature of trauma CTs.

Centrally organised bedside teaching led by junior doctors.

BACKGROUND: Clinical bedside teaching is arguably the most favoured form of teaching by medical students, but has been on the decline in recent years. Junior doctors are often underused as teachers and, with adequate training, may help to solve this problem. Bedside Teachers is a junior doctor-led teaching programme that is delivered throughout South-East Scotland, and is now in its third year. This study aimed to investigate the perceptions of final-year medical students participating in the Bedside Teachers programme, and how they compared this with teaching from senior staff. METHODS: Anonymised questionnaires were issued to all participants. Students were asked to rate statements relating to: (i) the quality of bedside teaching tutorials; and (ii) the teaching delivered by junior doctors compared with that delivered by senior staff. RESULTS: All students indicated that the tutorials improved their confidence in clinical examination. Eighty-seven per cent indicated that it provided a useful clinical experience that they would otherwise not have received. All respondents indicated that junior doctors were more approachable than senior staff. The majority of students indicated that they thought junior doctors covered more relevant material to being a good junior doctor, and that junior doctor-led teaching was at least as good or better than teaching by senior staff on a number of other criteria. CONCLUSIONS: With adequate training, junior doctors can be a useful resource for increasing the bedside teaching opportunities available to students, with potential advantages over using senior staff.

A three-digit dermofasciectomy for Dupuytren's disease.

In patients presenting to our unit with recurrent or aggressive Dupuytren's disease (DD), we favour the technique of radical excision and resurfacing popularised by Logan, who has described its use for the ulnar two digits of the hand at the same operation.(1) In patients in whom dermofasciectomy may be indicated in three or more digits, we have previously advised patients that the quality of the surgical attention and the post-operative physiotherapy might be better delivered by a staged approach. However, we demonstrate here with a case report that the technique can have excellent outcome when used for three digits at the same time. We are unaware of similar previous reports.

Femoral lengthening with lengthening over a nail has fewer complications than intramedullary skeletal kinetic distraction.

BACKGROUND: Lengthening over a nail and internal lengthening nails have been developed to minimize or eliminate patients' time wearing a frame during femur lengthening. However it is unclear whether either of these two approaches results in faster times to union or fewer complications over the other. QUESTIONS/PURPOSES: We asked which technique better achieved: (1) the lengthening goals, (2) the distraction rate control, (3) quality of the regenerate bone, (4) fewer complications, and (5) if SF-36 scores and American Academy of Orthopaedic Surgeons Lower Limb Module (AAOS LLM) scores differ in each treatment modality? METHODS: We retrospectively reviewed the records and radiographs of 11 patients who had 12 Intramedullary Skeletal Kinetic Distractor (ISKD) procedures between 2002 and 2005, and 21 patients with 22 femoral lengthenings performed as lengthening over nail procedures between 2005 and 2009. Details such as leg length discrepancies, operative time, time of removal of the external fixator or ISKD, and any complications encountered were recorded. SF-36 and AAOS LLM scores also were compiled. The minimum followups for the ISKD and the lengthening over nail cohorts were 62 months (average, 76 months; range, 62-93 months) and 13 months (average, 27 months; range, 13-38 months), respectively. RESULTS: We observed no difference in achieving the lengthening goals between the two procedures. Distraction was not well controlled in the ISKD group; the distraction rates were 1.7 mm per day for the fast group (distraction rate greater than 1 mm/day) and 0.84 mm per day for the slow group (less than 1 mm/day). The lengthening over nail group had an average distraction rate of 0.88 mm per day. One of 20 of the patients who had lengthening over a nail had complications requiring additional unanticipated surgeries whereas six of 12 patients who had femoral lengthening in the ISKD group had such complications. CONCLUSIONS: Based on our observations, we believe the lengthening over nail technique for femoral lengthening is associated with fewer complications than the ISKD. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder.

BACKGROUND: Posterior glenohumeral dislocation is less common than anterior dislocation, and less is known about its epidemiology, functional outcome, and complications. The purposes of this study were to determine the epidemiology and demographics of posterior dislocations and to assess the risk of recurrence and the functional outcome after treatment. METHODS: We performed a retrospective review of a prospective audit of the cases of 112 patients who sustained 120 posterior glenohumeral dislocations. Patients were treated with relocation, immobilization, and then physical therapy. Functional outcome was assessed with the Western Ontario Shoulder Instability Index (WOSI) and the limb-specific Disabilities of the Arm, Shoulder and Hand score (DASH) during the two years after the dislocation. RESULTS: The prevalence of posterior dislocation was 1.1 per 100,000 population per year, with peaks in male patients between twenty and forty-nine years old, and in the elderly patients over seventy years old. Most dislocations (67%) were produced by a traumatic accident, with most of the remainder produced by seizures. Twenty patients (twenty-three shoulders) developed recurrent instability. On survival analysis, 17.7% (95% confidence interval, 10.8% to 24.6%) of the shoulders developed recurrent instability within the first year. On multivariable analysis, an age of less than forty years, dislocation during a seizure, and a large reverse Hill-Sachs lesion (>1.5 cm3) were predictive of recurrent instability. Small persistent functional deficits were detected with the WOSI and DASH at two years. CONCLUSIONS: The prevalence of posterior dislocation is low. The most common complication after this injury is recurrent instability, which occurs at an early stage in 17.7% of shoulders within the first year after dislocation. The risk is highest in patients who are less than forty years old, sustain the dislocation during a seizure, and have a large humeral head defect. The risk is lower for most patients who sustain the injury from a traumatic accident, especially if they are older and have a small anterior humeral head defect. There are persistent deficits of shoulder function within the first two years after the injury.