Orthopaedic trauma residency programs: Perspectives from different countries across the world.

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Managing periprosthetic fractures: perspectives on periprosthetic pelvic fractures.

Periacetabular periprosthetic fractures are rare but potentially disastrous for the longevity of the adjacent implants, leading to multiple revision surgeries. It is of paramount importance to identify and treat intraoperative fractures, which will lead to satisfactory results. Postoperative fractures may be managed operatively or nonoperatively depending on the patient's pain and function, the fracture pattern, and the stability of the acetabular component.

Ultrasound-Guided A1 Pulley Release Versus Classic Open Surgery for Trigger Digit: A Randomized Clinical Trial.

OBJECTIVES: We compared an ultra-minimally invasive ultrasound-guided percutaneous A1 pulley release and a classic open surgery for trigger digit. METHODS: We designed a single-center randomized control trial. All cases had clinical signs of primary grade III trigger digit. Concealed allocation (1:1) was used for assigning patients to each group and data collectors were blinded. The Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire was our primary variable. Quick-DASH, two-point discrimination, grip strength, time until stopping analgesics, having full digital range of motion and restarting everyday activities were registered on the 1st, 3rd, and 6th weeks, 3rd and 6th months, and 1st year after the procedure. RESULTS: We randomized 84 patients to ultrasound-guided release and classic open surgery. Quick-DASH scores significantly favored the percutaneous technique until the 3rd month: 7.6 ± 1.2 versus 15.3 ± 2.4 (mean ± standard error of the mean). The percutaneous group obtained significantly better results in all the variables studied: time until stopping analgesics, achieving full range of motion and restarting everyday activities. Grip strength was significantly better in the percutaneous group for the 1st week only. Five cases of moderate local pain were observed in the open technique. There was one case of transient nerve numbness per group. CONCLUSIONS: The ultra-minimally invasive ultrasound-guided A1 pulley release was clinically superior to the classic open surgery in functional recovery with a lower complication rate.

Overview of fracture liaison services in the UK and Europe: standards, model of care, funding, and challenges.

Fragility fractures represent a growing global problem, including in the United Kingdom and European countries. Reports demonstrate the benefits of national guidance and organized fragility fracture programs through fracture liaison services to deliver care to patients who sustain these injuries. The challenge of assembling multidisciplinary teams, providing routine screening of appropriate patients, and monitoring therapies where there is a known compliance problem, remains an obstacle to the success of fragility fracture treatment programs to all. Efforts should continue to introduce and maintain fracture liaison services through coordinated national approaches and advanced systems.

Homemade 3D mirror imaging models utility for surgical treatment of complex fractures of scapula.

The treatment of complex articular scapular fractures requires obtaining an anatomic reduction. The experience of the surgeon and the surgical skills needed are still the most important aspect in this surgical field. 3D printed models at a 1:1 scale provides tactile and visual experience. We used a specular healthy scapula (reverse engineering) as a reliable template for preoperative planning. We pre-contour plates directly over a printed mold, for direct application, without further corrections during the surgical procedure. This reduces improvisation during surgery, the risks of complications and the total costs while improving the accuracy of the anatomical restoration of the native glenopolar angle derived from the indirect reduction of the fracture. Until recently, the use of RP (rapid prototyping) models for managing complex fractures required contracting the services provided by external companies, with the constraints posed on cost and time. We made the whole process ourselves in a DIY mode: from the post-processed radiological images to the 3D model printing, pre contoured plates and surgical simulation.

International trauma care: initial European approaches during the COVID 19 pandemic.

The world was not prepared for the global of pandemic in early 2020 with the arrival of COVID 19. Europe has some of the most developed health care systems in the world and this article explains the initial response to the pandemic from an orthopaedic and trauma viewpoint from 8 nations. Italy reported the first cluster in February, which then rapidly spread around the continent, requiring a rapid reorganization of services. The reports highlight how elective surgery was universally stopped, surgical services were reconfigured, and new practices, such as the widespread use of telemedicine, may well become permanent. It also emphasizes how the pandemic has re-educated us on the importance of a consistent and central approach to deal with a global health crisis, and how medical services need to remain flexible and responsive to new ways of working.

Hip fracture systems-European experience.

European countries have established health care systems but are struggling with the increasing rise of fragility fractures in their aging population. In trying to address this significant burden, countries are establishing national guidelines and standards, focusing on hip fractures, which represent the significant cost for this patient group. This has evolved with the establishment of national audits and guidelines. Reports from 4 European countries (England, Italy, Netherlands, and Spain) are presented. All nations have identified both deficiencies in their systems, and protocols to improve these deficiences. When standards are introduced, there has been evidence of improved results. Significantly more work is needed to understand the key components of the systems and pathways, and efforts to study and standardize care are ongoing.

Thromboprophylaxis Management in Surgical Patients: The Efficacy of a Protocol in the Electronic Prescription Program.

BACKGROUND AND OBJECTIVE: Venous thromboembolism (VTE) continues to be a problem in surgical patients, but thromboprophylactic measures are not always implemented. This study aimed to evaluate thromboprophylaxis practice in surgical patients at our institution by assessing appropriateness during admission and discharge; 60-day clinical outcomes are analyzed, and finally further interventions are discussed for continued improvement. METHODS: A cross-sectional, observational study was conducted in patients undergoing orthopedic and abdominal surgical procedures. Initially, the institution protocol was updated and embedded in the Computerized Physician Order Entry system. We then assessed prospective adequacy of thromboprophylaxis as per established in the protocol. The primary endpoint was thromboprophylaxis initiation and, secondarily, the quality of related prescriptions during hospitalization and at discharge. RESULTS: A total of 114 patients were included in the study. According to VTE risk, thromboprophylaxis was initiated in 85.1% of the patients as needed during hospitalization and 94.8% at discharge. The following inadequacies versus the protocol were found: no duration information in the discharge summary (32.5%), incorrect postsurgical administration time of pharmacological prophylaxis (15.8%), omission of mechanical prophylaxis (13.7%), misdosing (9.6%), and omission of pharmacological prophylaxis (2.6%). No VTE events occurred 60 days postdischarge. CONCLUSION: The electronic protocol was an effective tool, as evidenced by the fact that thromboprophylaxis was initiated in the majority of surgical patients in our institution during hospitalization and at discharge. Still, some aspects leave room for improvement (duration, dosing, and timing), and further measures such as implementation of Electronic Medication Administration Records and new functionalities in the Clinical Decision Support systems are proposed.

Ultrasound-guided supra-acetabular pelvic external fixator (US-SA FIX).

BACKGROUND: Between the different options in pelvic external fixation, the supra-acetabular pin placement is considered the best option by many authors. The aim of this study is to describe the surgical technique of the ultrasound-guided supra-acetabular pelvic external fixator (US-SA FIX). SURGICAL TECHNIQUE: Description of the steps to perform the US-SA FIX technique. DISCUSSION: The supra-acetabular pin placement is considered the best option and it is the most wildly used because it combines three crucial qualities: safety, simplicity, and effectiveness. Notwithstanding, when a severely multiple injured patient arrives at the emergency room we need to perform an emergency external fixation, however trained x-ray technicians or pelvic surgeons are not always present, making it difficult to perform the surgery with the proper intra-operative imaging, increasing the surgical time with potentially serious repercussions, a case scenario where the ultrasound can be a very helpful tool. Ultrasound-guided supra-acetabular pelvic external fixator pin placement is feasible without compromising the reliability of its placement, and the application of this new technique in clinical practice in our centre brings encouraging results.

3D surgical printing for preoperative planning of trabecular augments in acetabular fracture sequel.

We describe the methodical and possibilities of 3D surgical printing in preoperative planning for a total hip arthroplasty in acetabular deformity after acetabular fractures, showing a case of a 43-year-old with posttraumatic arthritis after both column fracture of the left acetabulum that was treated non operatively, supporting the do it yourself mode.

Ultrasound-guided supra-acetabular pin placement in pelvic external fixation: description of a surgical technique and results.

INTRODUCTION: Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in the context of damage control surgery. Supra-acetabular pin offers the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study was to analyze our results for an ultrasound-guided supra-acetabular pinning. MATERIAL AND METHODS: Cross-sectional study with cadaveric specimens. Ultrasound-guided pin placement assessed by fluoroscopy and dissection. RESULTS: Fourteen ultrasound-guided supra-acetabular pins were placed in seven cadaveric specimens. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixation after dissection. One femoral cutaneous nerve was not found during anatomic dissection and was assumed injured. CONCLUSION: Ultrasound-guided supra-acetabular pin placement is a feasible and effective technique. Our study indicates that pin placement without intraoperative fluoroscopy is feasible without compromising the reliability of its placement.

3D surgical printing and pre contoured plates for acetabular fractures.

We describe the methodical and possibilities of 3D surgical printing in preoperative planning of acetabular fractures showing a case of a 45-year-old with an associated transverse fracture of the left acetabulum with posterior wall fracture, with multiple fragments, and posterior ipsilateral hip dislocation, defending the do it your-self mode.

Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial.

OBJECTIVES: The purpose of this study was to compare the outcomes of 1-mm ultra-minimally invasive ultrasound-guided carpal tunnel release and 2-cm blind mini-open carpal tunnel release. METHODS: We conducted a single-center individual parallel-group controlled-superiority randomized control trial in an ambulatory office-based setting at a third-level referral hospital. Eligible participants had clinical signs of primary carpal tunnel syndrome and positive electrodiagnostic test results and were followed for 12 months. Independent outcome assessors were blinded. Patients were randomized by concealed allocation (1:1) by an independent blocked computer-generated list. The postoperative score on the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was the primary variable. Grip strength and time for discontinuation of oral analgesics, complete wrist flexion-extension, relief of paresthesia, and return to normal daily activities (including work) were assessed. RESULTS: Ninety-two of 128 eligible patients were randomly allocated and analyzed. QuickDASH scores were 2.2 to 3.3 times significantly lower in the ultra-minimally invasive group for the first 6 months: 23.6 [95% confidence interval (CI), 20.5, 27.4] versus 52.6 [95% CI, 49.4, 57.0] at the first week and 4.09 [95% CI, 1.5, 7.1] versus 13.0 [95% CI, 9.4, 18.9] at 6 months. Return to normal daily activities occurred significantly sooner in the ultra-minimally invasive group: 4.9 [95% CI, 3.2, 6.5] versus 25.4 [95% CI, 18.2, 32.6] days. CONCLUSIONS: Ultra-minimally invasive carpal tunnel release provides earlier functional return and less postoperative morbidity with the same neurologic recovery as mini-open carpal tunnel release for patients with symptomatic primary carpal tunnel syndrome.

The floating knee: a review on ipsilateral femoral and tibial fractures.

In 1975, Blake and McBryde established the concept of 'floating knee' to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions.After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation.Definitive internal fixation of both bones yields the best results in almost all series.Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular.Plates are the 'standard of care' in cases with articular fractures.A combination of implants are required by 40% of floating knees.Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042.

Retained Sponge: A Rare Complication in Acetabular Osteosinthesis.

Retained sponges after a surgical treatment of polytrauma may cause a broad spectrum of clinical symptoms and present a difficult diagnostic problem. We report a case of retained surgical sponge in a 35-year-old man transferred from another hospital, that sustained a open acetabular fracture. The fracture was reduced through a limited ilio-inguinal approach. After 4 days, he presented massive wound dehiscence of the surgical approach. An abdominal CT scan showed, lying adjacent to the outer aspect of the left iliac crest, a mass of 10 cm, identified as probable foreign body. The possibility of this rare complication should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures.

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

Tantalum cones in revision total knee arthroplasty. A promising short-term result with 29 cones in 21 patients.

Twenty-nine porous tantalum metaphyseal cones were implanted in 21 patients (14 women and 7 men) during revision TKA. The average age at the time of the procedure was 73.3 years. Sixteen revisions were considered aseptic and 5 were reimplantations after sepsis. Eight patients had stemmed revision implants and thirteen primary designs. According to the Anderson Orthopaedic Research Institute bone defect classification, femoral defects were rated as F3 in 14 knees and F2B in 3 knees. Tibial defects were rated as T2A in 3 cases, T2B in 3 cases and T3 in 5 cases. A femoral cone was inserted in 10 patients, a double cone (femur and tibia) in 8, and a single tibial cone in 3. A rotating hinge knee prosthesis (RHK, Zimmer) was inserted in 10 patients and a constrained condylar prosthesis (LCCK, Zimmer) in 11 patients. The diaphysis was cemented in 9 cases and, in 11 cases, just the metaphysis. At an average follow up of 36 months only one reconstruction was removed due to persistent infection. All metaphyseal cones showed evidence of stable osseointegration. According to the Knee Society Score the results were rated as excellent in 12 cases, good in 5 cases, fair in 3 and poor in 1 case. In the short term, porous tantalum metaphyseal cones provided structural support for large femoral and tibial defects. They also provided the environment for bone graft osseointegration, repair of femoral fractures and effective interdigitation of cement mantle into the trabecular metal cone.