Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center.

OBJECTIVES: The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures. DESIGN: A prospectively maintained database was retrospectively interrogated. SETTING: Single major trauma center in the United Kingdom. PATIENT SELECTION CRITERIA: All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors. OUTCOME MEASURES AND COMPARISONS: The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. RESULTS: Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases. CONCLUSIONS: Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

BACKGROUND:  Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes. MATERIALS AND METHODS:  A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients. RESULTS:  Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome. CONCLUSION:  The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

A Systematic Review of the Utility of Intraoperative Navigation During Total Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA) has been demonstrated to successfully recover function to shoulders impaired by arthrosis and rotator cuff insufficiency. Long-term survival depends on the correct positioning of glenoid components and secure bone fixation. Computed tomography (CT)-based intraoperative navigation has proven to be an effective technique for successful TSA procedures. This paper presents a review of CT-based intraoperative navigation considering its advantages and disadvantages. The crucial factors that contribute to the success of this technique are glenoid component positioning, operative duration, and screw selection, which are detailed in this review.

Course Review: Doctors Academy Basic Sciences and Clinical Application for the Membership of the Royal College of Surgeons Part A Course.

The Membership of the Royal College of Surgeons (MRCS part A and B) is a mandatory examination that is required by all trainees to enter the surgical speciality training programme in the United Kingdom. Students and clinicians alike often find it a struggle to succeed in passing these exams given the breadth and depth of knowledge required across a spectrum of surgical sciences. There are several factors contributing to success, including ethnic background, number of attempts, and medical school performance. Studies have also shown that a marker of success for Part B was influenced by the Part A performance. During the COVID-19 peak, the MRCS Part A written exam has had its format changed to an online exam reflecting the policy surrounding social distancing. Due to this, the pass mark has become more difficult to attain compared to traditional face-to-face settings. As such, many trainees are finding it more difficult to succeed in the exam, leading to more emphasis on more thorough preparation for exams. This can be in the form of courses, textbooks, and using more of the online question banks. The Basic Sciences and Clinical Application for MRCS A Course is organised by the Doctors Academy group and details an intensive and interactive three-day revision course held intermittently throughout the year in Cardiff, Wales multiple times a year. Delivered by an expert faculty, it aims to provide maximum preparation in the lead up to the MRCS Part A exam with emphasis on retaining high-yield knowledge and application of key exam revision techniques. We reviewed the post-course surveys from 2019 to 2021 and found that the majority of attendees found the course content to be excellent and relevant to the exams. These questions were a mandatory part of the course and reflect a variety of training grades from foundation to core training/speciality training (CT1/2 to ST1/2). Overall, candidates found that this course aided their exam preparation immensely and contributed to passing.

Revision ACL reconstruction with autograft: long-term functional outcomes and influencing factors.

PURPOSE: To present the long-term functional outcomes of revision anterior cruciate ligament (ACL) reconstruction with autograft and factors that influence the outcomes. METHODS: Retrospective study of 51 consecutive revision ACL reconstructions performed using autograft under the care of a single surgeon with interference screw fixation. Bone-patellar tendon-bone graft was used in 35 (69%) and hamstring tendons in 16 (31%). The subjective IKDC activity level and Lysholm Knee functional scores were collected at mean follow-up of 9.0 years (range 5.17-14.75 years). RESULTS: Five (9.8%) had re-ruptured and one patient had a total knee replacement. Functional scores were available for 43 patients (84.3%). Twenty-eight had IKDC activity level I or II (65%), level III in 12 (28%) and level IV in 3 (7%). The average Lysholm score was 86.2 ± 12.88, and there is a statistically significant relationship with age (95% CI: - 0.88, - 0.60) (P < 0.05). For each additional 10 years of age, there is a reduction of 5.18 points. No statistically significant effect of sex has been detected. The mean Lysholm score was lower in patients who had partial medial meniscectomy (77.33), although this was not statistically significant (P = 0.06). Regression analysis of the Lysholm score means by chondral damage category adjusted for age, showed that the Grade 3 or 4 group shows a reduction of about 25 points for every 10 years increase in age (95% CI; P = 0.05). CONCLUSION: Revision ACL reconstruction with autograft affords satisfactory long-term outcomes. Expectations should be carefully managed in patients with increasing age associated with severe chondral damage and previous medial meniscectomy.