Indian orthopaedics: the past, present, and future.

The editorial summarizes the Indian orthopaedic history in brief and provides an overview of the articles to be published in the Indian traumatology edition.

Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option.

The gold standard for fractures of the acetabulum is to perform an open reduction and internal fixation in order to achieve anatomical reduction. In a well-defined subset of patients, percutaneous techniques may be employed but achieving reduction by closed means can be challenging especially for fractures with large degrees of displacement. Such patient may include elderly patients who may not have the physiologic reserve to withstand open approaches. In our paper, we present a new option using laparoscopic assisted reduction of the acetabular fracture and percutaneous fixation. The young obese patient refused all forms of blood products transfusion and presented with a displaced transverse posterior wall fracture. While we do not recommend routine use of such technique and recognize its numerous limitations, we present it as an alternative strategy in a small subset of patients.

The role of biofilm on orthopaedic implants: the "Holy Grail" of post-traumatic infection management?

The development of post-traumatic infection is potentially a limb threatening condition. The orthopaedic trauma literature lags behind the research performed by our arthroplasty colleagues on the topic of implant-related infections. Surgical site infections in the setting of a recent ORIF are notoriously hard to eradicate due to biofilm formation around the implant. This bacteria-friendly, dynamic, living pluri-organism structure has the ability to morph and adapt to virtually any environment with the aim to maintain the causative organism alive. The challenges are twofold: establishing an accurate diagnosis with speciation/sensitivity and eradicating the infection. Multiple strategies have been researched to improve diagnostic accuracy, to prevent biofilm formation on orthopaedic implants, to mobilize/detach or weaken the biofilm or to target specifically bacteria embedded in the biofilm. The purpose of our paper is to review the patho-physiology of this mysterious pluri-cellular structure and to summarize some of the most pertinent research performed to improve diagnostic and treatment strategies in biofilm-related infections.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy.

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Evidence-based medicine: a 'hidden threat' for patient safety and surgical innovation?

We explore the limitations of complete reliance on evidence-based medicine which can be diminished by confounding issues and sampling bias. Other strategies which may be reasonably invoked are discussed.

Study protocol: trial of inflation osteoplasty in the management of tibial plateau fractures.

INTRODUCTION: Restoration of articular congruency is a key factor in preventing post-traumatic osteoarthritis following tibial plateau fractures. Current surgical techniques using a bone tamp carry the risk of joint perforation and comminution of the depressed fragments which affect patient outcome. Successful use of inflation osteoplasty has been reported in both in vitro studies (Broome et al. in J Orthopaed Traumatol 13(2):89-95, 2012; Mauffrey et al. in Patient Saf Surg 6:6, 2012) and case reports in the management of fractures of the calcaneus, cuboid, distal radius, tibial plateau and acetabulum (Gupta et al. in Foot Ankle Int 32(2):205-210, 2011; Heim et al. in Foot Ankle Int 29(11):1154-1157, 2008; Konig et al. in Case Rep Unfallchirurg 109(4):328-331, 2006; Reiley in J Orthop Trauma 17:141-163, 2006). The aim of our study is to assess whether the use of the balloon osteoplasty improves the quality of reduction of a depressed tibial plateau fracture when compared to traditional methods of fracture reduction. METHOD: This is a single-centred randomised trial. We will recruit 24 adult patients admitted with either a depressed or split depressed tibial plateau fracture (medial or lateral) requiring surgical intervention. Consenting patients will be randomly allocated to the two treatment groups. Patients with concomitant injuries influencing the management of the tibial plateau fracture will be excluded from our study. The primary outcome measure is the quality of reduction based on the post-operative CT scan. Secondary outcome measures will be any surgical complication and patient satisfaction, measured using the Oxford Knee score and SF12 questionnaire at 3, 6 and 12 months. Principal analysis will be for the success of fracture reduction from the two techniques and the effect the operative technique had on patient satisfaction and the prevalence of surgical complications.

A randomised pilot trial of "locking plate" fixation versus intramedullary nailing for extra-articular fractures of the distal tibia.

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure. We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation.

Bone graft substitutes for articular support and metaphyseal comminution: what are the options?

Subchondral and metaphyseal bone defects pose a great challenge for the Orthopaedic surgeon not only because the support for the articular surface has been lost but also because the mechanism for the nourishment of articular cartilage through the subchondral plate is distorted. A number of options are available to the surgeons, none of them perfect. Autografting has an appreciable high rate of harvest site morbidity, allograft is associated with infection transmission and host immunologic response. These realities have stimulated interest in supplying bone replacement materials (demineralised bone matrix, synthetic bone substitutes, bone morphogenic proteins). This paper presents the indications and applications of bone substitutes for metaphyseal defects and subchondral support in orthopaedic trauma.

Unicompartmental knee replacements with Miller-Galante prosthesis: two to 16-year follow-up of a single surgeon series.

We report the outcome of 94 Miller-Galante unicompartmental knee replacements done by a single surgeon over 16 years in a district general hospital in the UK. Patellofemoral arthritis was considered a contraindication only if symptomatic and confirmed on radiography and surgery. Deformity when present was correctable. The mean age at surgery was 66.54 years. The mean follow-up was 10.8 years (2-16 years). The mean Bristol knee score was 43.1 (28-50); 86% of the patients had good or excellent scores. The average range of flexion was 110.6° (80-130°); 89% of the knees had an appropriate alignment. Using revision as the endpoint, outcome for every knee was established. The survival rate for medial unicompartmental knee replacements was 94% at ten years and 87% at 15 years. Although the survival rate for the lateral unicompartmental knee replacement was 97% at five years, it dropped to 41% at eight years. Lateral unicompartmental knee replacements formed only 9.6% of all the replacements in this series. The results for medial unicompartmental knee replacements are similar to reports by other authors for similar and mobile bearing designs. Unicompartmental knee replacement results in a more kinematic knee and produces good functional results.

Olecranon fractures.

Several options exist for the management olecranon fractures. These include tension band, plate and intramedullary fixation techniques as well as fragment excision with triceps advancement and non-operative management. No one technique is suitable for the management of all olecranon fractures. In deciding how to treat this common trauma presentation, the surgeon needs a good understanding of the anatomy, different fracture morphologies, surgical options and potential complications. With appropriate management and early mobilisation good functional results can be expected in the majority of patients.

The use of circular fine wire frames for the treatment of displaced intra-articular calcaneal fractures.

BACKGROUND: The treatment of displaced intra-articular calcaneal fractures is still controversial. MATERIALS AND METHODS: Sixteen consecutive patients admitted at University Hospital with intra-articular fractures were treated with fine wire circular frames and followed up at an average of 160 days from their injuries. We focused on radiological outcome and functional outcome using a patient-based questionnaire. RESULTS: We had no secondary reconstruction procedures. With the numbers available, the difference between the preoperative values and the follow-up measurements for Böhler's angle, Gissane's angle and posterior subtalar joint space was not statistically significant (P = 0.8, P = 0.2, and P = 0.4, respectively). The standardized AAOS FAS ranged from 42 to 96, with a mean of 80 and a standard deviation of 19. CONCLUSIONS: Fine wire circular frame is a good alternative to ORIF in displaced intra-articular calcaneal fractures, yielding good patient function, a high return-to-work rate and a low complication rate.

Cauda equina syndrome: an anatomically driven review.

Cauda equina syndrome results from an injury to the lumbosacral nerve roots below the tip of the conus medullaris, occuring in between 2 and 6% of all laminectomies performed for lumbar disc herniation. This article relates the anatomy of the nervous system of the bladder, rectum, anus and sexual organs to the signs and symptoms of cauda equina syndrome, and reviews the literature for the acute management of these patients.

A review of 1241 trauma cases: a study of efficiency in trauma theatres.

BACKGROUND: Our trauma department has recently moved to a newly built University hospital. Its geographic situation and the fact that all surgical sub-specialties are represented make it a very busy level 1 trauma centre. Our aim was to assess our activity and efficiency in trauma looking at 1241 consecutive trauma operations over a period of 6 months. Furthermore we evaluate the impact of the move to the new hospital on our activity. METHOD: A total of 1241 consecutive trauma operations were reviewed, looking at transit times of patients to theatre, the duration of induction of anaesthesia, time to prepare and drape the patients and duration of surgery. Daily starting and finishing times were also analysed. We looked at operations done from April 2006 to July 2006 in our old site and compared the timings to the first 2 months in the new University hospital. In addition, we looked at the most recent 2 months in our new hospital. RESULTS: The mean number of cases done daily and the distribution of time in trauma theatre were not significantly different in the 2 hospitals. A mean of 4.9 trauma operations are done per day with a mean of 18.6% of trauma lists starting on time. Furthermore, only around 55% of total theatre time is spent operating. The efficiency of trauma theatre utilisation is far from optimal but seems to correspond with the findings in the general literature. CONCLUSION: Activity and theatre utilisation in trauma should be monitored regularly in order to assess the time distribution of surgical cases. This monitoring enables the department to highlight causes of inefficiencies and has been shown to improve the activity in trauma theatres.