Operative versus non-operative treatment of extra-articular distal humeral shaft fractures: a retrospective comparative study evaluating clinical and radiological outcomes.

PURPOSE: There is limited evidence for comparing operative and non-operative management of closed, extra-articular distal humeral shaft fractures. This study aims to evaluate these outcomes. METHODS: A comparative retrospective study was performed for patients who underwent either operative fixation or conservative management with a humeral brace, with clinical and radiological outcomes at minimum 2-year follow-up. RESULTS: Forty-two patients with median 4.6 years follow-up were included; 24 had surgical fixation and 18 were managed with humeral brace. Assessment of clinical and radiological outcomes demonstrated few statistically significant functional differences between the two groups. Surgical patients achieved faster union for non-comminuted fractures. All patients maintained functional range of motion, with similar complication rates. CONCLUSION: This study suggests that similar outcomes can be achieved with both managements, though faster union times may be seen in the operative group. Further studies are recommended to evaluate the impact of fracture comminution causing delayed unions.

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study.

PURPOSE: The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture. METHODS: A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures" were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27. RESULTS: A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978). CONCLUSION: Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID" and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.

Impact of the COVID-19 pandemic on paediatric orthopaedic trauma workload in central London: a multi-centre longitudinal observational study over the "golden weeks".

Background and purpose - The COVID-19 pandemic has been recognised as an unprecedented global health crisis. This study assesses the impact on a large acute paediatric hospital service in London, evaluating the trends in the acute paediatric orthopaedic trauma referral caseload and operative casemix before (2019) and during (2020) COVID-19 lockdown. Patients and methods - A longitudinal retrospective observational prevalence study of both acute paediatric orthopaedic trauma referrals and operative caseload was performed for the first 6 "golden weeks" of lockdown. These data were compared with the same period in 2019. Statistical analyses included median (± median absolute deviation), risk and odds ratios as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results - Acute paediatric trauma referrals in 2020 were reduced by two-thirds compared with 2019 (n = 302 vs. 97) with a halving risk (RR 0.55) and odds ratios (OR 0.43) of sporting-related mechanism of injuries (p = 0.002). There was a greater use of outpatient telemedicine in the COVID-19 period with more Virtual Fracture Clinic use (OR 97, RR 84, p < 0.001), and fewer patients being seen for consultation and followed up face to face (OR 0.55, RR 0.05, p < 0.001). Interpretation - The impact of the COVID-19 pandemic has led to a decline in the number of acute paediatric trauma referrals, admissions, and operations during the COVID period. There has also been a significant change in the patient pathway with more being reviewed via the means of telemedicine to reduce the risk of COVID-19 transmission and exposure. More work is required to observe for similar trends nationwide and globally as the pandemic has permanently affected the entire healthcare infrastructure.

Origin and insertion of the medial patellofemoral ligament: a systematic review of anatomy.

PURPOSE: The medial patellofemoral ligament (MPFL) is the major medial soft-tissue stabiliser of the patella, originating from the medial femoral condyle and inserting onto the medial patella. The exact position reported in the literature varies. Understanding the true anatomical origin and insertion of the MPFL is critical to successful reconstruction. The purpose of this systematic review was to determine these locations. METHODS: A systematic search of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed and Cochrane Library) and unpublished literature databases was conducted from their inception to the 3 February 2016. All papers investigating the anatomy of the MPFL were eligible. Methodological quality was assessed using a modified CASP tool. A narrative analysis approach was adopted to synthesise the findings. RESULTS: After screening and review of 2045 papers, a total of 67 studies investigating the relevant anatomy were included. From this, the origin appears to be from an area rather than (as previously reported) a single point on the medial femoral condyle. The weighted average length was 56 mm with an 'hourglass' shape, fanning out at both ligament ends. CONCLUSION: The MPFL is an hourglass-shaped structure running from a triangular space between the adductor tubercle, medial femoral epicondyle and gastrocnemius tubercle and inserts onto the superomedial aspect of the patella. Awareness of anatomy is critical for assessment, anatomical repair and successful surgical patellar stabilisation. LEVEL OF EVIDENCE: Systematic review of anatomical dissections and imaging studies, Level IV.

Policy and practice review consensus statements and clinical guidelines on managing pediatric trauma and orthopedics during the COVID-19 pandemic: a systematic review on the global response for future pandemics and public health crises.

Introduction: The COVID-19 pandemic has been recognized as an unprecedented global health crisis. Over 7 million mortalities have been documented with many paediatric fatalities. Trauma and orthopaedic care, much like other specialities, were marginalized due to resource allocation during the pandemic which affected paediatric care. This is the first systematic review to centralise and compile the recommended published guidelines from professional bodies in principally English speaking countries on managing paediatric trauma and orthopaedic care. These guidelines will be required to be implemented sooner and more effectively in case of future pandemics with similar impact. Methods: A search was conducted on PubMed/MedLine, Cochrane Library and Embase using terms including p(a)ediatric or child* and/or COVID* or coronavirus or SARS-CoV-2 and/or trauma and/or orthop(a)edic* with a simplified MeSH heading [mh] in order to make the search as comprehensive as possible. General terminology was utilized to make the search as exhaustive as possible for this systematic review. Another search was conducted on resources available in the public domain from professional bodies publishing on consensus statements and clinical practice guidelines in countries where English is the principal language managing pediatric trauma and orthopedics. The review adhered to PRISMA guidance. Results: The search revealed a total of 62 results from both databases and professional bodies. Duplicates were removed. This was then reviewed to identify a total of 21 results which fit the inclusion criteria and included within the main analysis. The guidelines from professional bodies were outlined and categorized into aspects of clinical care. Discussion: The impact of COVID-19 pandemic has compelled for changes in clinical practice and pediatric management. The systematic review highlights the relevant guidelines on service provision for pediatric patients including indications for urgent referrals, surgical prioritization, reasons for follow-up and trauma guidelines. The rationale for care during the unpredictable evolution of the COVID-19 pandemic may have the potential to be translated and replicated in future pandemics of similar significance.

Impact of COVID-19 on acute trauma and orthopaedic referrals and surgery in the UK during the first wave of the pandemic: a multicentre observational study from the COVid Emergency-Related Trauma and orthopaedics (COVERT) Collaborative.

OBJECTIVE: This is the first British multicentre study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during its peak. DESIGN: A longitudinal, multicentre, retrospective, observational, cohort study was conducted during the peak 6 weeks of the first wave from 17 March 2020 compared with the same period in 2019. SETTING: Hospitals from six major urban cities were recruited around the UK, including London. PARTICIPANTS: A total of 4840 clinical encounters were initially recorded. 4668 clinical encounters were analysed post-exclusion. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included the number of acute trauma referrals and those undergoing operative intervention, mortality rates and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia used. RESULTS: During the COVID-19 period, there was a 34% reduction in acute orthopaedic trauma referrals compared with 2019 (1792 down to 1183 referrals), and a 29.5% reduction in surgical interventions (993 down to 700 operations). The mortality rate was more than doubled for both risk and odds ratios during the COVID-19 period for all referrals (1.3% vs 3.8%, p=0.0005) and for those undergoing operative intervention (2.2% vs 4.9%, p=0.004). Moreover, mortality due to COVID-19-related complications (vs non-COVID-19 causes) had greater odds by a factor of at least 20 times. For the operative cohort during COVID-19, there was an increase in odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters, as well as doubled odds of a consultant acting as the primary surgeon. CONCLUSION: Although there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared with the same time interval 1 year ago.

Impact of COVID-19 pandemic on hip fractures: the central London experience COVID-related urgent geriatric hip trauma (COUGH) study COVERT ( COVid Emergency-Related Trauma and orthopaedics) collaborative.

INTRODUCTION: COVID-19 has been recognized as the unprecedented global health crisis in modern times. The purpose of this study was to assess the impact of COVID-19 on treatment of neck of femur fractures (NOFF) against the current guidelines and meeting best practice key performance indicators (KPIs) according to the National Hip Fracture Database (NHFD) in two large central London hospitals. MATERIALS AND METHODS: A multi-center, longitudinal, retrospective, observational study of NOFF patients was performed for the first 'golden' month following the lockdown measures introduced in mid-March 2020. This was compared to the same time period in 2019. RESULTS: A total of 78 cases were observed. NOFFs accounted for 11% more of all acute referrals during the COVID era. There were fewer overall breaches in KPIs in time to theatre in 2020 and also for those awaiting an orthogeriatric review. Time to discharge from the trust during the pandemic was improved by 54% (p < 0.00001) but patients were 51% less likely to return to their usual residence (p = 0.007). The odds ratio was significantly higher for consultant surgeon-led operations and consultant orthogeriatric-led review in the post-COVID era. There was no significant difference in using aerosol-generating anaesthetic procedures or immortality rates between both years. CONCLUSION: The impact of COVID-19 pandemic has not adversely affected the KPIs for the treatment of NOFF patients with significant improvement in numerous care domains. These findings may represent the efforts to ensure that these vulnerable patients are treated promptly to minimize their risks from the coronavirus.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown.

Background: This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown. Methods: A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results: There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days. Conclusion: The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

The impact of the novel coronavirus on trauma and orthopaedics in the UK.

At first glance, the novel coronavirus pandemic and orthopaedic surgery appear separate entities. Orthopaedic surgeons are not generally considered front-line staff in terms of the treatment of the disease that the novel coronavirus causes compared with anaesthetic and medical colleagues. However, the impact that the novel coronavirus is likely to have on the musculoskeletal injury burden and the morbidity associated with chronic musculoskeletal disease is significant. This article summarises the strategies currently being developed for the remodelling of orthopaedic services in the UK and the emergency British Orthopaedic Association Standards for Trauma and Orthopaedic guidelines released on 24 March 2020 in managing urgent orthopaedic patients during the novel coronavirus pandemic.

Kinematic alignment of current TKA implants does not restore the native trochlear anatomy.

INTRODUCTION: Preserving constitutional patellofemoral anatomy, and thus producing physiological patellofemoral kinematics, could prevent patellofemoral complications and improve clinical outcomes after kinematically aligned TKA (KA TKA). Our study aims 1) to compare the native and prosthetic trochleae (planned or implanted), and 2) to estimate the safety of implanting a larger Persona® femoral component size matching the proximal lateral trochlea facet height (flange area) in order to reduce the native articular surfaces understuffing generated by the prosthetic KA trochlea. METHODS: Persona® femoral component 3D model was virtually kinematically aligned on 3D bone-cartilage models of healthy knees by using a conventional KA technique (group 1, 36models, planned KA TKA) or an alternative KA technique (AT KA TKA) aiming to match the proximal (flange area) lateral facet height (10 models, planned AT KA TKA). Also, 13postoperative bone-implant (KA Persona®) models were co-registered to the same coordinate geometry as their preoperative bone-cartilage models (group 2implanted KA TKA). In-house analysis software was used to compare native and prosthetic trochlea articular surfaces and medio-lateral implant overhangs for every group. RESULTS: The planned and performed prosthetic trochleae were similar and valgus oriented (6.1 and 8.5, respectively), substantially proximally understuffed compared to the native trochlea. The AT KA TKAs shows a high rate of native trochlea surface overstuffing (70%, 90%, and 100% for lateral facet, groove, medial facet) and mediolateral implant overhang (60%). There was no overstuffing with conventional KA TKAs having their anterior femoral cut flush. CONCLUSION: We found that with both the planned and implanted femoral components, the KA Persona® trochlea was more valgus oriented and understuffed compared to the native trochlear anatomy. In addition, restoring the lateral trochlea facet height by increasing the femoral component size generated a high rate of trochlea overstuffing and mediolateral implant overhang. While restoring a native trochlea with KA TKA is not possible, the clinical impact of this is low, especially on PF complications. In current practice it is better to undersize the implants even if it does not restore the native anatomy. Longer follow-up is needed for KA TKAs performed with current implant, and the debate of developing new, more anatomic, implants specifically designed for KA technique is now opened. LEVEL OF EVIDENCE: II, Laboratory controlled study.

BASK survey of The Knee readership 2015.

A convenience sample of the attendees of the 2015 annual meeting of the British Association of Knee showed that the majority of the attendees who responded read The Knee, would like a section on surgical tips, more themed supplements and guest editorials. There is still not enough support for purely electronic publication. For those that have submitted papers, the experience with the publication process was positive.

Macrophage activation syndrome or septic arthritis: a case of mistaken identity.

We present an interesting case of macrophage activation syndrome in a 2-year-old, with no previous rheumatological diagnoses, incorrectly diagnosed with septic arthritis, to highlight the diagnostic difficulties, especially in small hospital units. We aim to present the similarities between the two conditions and to summarize the clinical, radiological and epidemiological features of macrophage activation syndrome, an underdiagnosed condition. A review of the current literature was performed, and a diagnostic algorithm was created. No current set treatment regimen exists, but current recommendations have been included. We have demonstrated the pitfalls in diagnosis and the importance of immediate treatment in optimizing prognosis.

Ward round documentation in a major trauma centre: can we improve patient safety?

Our objective was to improve documentation and patient safety in a major trauma centre. A retrospective audit was undertaken in March 2014. Ward round entries for each orthopaedic patients on three dates were assessed against standards and analysed. The audit was repeated in April 2014, and again in August 2014. Thorough documentation is paramount in a major trauma centre. It forms a useful record of the patients hospital stay, is a legal document and is highlighted in national guidelines. It provides a basis for good handover, ensuring continuation of care and maintaining patient safety. Resultant poor compliance with Royal College guidelines in the initial audit led to the production of a new electronic based note keeping system. A meeting was held with all staff prior to introduction. Our initial results gained 75 entries, and none showed full compliance. Mean compliance per entry was 59% (0-81%). The second attempt gained 90 entries, with 30 from the weekend. Mean compliance per entry 97%. Third attempt received 61 entries, with 27 from the weekend. Mean compliance was 96%, meaning that the improvement was being maintained. Recent distressing reports regarding patient highlighted the importance of patient. Our initial audit proved there were many areas lacking in our documentation and improvement was necessary. Prior to introducing electronic systems, the implemented change has produced improvement in documentation, and provides a useful handover tool for staff.