Aims. Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication. Cite this article: Bone Jt Open 2024;5(4):361–366

Multiligament knee injuries (MLKI) are associated with significant morbidity and healthcare requirements. The primary aim of this study is to report the patient reported outcomes measures (PROMs) after reconstructive surgery.

Patients undergoing surgery for MLKI between 2014 and 2018 in the single large-volume trauma centre were included. Electronic patient records were reviewed for demographic data, details of surgery and complications. PROMs collected were EQ-5D-5L, Lysholm Knee Score (LKS), UCLA Activity and Sport and patient satisfaction.

Thirty-five patients were included. Mean age was 31 years (range 16-66), and 71% were male. The most common mechanism of injury was sports-related (71%). Obesity was present in eight (23%) patients. No vascular injuries were recorded and four patients sustained nerve injuries. PROMs were available for 18 patients (51%) with a median follow up of 4.5 years. Median EQ-5D-5L was 0.78 (IQR 0.14). Median LKS was 84.5 (IQR 21) and there was no correlation with time to surgery (p=0.43). Grade of MLKI did not impact LKS (p=0.09). Fifteen patients (83%) saw a reduction in their activity level. All patients were satisfied with their surgical treatment. Recurrent instability was noted in four patients (11%). Three patients (8%) required further surgery (one revision reconstruction, one meniscectomy, one conversion to a hinged knee replacement.

This study demonstrates two groups of patients who sustain MLKI: the sporting population and obese patients. Health related quality of life, functional outcomes and satisfaction are high after surgery. Time to surgery did not impact on functional outcomes.

Introduction

The COVID-19 pandemic led to a swift adoption of telehealth in orthopedic surgery. The purpose of this study was to analyze patient and surgeon satisfaction with a rapid expansion of telehealth use during COVID-19 pandemic within the division of adult reconstructive surgery at a major urban academic hospital.

Introduction

There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population.

Introduction

Surgical reconstruction of Charcot joint deformity is increasingly being offered to patients. In our centre a hybrid type fixation technique is utilised: internal and external fixation. This combined fixation has better wound management and earlier mobilisation in this deconditioned patient group. The aim of this study was to assess clinical, radiological and patient reported outcomes for all patients who underwent this hybrid technique.

Tissue engineering in reconstructive surgery has many potential attractions, not the least to avoid donor site morbidity and reduce the potential need for allografts and prostheses. Currently there are only two products that have FDA approval in the United States, namely skin and cartilage. Other potential products being trialled are artificial blood vessels and heart valves. The common denominator of these is that they are essentially two dimensional and relatively avascular. Three dimensional tissue engineering has three essential components, (1) cells, (2) scaffold and (3) blood supply. Cells are most easily derived from an autologous source, by conventional tissue culture where they are expanded and implanted into the required site. They are committed cells and usually a large source of donor tissue is required to obtain an adequate source of cells for reconstruction. Stem cells have the potential to grow and differentiate, they may be embryonal which introduces ethical problems or adult stem cells. Cells can be genetically engineered to produce specific growth factors for the purpose of further cell proliferation, such as vascular endothelial growth factor for angiogenesis. The second essential is a scaffold for cells to adhere to and grow. This is particularly important for the development of the vascular network. Fibrin, PTFE (Dexon) Matrigel (a form of Laminen) or collagen are the most popular forms of matrix. The third and most essential component for three-dimensional tissue engineering is vascularization. To date, most tissue engineering research involves invitro studies of cell differentiation and growth but the invivo potential is limited because of inability to transfer a blood supply.

At the Bernard O’Brien Institute at St Vincent’s Hospital, Melbourne, we have developed a model of invivo tissue engineering which involves the initial creation of a vascular core inside a plastic chamber which can be moulded to any desired shape. This construct seems to be an ideal environment for seeding of cells, including stem cells which allows them to survive and differentiate into various mesenchymal tissues. To date we have been able to generate skin flaps, fat, tissue and skeletal muscle. Although our prime interest has not been bone or cartilage it is reasonable to assume that this can be relatively simply produced in the same model from either stem cell sources or by the use of differentiating factors.

Surgical treatment of complex deformities necessitates a detailed appreciation of the complex three dimensional abnormal anatomies involved. Preoperative planning for these complex cases traditionally involves x-ray and computerised tomography (CT). These modalities offer only two-dimensional images to represent three-dimensional anatomy. Advances in digital imaging have allowed three-dimensional reconstructions to be derived from CT images. These greatly improve understanding of complex deformities, but will never be able to replace the intuitive understanding that is gained by handling a physical model.

The Rapid Prototyping technique Selective Laser Sintering (SLS) is used in the industrial setting to manufacture prototype models from Computer Aided Designs (CAD). This technology can be utilised to convert CT images into accurate three-dimensional physical models of the human bony anatomy.

We present the use of SLS modelling to aid in the preoperative planning of complex reconstructive surgery in children. Cases include bladder exstrophy, developmental dysplasia of the hip and reconstruction of a complex elbow malunion.

The models provide invaluable visual and tactile information to the operating surgeon, accurately demonstrating the abnormal anatomy in an easily comprehensible manner. They allow estimation of the magnitude and degree of corrections necessary and evaluation of bony deficiencies.

Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible.

Introduction

Hindfoot surgery is assumed to be more painful than midfoot/forefoot procedures with the former often requiring an inpatient stay for pain relief. Poorly controlled pain is associated with adverse patient outcomes and consequently, peripheral nerve blocks (PNB) have become popular for their effective pain control.

Background: The reconstructive surgery of the upper limb is able to avoid an amputation and a severe functional impairment. Nevertheless the therapeutic challenge is difficult because of the diversity of the injuries and the complex function of the upper limb.

Aim: The aim of this study is to assess the results of vascularised fibular bone graft in the immediate and secondary post traumatic reconstructive surgery of the upper limb.

Material and method: Between 1985 and 2006, 16 vascularised fibular bone grafts were performed for 15 post traumatic reconstructions of the upper limb. In this study there were 7 females and 8 males, with an average age of 42 years (20–79). The fibular bone grafting was performed in 9 cases in the immediate post traumatic reconstructive surgery. In 7 cases the fibular bone graft was performed after a first failed surgery, as salvage reconstructive surgery. The transfer was composed of bone and skin in 2 cases, of bone and muscle in 6 cases and of only bone in 8 cases.

Results: The percentage of bone union was 80%. Eight fibular bone graft healed spontaneously, 2 after a additional iliac crest bone grafting. The average duration of bone healing was 6,5 months, from 4 to 12 months. The functional result was good for 10 patients allowing them to go back to their initial activities.

Discussion: In severe bone and soft tissues destruction of the upper limb, a complete reconstruction in one operative session may be performed in order to reduce the time of bone healing and rehabilitation. The micro-vascularized fibular bone grafting may be an excellent therapeutic option. The other techniques as amputation or conventional bone grafting techniques are usually proposed when the vital status of the patient is not compatible with a to extended surgery.

The fibular bone grafting appeared as a very reliable technique with a small morbidity on the donor site. Malunions are frequently described in the literature. It might be partially due to the difficulty in having a stable internal fixation. It has to be as less aggressive a possible on the fibular bone graft vascularisation but has also to offer a good stability. The internal fixation used in these cases was not perfectly adapted for this bifocal fixation of the fibular bone graft on the upper limb. A better device should be developed, with an endomedullary fixation and an axial compression effect.

Conclusion: We recommend this technique in severe trauma cases of the upper limb as salvage procedure at an early stage when is compatible with the initial general status of the patient.

Regulations and in force laws impose to obtain an informed consent prior to any care, especially in surgical setting. Such consent must be informed, explicit, personal, specific and aware. Aim of the present study was the drawing of an informed consent form to be used in external fixation.

The possible drawbacks of using external fixation have been divided in three main groups: general biological, local biological and external fixation related. Moreover, within this consent, a detailed patient compliance section has been included because of this particular fixation system, with regard on nursing, medications and treatment time. As for the specificity of indications in trauma, the pre-existing of risk factors as cigarette smoking or open fracture has been clearly stressed. Finally, the consent for hardware removal has been predisposed, too.

Acute total knee dislocations are uncommon injuries for which some surgeons use artificial ligaments as their choice of graft for reconstruction. The goal of this study is to evaluate on a short and long term basis the stability and function of the LARS reconstructed knee. Flexion ROM was the only parameter which showed significant difference (p< 0.05) between subgroups. Therefore this treatment option for dislocated knee reconstruction seems to give good and lasting results even though patient’s quality of life may suffer.

Although a variety of options have been proposed for the treatment of knee dislocations, the optimal one remains controversial. Allografts and autografts have both been used for reconstruction of the cruciate ligaments. The purpose of this study is to evaluate acute reconstruction of both cruciate ligaments using Ligament Advanced Reinforced System (LARS) artificial ligaments.

We reviewed treatment of forty-eight acute knee dislocations. All patients had reconstruction of both cruciate ligaments with LARS ligaments. Patients were assed using SF-36, Lysholm and IKDC questionnaires as well as a physical exam. Stability of the reconstructed knee was evaluated radiologically using TELOS instrumentation. The controlateral knee was used as reference.

The forty-eight patients were subdivided into four groups of post-operative intervals ranging from six months to seven years. The average ROM was 120°of flexion and −1.4° of extension. The differential average TELOS for LCA, LCP at 30° and LCP at 90° were respectively 2.9 mm, 2.8 mm, 6.9 mm. and their average Lysholm, SF-36 and IKDC scores were 72.0, 72.5, 53.5. Statistical results showed no significant difference (p> 0.05) between subgroups in terms function, laxity and extension but did in flexion.

Our data show that patients treated by this method can regain a functional knee in terms of motion, stability and functional status and does not seem to deteriorate with time.

Knee reconstruction with artificial ligaments shows promising results at short and longer term even though it seems to affect quality of life in this population.

Financing: This study was partially financed by JK Orthomedic Inc.

INTRODUCTION

The burden of Musculoskeletal (M-S) diseases and prosthetic revision operations is huge and increasing rapidly with the aging population. For patients that require a major surgical intervention, procedures are unsafe, uncertain in outcome and have a high complication rate. The goal of this project is to create an ICT-based patient-specific surgical navigation system that helps the surgeon safely reaching the optimal functional result for the patient and is a user friendly training facility for the surgeons. The purpose of this paper is to demonstrate the advancements in personalized musculoskeletal modeling for patients who require severe reconstructive surgery of the lower extremity.

Introduction: Different tendons and ligaments have a specific elasticity which relates to their role in joint movement and locomotion. To ensure an optimal functional outcome it is essential that this mechanical property is restored following surgical procedures to repair or replace damaged tendons and ligaments. This demands appropriate selection of an autograft or artificial construct aided by an understanding of how molecular composition and morphology determines the stiffness of the material. This study tests the hypothesis that tendons with a higher elastic modulus (stiffer) have larger collagen fibril diameters and lower water and sulphated glycosaminoglycan (GAG) contents.

Methods: The superficial digital flexor tendon (SDFT, 30 pairs), deep digital flexor tendon (DDFT, 6 pairs), suspensory ligament (SL, 6 pairs) and common digital extensor tendon (CDET, 6 pairs) were collected from the forelimbs of horses aged 2–23 years destroyed for reasons other than tendon injuries. Left limb tendons were tested to failure in a hydraulic materials testing machine (Dartec) following measurement of cross sectional area. Collagen fibril diameters, water content and sulphated GAG content were measured in tendon tissue from the right limb. Statistical significance was evaluated using Spearman’s correlation and a general linear model (SPSS software).

Results: The elastic modulus was significantly (p< 0.001) different between the different structures and showed a significant positive correlation with the mass average collagen fibril diameter (MAFD) for the different structures and within the SDFT (FIG. I). The water content showed a significant negative correlation with elastic modulus and significant positive correlation with GAG content.

Discussion and Conclusion: Tendons composed of a stiffer material have larger collagen fibril diameters which are associated with lower water and GAG contents. These characteristics should be considered when choosing suitable replacements in tendon reconstruction procedures. Future work to determine the mechanisms that control collagen fibril diameters and water content will aid in the design of bioengineered constructs.

Calcium sulphate is now a proven adjunct to the replenishment of bone stock in joint replacement surgery. Alone and as a composite, it has been used successfully for many years in both dental and orthopaedic applications. OsteoSet (Wright Medical Technology), a processed, purified material, has been used as a bone void filler in 51 revision total hip arthroplasty (THA) procedures.

Follow-up of these cases ranges from 3 to 48 months. Radiographs show that the calcium sulphate has disappeared in all cases. In all but three patients, all of whom had failure of the acetabular component or infection, the calcium sulphate has been replaced with what appears to be trabeculated cancellous bone. Clinical results for cases that did not have mechanical failure or infection are indistinguishable from any revision THA in which the acetabular component is well fixed.

Implantation of the calcium sulphate pellets calls for preparation of a well vascularised bed. The pellets are placed in such a way that load is not transferred to them from the implanted acetabular component. Rather, the load should be transferred from the acetabular component directly to host bone. Postoperatively, load bearing is limited for at least eight weeks and for longer of the quality of the supporting bone is poor.

Purpose: Knee dislocation, although very rare, remains a devastating injury with many complications because of the complex nature of this trauma. The best treatment for knee dislocation is yet to be determined. The purposes of the study were to describe our surgical method, to report our results and to compare them with those of other surgical reconstruction techniques for knee dislocation.

Method: Fifty-six (56) patients with knee dislocation underwent acute combined reparation and reconstruction using Ligament Advancement Reinforcement System (LARS) artificial ligament. Patients were divided in three different groups according to the follow-up period. Group 1 (G1) included patients with a follow-up between two and six months post-op, group 2 (G2) involved patients with a follow-up between six months and twenty-four (24) months and group 3 (G3) was composed of patients who had a follow-up between twenty-four (24) and ninety-one (91) months.

Results: There was a significant difference between G1 and G3 for the Lysholm score and for the posterior stability at 90o of flexion measured with the Telos.

Conclusion: The subjective and objective findings from our series are satisfactory and comparable to the results of other series of knee dislocations. Our findings suggest that with a follow-up at seven years, acute combined reparation and reconstruction with LARS ligaments is a valid alternative for the treatment of knee dislocation.

Loss of bone stock resulting from wear particle-induced osteolysis may compromise the stability and osteoin-tegration of arthroplasty implants. Usually allogeneic corticocancellous bone is used around an implant to fill the defects, but because of the safety and availability of these grafts, the use of synthetic substitute of bone is becoming everyday frequently. BoneSave™ is an osteo-conductive biomaterial prevalently used in reconstructive surgery but it can be used to fill every bone defects or in traumatology like adjuvant of an osteosynthesis. The particles of BoneSave™ (2–4 mm or 4–6 mm) are made of tricalcium phosphate 80% and hydroxyapatite 20%, they have a superficial porosity of 50% (range 10–400 mm). Usually the osteointegration happens after 2–3 years. Recently studies have described that the mixture of 80% TCP/20% HA with human mesenchymal stem cells induced bone formation in vivo faster than the other formulations of the same elements, In vitro studies also demonstrated the expression of osteocalcin. The mixture of TCP/HA with bone-marrow aspiration could be useful if human stem cells are not available. Orthopaedic and traumatology cases will be shown where the use of Bone-Save™ has lead to good clinical and radiological results after a follow-up of 24 months.

Purpose: Tourniquet cuff pressures in paediatric patients are commonly set at standard pressures. Recent evidence on adult subjects has shown that safer and more effective cuff pressures can be achieved by measuring limb occlusion pressure (LOP) and using a wide, contour cuff. There is little evidence validating these techniques in children. The primary objective of this study was to evaluate if a difference in tourniquet cuff pressure can be achieved in a paediatric population using a wide contour cuff in conjunction with measured LOP when compared to a standard cuff and pressure.

Method: Subjects aged 10 to 17 years that underwent anterior cruciate ligament repair were included and ran-domised into either the control group or the experimental ‘LOP’ group using variable block randomisation. The tourniquet cuff was inflated to 300 mmHg in the control group or to the recommended tourniquet pressure based on LOP measurement in the LOP group. The surgeon was blinded to cuff selection, application and pressure throughout the surgical procedure. Immediately following the surgical procedure, the surgeon rated the quality of the bloodless field on a visual analogue scale (VAS). This study was powered as an effectiveness trial and intention to treat analysis was used.

Results: Following a planned interim analysis at midpoint, complete data was recorded for 11 patients (control group) and 10 patients (LOP group). The quality of the surgical field was not different between groups (p= 0.053). There was a statistically significant difference in mean cuff pressure between the control group (300 mmHg) and the LOP group (151 mmHg) (p < 0.001). We ran the same analysis comparing the LOP data to hypothetical control data of 250 mmHg and our results remained statistically significant (p < 0.001).

Conclusion: The use of an automatic LOP measurement with the use wide contour cuffs can significantly reduce average tourniquet cuff pressures in paediatric patients compared to typical practice of 300 mmHg or 250 mmHg without compromising the quality of the surgical field.

To illustrate our clinical experience of using a complete biological method of fixation in ACL surgery and correlate the histology at the graft and the host bone interface performed in an animal experiment.

Materials: 18 male patients of mean age were 31.2 years (range 18 to 50 years) were operated on. The autogenous graft prepared from lateral part of the quadriceps aponeurosis, part of the patella and ligament leaving distal tibial attachment, passed through the trans-osseous tunnel so that bony part of the graft stay within the femoral tunnel, remaining part was sutured with the iliotibial tract.

Patients began immediate knee exercises with continous-passive-motion devices in the recovery room. With 100 degrees of knee motion, they allowed to bear full weight on the operatively treated limb with knee in a brace in extension

Results: 3 patients had superficial wound infection and 2 had haemarthrosis. None had any laxity or flexion contracture, mean flexion arc was135 (130–145) degree.

Conclusion: Histology of the bone graft and host tunnel confirms full incorporation of the graft in experimental animals performed by our senior author. The procedure of biologic fixation method in ACL reconstruction surgery to preserve the biological integrity of the patellar ligament distally in the tibial end may avoid early failure in fixation method. The biological integration producing a bone block in the femoral tunnel may enable clinician to start early rehabilitation program.

Mobility plays an important role, in particular for patients with osteoporosis and after trauma surgery, both as an outcome and as treatment. Mobility is closely linked to the patient”s quality of life and exercise is a powerful additional treatment option. In order to be able to generate an evidence base to evaluate various surgical and non-surgical treatment options, objective measurements of patient mobility and exercise over a certain time period are needed. Wearables are a promising candidate, with obvious advantages compared to questionnaires and/or PROs. However, when extracting parameters with wearables, one often faces the problem of algorithms not performing well enough for special cases like slow gait speeds or impaired gait, as they typically appear in this patient group. We plan to further extend the applicability of the actibelt system (3D accelerometer, 100Hz), in particular to improve the measurement precision of real-world walking speed in slow and impaired walking. We are using a special measurement wheel including a rotating 3D accelerometer that allows to capture high quality real-world walking speed and distance measurements, and a mobile high resolution camera system. In a first block 20 patients with osteoporosis were included in the study at the Ludwigs-Maximilians-University”s Department of General, Trauma and Reconstructive Surgery in Munich, Germany and equipped with an actibelt. Patients were asked to walk as “normal” as possible, while wearing their usual apparel, in the building and outside the building. They climbed stairs and had to deal with all unexpected “stop and go” events that appear in real-world walking. Various gait parameters will be extracted from the recorded data and compared to the gold standard. We will then tune the existing algorithms as well as new algorithms (e.g. step detection based on continuous wavelet transformation) to explore potential improvements of both step detection and speed estimation algorithms. Further refinement and validation using real world data is warranted