Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database. Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X. 2. =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X. 2. =5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%. Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally

Background. Hip fractures cost the NHS £2 billion per annum. British guidelines within 36 hours of admission. However, these guidelines do not consider the time the patient spends between injury and admission. Our study aims to investigate pre-hospital time (PHT) and its effect on outcomes. Primary outcome measures were mortality, length of stay (LOS), pressure sores and abbreviated mental test scores (AMTS). Methods. Hip fracture data was retrospectively collected from our hospital IT system (Clinical Workstation) between February and August 2020. Admission data, ambulance timings, and outcome data was extracted. Statistical analysis was performed using GraphPad Prism V9.5.1. Results. Two hundred eleven data sets were analysed. Mean age was 82.4, with 2:1 Females to males and median ASA of 3. The mean PHT was 690 minutes (85 to 6057). There was a positive correlation between increased PHT and mortality, though this did not reach statistical significance. There was a significant positive association between PHT and LOS (P=0.0027). Increased PHT was associated with lower admission AMTS (P<0.0001) and higher rate of pressure sore formation (P=0.0001). There was also a significantly positive correlation between PHT and time to mobility (P=0.049). Conclusion. There is an unobserved delay in hip fracture patients presenting to the hospital. Current treatment guidelines advocate early surgery but do not consider pre-hospital time. PHT in our patient population is 690 minutes on average, with increasing delay correlating with worse outcomes. Pre-hospital time should be considered when managing hip fracture patients with a view to expedite surgery and medical assessment

The Ponseti method is the gold standard treatment for clubfoot. It begins in early infancy with weekly serial casting for up to 3 months. Globally, a commonly reported barrier to accessing clubfoot treatment is increased distance patients must travel for intervention. This study aims to evaluate the impact of the distance traveled by families to the hospital on the treatment course and outcomes for idiopathic clubfoot. No prior studies in Canada have examined this potential barrier. This is a retrospective cohort study of patients managed at a single urban tertiary care center for idiopathic clubfoot deformity. All patients were enrolled in the Pediatric Clubfoot Research Registry between 2003 and April 2021. Inclusion criteria consisted of patients presenting at after percutaneous Achilles tenotomy. Postal codes were used to determine distance from patients’ home address to the hospital. Patients were divided into three groups based on distance traveled to hospital: those living within the city, within the Greater Metro Area (GMA) and outside of the GMA (non-GMA). The primary outcome evaluated was occurrence of deformity relapse and secondary outcomes included need for surgery, treatment interruptions/missed appointments, and complications with bracing or casting. A total of 320 patients met inclusion criteria. Of these, 32.8% lived in the city, 41% in the GMA and 26% outside of the GMA. The average travel distance to the treatment centre in each group was 13.3km, 49.5km and 264km, respectively. Over 22% of patients travelled over 100km, with the furthest patient travelling 831km. The average age of presentation was 0.91 months for patients living in the city, 1.15 months for those within the GMA and 1.33 months for patients outside of the GMA. The mean number of total casts applied was similar with 7.1, 7.8 and 7.3 casts in the city, GMA and non-GMA groups, respectively. At least one two or more-week gap was identified between serial casting appointments in 49% of patients outside the GMA, compared to 27% (GMA) and 24% (city). Relapse occurred in at least one foot in 40% of non-GMA patients, versus 27% (GMA) and 24% (city), with a mean age at first relapse of 50.3 months in non-GMA patients, 42.4 months in GMA and 35.7 months in city-dwelling patients. 12% of the non-GMA group, 6.8% of the GMA group and 5.7% of the city group underwent surgery, with a mean age at time of initial surgery of 79 months, 67 months and 76 months, respectively. Complications, such as pressure sores, casts slips and soiled casts, occurred in 35% (non-GMA), 32% (GMA) and 24% (city) of patients. These findings suggest that greater travel distance for clubfoot management is associated with more missed appointments, increased risk of relapse and treatment complications. Distance to a treatment center is a modifiable barrier. Improving access to clubfoot care by establishing clinics in more remote communities may improve clinical outcomes and significantly decrease the burdens of travel on patients and families

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively

Purpose. The objective of this meta-analysis was to compare the effects of early and delayed surgery on the risk of mortality, common post-operative complications, and length of hospital stay among elderly hip fracture patients. Methods. We searched MEDLINE and EMBASE for relevant prospective studies evaluating surgical delay in patients undergoing surgery for hip fractures published in all languages between 1966 and 2008. Two reviewers independently assessed methodological quality and extracted relevant data. Results. Of 1939 citations identified, 16 observational studies that included a total of 13,478 patients with complete mortality data (1764 total deaths) met our inclusion criteria. Irrespective of the cut-off for delay (24, 48, or 72 hours), earlier surgery (< 24, < 48, or < 72 hours) was significantly associated with a reduction in the risk of unadjusted one-year mortality (relative risk 0.55; 95% confidence interval, 0.40 to 0.75, p=0.0002) and adjusted mortality rates (relative risk 0.81; 95% confidence interval, 0.68 to 0.96, p=0.01). Based on unadjusted data, earlier surgery also reduced in-hospital pneumonia (relative risk 0.59; 95% confidence interval, 0.37 to 0.93, p=0.02), pressure sores (relative risk 0.48; 95% confidence interval, 0.34 to 0.69, p< 0.0001) and hospital stay (weighted mean difference 9.95 days; 95% confidence interval, 1.52 to 18.39, p=0.02). Conclusion. Earlier surgery was associated with a reduced risk of mortality, post-operative pneumonia, pressure sores, and length of hospital stay among elderly hip fracture patients. This suggests that it may be warranted to reduce surgical delays whenever possible. However, unadjusted analyses are certainly confounded, and residual confounding may be responsible for apparent effects in adjusted analyses. A definitive answer to this issue will require the conduct of a large randomised controlled trial to evaluate the effect of earlier surgery among patients admitted with a hip fracture

Hip fractures are estimated to cost the NHS over £2 billion per year and, with an ageing society, this is likely to increase. Rehabilitation and discharge planning in this population can be met with significant delays and prolonged hospital stay leading to bed shortages for acute and elective admissions. Planning care for these patients relies on a multidisciplinary approach with allied healthcare providers. The number of hip fracture patients in our hospital averages between 450–500/annum, the second largest number in the North West. The current average length of stay for the hip fracture patients is 22.9 days. We evaluated the impact and performance of a pilot early supported discharge service (ESD) for patients admitted with a hip fracture. The pilot period commenced 22 September 2014 for 3 months and included an initial phase to set up the service and supporting processes, followed by the recruitment of 20 patients during the pilot period. The length of stay and post-discharge care was reviewed. The journey of 20 patients was evaluated. The length of stay was dramatically reduced from an average of 22.9 days to 8.8 days in patients on the ESD pathway. Family feedback showed excellent results with communication regarding the ESD pathway and relatives felt the ESD helped patients return home (100% positive feedback). Prolonged recumbency adversely affects the long-term health of these patients leading to significant morbidity such as pressure sores, respiratory tract infections and loss of muscle mass leading to weakness. Mortality is also a significant risk for these patients. Longer hospital stays lead to disorientation, institutionalisation and loss of motivation. Enhancing self-efficacy has been shown to improve balance, confidence, independence and physical activity. This pilot has proven that the Fracture Neck of Femur ESD service can significantly reduce the length of hospital stay and also deliver excellent patient and family feedback. The benefits of patients with a lower length of stay, with effective rehabilitation in hospital and within the home, will provide significant benefits to the Wirral healthcare economy

Background:. Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. Aim:. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children. Methods:. A retrospective review was performed of a single surgeon series of paediatric myelomeningocele patients who underwent kyphectomy surgery. All the patients had posterior fusion, employing pedicle screws and sub laminar wiring. All the posterior fusions extended to the pelvis either to include S1 or the ilium. Prior to surgery, three children had open wounds over the apex of the deformity. Despite prone nursing, these failed to heal. These were closed primarily intra-operatively without the requirement of flaps. Results:. Seven children (four males, three females) were identified with an average age of 9.5 (8–13) years. The kyphosis was corrected from a mean range of 110° (88°–180°) to post-operative range of 5°–45°. The operative time averaged 240 min (165–284 min) with an estimated blood loss average of 957 ml (500–2550 ml). All the patients recovered well and no short-term complications were experienced except one transient CSF leak intra operatively. Two patients presented with sub-acute delayed infection requiring removal of instrumentation once the spine had fused. There was one case of instrumentation failure. All patients had improved wheel chair seating. Conclusion:. Kyphectomy in myelomeningocele is an infrequently required procedure which is effective in sagittal correction and improved seating with an acceptable complication rate

Patients with spinal injuries are very vulnerable to early complications or secondary spinal cord injuries before and during transfer, which may delay their rehabilitation. We designed transfer guidelines following concerns raised in a pilot study of the transfer of 16 patients. We then examined the effectiveness of the guidelines in 100 consecutive patients and completed the cycle by re-auditing a further 254 consecutive admissions after incorporating changes from the initial audit. The transfer guidelines addressed ten areas of clinical concern. We recorded a 50% improvement in airway monitoring and management. There was also improvement in anti-ulcer therapy and thromboprophylaxis (from 50% to 96%). We saw a 50% improvement in the use of appropriate support staff during the transfer. The re-audit showed that initial improvements were maintained and further improvements were noted in the transfer of relevant documentation and investigations. Improvement was also noted in the use of a vacuum mattress for the transfer of spinal injury patients and subsequently reduced incidence of pressure sores by a statistically significant level, which helped in the early rehabilitation of these patients. The majority of transfers were safe. The transfer guidelines were easy to use and improved patient care by ensuring that common problems had been addressed before and during transfer. This system reduced the risk of preventable complications during inter-hospital transfer. There may be wider application of similar guidelines to other trauma patients who require inter-hospital transfer, where there is a possibility of preventable secondary injury

The majority of hip fracture patients receive operative treatment, although the National Hip Fracture Database (NHFD) 2012 suggest 2.6% were treated conservatively. One of only a few published reports on the outcomes of these patients has demonstrated that mortality rates beyond 30 days remain comparable to patients receiving surgery. We have assessed the outcomes of conservatively managed patients in our unit. Patients treated conservatively at our hospital between 2010 and 2012 inclusive were identified using the NHFD. Data collection included mobility status, ASA grade, Nottingham Hip Fracture Score (NHFS), mortality (30 days and 1 year) and pain scores. The study group (N=31) had a mean age 85, mean ASA was 4 and mean NHFS mortality risk 21.3%. Morbidity included one case of pneumonia and one infection from another source, however there were no pressure sores or VTE. Three patients later received surgery once their health had improved. Pain control was achieved in 91% patients (21/23) and although mobility decreased, 34.8% of patients were able to mobilise with either two aids or a frame. Given the selection bias for conservative treatment in unwell patients, the higher mortality figure is not unexpected. Although the 30 day mortality data is higher than the national average for operative management, those patients surviving 30 days have a mortality similar to those managed operatively. Despite mobility decreasing from the pre-admission status, a significant number of patients were pain free and could mobilise. Therefore conservative management can produce acceptable results in these patients

Previous reports have shown the efficacy of muscle interposition grafts in treating recalcitrant infection in the presence of hip arthroplasty. We report our experience with a two stage debridement and rectus femoris pedicled interposition graft technique in chronic severe native hip infection with a persistent draining sinus. During the last 16 months, three paraplegic patients presented with persistently draining sinuses and chronic osteomyelitis of the pelvis, acetabulum and proximal femur, in a total of four hips. The mean patient age was 49 years (range, 40 to 59 years). In all patients there had been previous attempts to control the infection with wound debridement and long-term antibiotics. A two-stage operative treatment was used in all patients. The first stage comprised wound debridement, washout, gentamycin-bead application and temporary vacuum assisted wound coverage. At the second stage, approximately ten days later, through a standard anterior midline incision, the rectus femoris muscle was elevated on its pedicle, rolled, transposed into the acetabulum and sutured to the transverse acetabular ligament. At the second stage, all patients had local administration of antibiotics with genetamycin impregnated absorbable collagen fleece and all wounds were closed by delayed primary closure with a negative pressure dressing placed over the closed wound. All patients were commenced on a 6 week course of intravenous antibiotics, according to sensitivities. No loss of flap occurred in any of the patients. One wound had partial dehiscence and required a split skin graft. At the final follow-up examination all the wounds were healed and there was no recurrence of draining sinuses, pressure sores or systemic sepsis. The two stage technique with a pedicled rectus femoris interposition graft may be a useful technique for the treatment of complex chronic persistent osteomyelitis of the pelvis, acetabulum and proximal femur, with the primary aim of stopping the discharging sinus

In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies were extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265,137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home. There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229,418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduced mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery, apart from one study of 399 patients which reported an increased mortality and morbidity for those operated on within 24 hours of admission. In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay

Background. Arthrogryposis Multiplex Congenita is a rare congenital disorder associated with multiple musculoskeletal contractures which causes substantial morbidity. Knee involvement is commonly seen among children with arthrogryposis, with flexion contracture being the most frequent. The purpose of this study was to assess the effectiveness of orthopaedic procedures, namely distal femoral supracondylar extension osteotomy and/or Ilizarov external fixator, on the ambulation status of children with knee flexion contracture and whether any functional gains are maintained at the latest follow-up. Methods. Fifteen patients were identified and their medical records reviewed. The mean age at their first surgery was 7.6 years (range, 2-16 years). The etiology for all patients was amyoplasia. The mean length of follow-up was 58 months (range, 12-117 months). Contractures were treated with femoral extension osteotomy (n=8), Ilizarov external fixator (n=2), or both (n=5). Results. Pre-operatively, 11 patients were non-ambulatory, three patients were household ambulators, and one patient walked with orthoses in the community. There was an average of 1.5 knee surgeries done per patient. At the latest follow-up, nine patients were ambulatory with technical aids, two patients were household ambulators, one patient used a wheelchair but was independent for transfers, and three patients remained non-ambulatory. The mean flexion contracture prior to the first surgery was 62.8 ± 26.7 degrees. Post-operatively, the mean flexion contracture was 13.5 ± 16.4 degrees. At the latest follow-up, the mean flexion contracture was 33.8 ± 23.6 degrees. There were complications in three patients which included infected hardware, transient neurological compromise, and pressure sores, which eventually all resolved. Conclusion. early and aggressive orthopaedic management of flexion contractures in children with arthrogryposis is supported by our findings, and may contribute to functional gains

Aim. To assess the results of Castles procedure performed at our hospital compared with those available in literature. Introduction. Fifteen patients (19 hips) with severe disability and hip subluxation/dislocation underwent proximal femoral resection arthroplasty (Castles procedure) over a 10 year period under the care of 2 paediatric orthopaedic surgeons. We conducted a retrospective study of case series whether the surgery (Castles procedure) improved the pain levels, sitting tolerance, ability to use commode/nappy change, ease of dressing and the carers overall satisfaction with the procedure. Patients and methods. We reviewed the surgeons' and theatre log books for patients' details. We then contacted the patients' parents/guardian by telephone, and using a set questionnaire, we obtained valuable information on how successful the surgery had been in their opinion. Results. Out of 15 patients, 14 had severe cerebral palsy and one had severe brain damage secondary to trauma. The average age at surgery was 4.23 years (range 6–118 months). 14 patients obtained significant pain relief but one patient remained the same. 13 patients were found to have both sitting tolerance and sleeping improved. One patient suffered a pressure sore which has healed with conservative management. 2 patients had additional trimming procedure for heterotopic ossification excision. Apart from this there were no cases of skin breakdown. All patients found the bathing and dressing change was easier post operatively. 2 carers required extra help as the limbs were floppy but not a major issue compared to the overall benefits from the Castles procedure. Overall 13 carers were very satisfied with the procedure, two were satisfied and none were unsatisfied. Conclusion. Our telephone survey shows the Castles procedure was a successful salvage procedure for painful dislocated hips in non-ambulatory patients with severe disability

Background. Hip fracture in the elderly has high morbidity and mortality. National guidelines have recommended low molecular weight (LMW) heparin or aspirin for thromboprophylaxis in hip fracture. Unlike other types of major surgery, there is a lack of trial evidence for graduated elasticated compression (GEC) stockings in hip fracture patients. Objective. To explore the effect of thromboprophylaxis on survival in hip fracture patients. Participants. 8470 Scottish Hip Fracture Audit (SHFA) participants aged 60 years and over, admitted 1998-2003. Methods. SHFA records were linked to routinely collected hospital discharge and death records occurring within one year of hip fracture admission. Cox proportional hazards regression was used to adjust for age, gender, previous hospital admissions, previous walking ability and residence, American Society of Anesthesiologists grade, fracture type, pressure sores prior to surgery, and delay to surgery. Results. 2531 (30%) patients died within one year of hip fracture admission. GEC stockings appeared to be protective against death (hazard ratio 0.88, 95% confidence interval 0.80-0.97) as did aspirin (HR 0.85, 95% CI 0.76-0.95). However heparin did not appear to protect against death (HR 0.97, 95% CI 0.87-1.08), even when only LMW heparin was included in the analysis. Overall, 3318 (39%) patients were given GEC stockings, 2735 (32%) aspirin, and 4527 (53%) heparin. Patients commonly received more than one type of thromboprophylaxis. Conclusions. This study provides evidence for a protective effect of GEC stockings and aspirin following hip fracture, but not heparin. The study design allowed sophisticated analysis, adjusting for a number of functional, social, surgical, anaesthetic and medical factors. The findings may however be explained by other confounding factors not included in the analysis. These findings suggest that a randomised controlled trial of GEC stockings, aspirin and heparin in hip fracture patients is warranted

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention. There were no implant related complications. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions

Purpose. Conservative treatment of minimally displaced distal radius fractures (DFR) remains controversial. Circumferential casting (CC) in the acute setting is believed to supply superior support compared to splinting, but is generally cautioned due to the limited capacity of a cast to accommodate ongoing limb swelling possibly leading to complications. However, there is no conclusive data on which to base these beliefs. Moreover, the appropriate management of cast complications while minimizing risk to fracture integrity remains unclear. This retrospective study of distal radius fractures treated conservatively with circumferential cast in the acute setting aims to: A. Determine demographic, fracture dependant or management risk factors for CC complications. B. Determine the natural history for both patients with CC and those with CC necessitating cast modification. Method. Hospital records and radiographic data of 316 patients with DRFs treated with CC at a tertiary-care university hospital between the years 2006 to 2009 were reviewed. Our primary outcome was to access risk factors for cast complications including swelling, pressure sores, neuropathies and loss of cast immobilization. Our secondary outcome accessed reduction stability in patients undergoing cast re-manipulation. Results. 31% of patients experienced cast related complications within the first two weeks of treatment. 22% of patients had their cast manipulated (replaced, split, trimmed or windowed). Increasing patient age or polytrauma were both associated with an increased risk of developing cast complications. Polytrauma was also associated with a poor overall rate of fracture reduction following non-operative management. Patient gender, physician specialty placing the cast as well as fracture type (AO classification) did not influence risk. Overall, patients with acute cast complications had no increased risk of losing reduction compared to patients with normal management. However, patients who complained of pressure in cast had a higher risk of loss reduction if their cast was split as opposed to being replaced. Conclusion. Circumferential casting in the acute setting of minimally displaced DRF reduces the workload of an orthopedic department. No previous study has shown improved fracture outcome compared to CC using other immobilization methods. This study has identified that elderly patients and polytrauma patients are at greater risk of returning to clinic for cast complications. Furthermore, replacing a cast as opposed to splitting it when accommodating painful swelling may aid in maintaining reduction integrity

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

Aims

Single-event multilevel surgery (SEMLS) has been used as an effective intervention in children with bilateral spastic cerebral palsy (BSCP) for 30 years. To date there is no evidence for SEMLS in adults with BSCP and the intervention remains focus of debate.

We report our experience using a biodegradable calcium sulphate antibiotic carrier containing tobramycin in the surgical management of patients with chronic osteomyelitis. The patients were reviewed to determine the rate of recurrent infection, the filling of bony defects, and any problems with wound healing. A total of 193 patients (195 cases) with a mean age of 46.1 years (16.1 to 82.0) underwent surgery. According to the Cierny–Mader classification of osteomyelitis there were 12 type I, 1 type II, 144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3 to 7.1) with recurrent infection occurring in 18 cases (9.2%) at a mean of 10.3 months post-operatively (1 to 25.0). After further treatment the infection resolved in 191 cases (97.9%). Prolonged wound ooze (longer than two weeks post-operatively) occurred in 30 cases (15.4%) in which there were no recurrent infection. Radiographic assessment at final follow-up showed no filling of the defect with bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling in eight (4.4%). A fracture occurred in nine (4.6%) of the treated osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after operation.

We conclude that Osteoset T is helpful in the management of patients with chronic osteomyelitis, but the filling of the defect in bone is variable. Prolonged wound ooze is usually self-limiting and not associated with recurrent infection.

Cite this article: Bone Joint J 2014; 96-B:829–36