Aims

This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google.

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts

Aims. Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites. Methods. A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively. Results. A total of 1,142 patients were included, 47 declined surgery, and 110 were deemed high-risk or requiring specialist resources. In the ten-week study period, 28 high-risk patients underwent surgery, during which 68% (13/19) of Priority 2 (P. 2. , surgery within one month) patients underwent surgery, and 15% (3/20) of P. 3. (< three months) and 16% (11/71) of P. 4. (> three months) groups. Of the 1,032 low-risk patients, 322 patients underwent surgery. Overall, 21 P. 3. and P. 4. patients were expedited to ‘Urgent’ based on biopsychosocial factors identified by the SPAG. During the study period, 91% (19/21) of the Urgent group, 52% (49/95) of P. 2. , 36% (70/196) of P. 3. , and 26% (184/720) of P. 4. underwent surgery. No patients died or were admitted to HDU/ICU, or contracted COVID-19. Conclusion. Our widely generalizable model enabled the restart of planned surgery during the COVID-19 pandemic, without compromising patient safety or excluding high-risk or complex cases. Patients classified as Urgent or P. 2. were most likely to undergo surgery, including those deemed high-risk. This model, which includes assessment of biopsychosocial factors alongside disease severity, can assist in equitably prioritizing the substantial list of patients now awaiting planned orthopaedic surgery worldwide. Cite this article: Bone Jt Open 2021;2(2):134–140

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

The Canadian Institute for Health Information (CIHI) and the Organisation for Economic Co-operation and Development (OECD) have partnered to advance international patient-reported outcome measures (PROMs) collection and reporting standards for hip and knee arthroplasty. This project is part of the OECD's Patient-Reported Indicator Survey (PaRIS) initiative, which aims to address the need for internationally comparable patient-reported outcome and experience measures in order to better monitor health system performance and drive continuous improvement. PROMs are in varying stages of implementation across OECD health systems, with differences in collection and reporting practices across existing programs. CIHI and the OECD are leading an international working group for PROMs in hip and knee replacement surgery in order to build consensus on PROMs data collection standards and develop indicators for international reporting. Working group members include patient representatives, clinicians, national arthroplasty registries, the International Society of Arthroplasty Registries (ISAR), experts in PROMs measurement, and government representatives of several OECD member countries. Activities of the working group focus on two main priorities: 1) Use existing PROMs programs to maximize pilot comparable reporting in OECD's Health at a Glance 2019 report, and 2) Advance new PROMs standards and data collection to maximize comparable reporting beyond Health at a Glance 2019. An environmental scan of PROMs in hip and knee arthroplasty found that a number of countries are collecting this data, however, there are variations in survey instruments as well as administration and reporting methods within and across countries. As part of priority 1, the working group has achieved consensus on a number of aspects around pilot reporting. The project is compiling data from existing PROMs programs in order to report results in the Health at a Glance 2019 publication. For priority 2, the most notable challenge is establishing an agreement across countries on common survey tools, as well as a minimum data set that works for all, given the disparities of existing collection across countries. Many international programs lack the flexibility to change PROMs tools or collections methods, and have concerns regarding the break in trend for PROMs data within their own countries if they were to change methods. The project is exploring the use of crosswalks and other opportunities for comparable reporting, such as the use of single-item anchor questions. To date, the working group continues to develop consensus on international standards for PROMs collection and reporting. Results of the international consensus building and work to date will be shared. PROMs incorporate the patient's perspective into the delivery of treatments and care – such as hip and knee arthroplasty – that aim to improve a patient's quality of life. Alignment of standards in PROMs collection across countries will make comparable data available for reporting, in order to inform quality improvement initiatives within health systems to provide better care for patients. CIHI and the OECD will continue to work with member countries to develop international data collection and reporting standards for PROMs, and encourage the adoption of common approaches across countries

Introduction. The Te Whatu Ora Southern catchment area covers the largest geographical region in New Zealand (over 62,000 km2) creating logistical challenges in providing timely access to emergency neck of femur (NOF) fracture surgery. Current Australian and New Zealand guidelines recommend that NoF surgery be performed within 48 hours of presentation. The purpose of this study was to compare the outcomes for patients with NoF fractures who present directly to a referral hospital (Southland Hospital) compared to those are transferred from rural peripheral centres. Methods. A retrospective cohort study identified 79 patients with NoF who were transferred from rural peripheral centres to a referral hospital for operative management between January 2011 to December 2020. This cohort was matched 1:1 by age and sex to patients with NoF who presently directly to the referral hospital over the same period. The primary outcome was to compare time to surgery between the groups and secondary outcomes were to compare length of hospital stay, complication rates and mortality rates at 30-days and 1-year. Results. The mean delay in transfer time from peripheral centres was 11.5 ± 6.4 h. The mean time to surgery was higher, but not significantly different (p=0.155), for patients transferred from peripheral centres compared to patients presenting directly to the referral hospital (30.7 ± 16.5 h vs. 26.8 ± 17.2 h, respectively). However, rates of surgery within 48 h were similar between the patients transferred from peripheral centres and patients presenting directly to the referral hospital (8.8% vs 7.6%, p>0.999). There were no significant differences in complication rates, length of stay or 30-day or 1-year mortality between the groups. Discussion and Conclusion. Significant delays in transfer from peripheral centres to the referral hospital were identified, averaging 11.5 h. There was a strong trend towards increased time to surgery for patients transferred from peripheral centres. Early transfer of patients with NoF to a referral hospital should continue to be made a high priority

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Aims. The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. Methods. A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded. Results. During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. Conclusion. Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774–1781

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

Abstract. Background. Fracture dislocation of the knee involves disruption of two or more knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee(IKDC) score and Knee Injury & Osteoarthritis Outcome Score(KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements & complications. Results. 23 patients were presented with the mean age was 37 years(17–74). 14% of patients sustained vascular injury & 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within 3 weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 & KOOS was 73. The mean postoperative Tegner Activity Scale was 3.6 with mean flexion of 115(90–130). We observed some patterns of tibial plateau fractures are associated with similar patterns of ligamentous injuries. The anterio-medial rim fractures (52%) were associated with PCL, ACL & avulsion injuries of posterio-lateral corner structures. Most of the neurovascular injuries happened in this group. The other recognisable pattern was posterio-medial fractures, which were associated with ACL avulsion injury. Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Aims. As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. Methods. This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. Results. Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03). Conclusion. Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services. Cite this article: Bone Joint Open 2020;1-6:267–271

Aim. Staphylococcus epidermidis (S. epidermidis) is one of the main pathogens responsible for bone and joint infections especially those involving prosthetic materials (PJI). Although less virulent than S. aureus, S. epidermidis is involved in chronic infections notably due to its ability to form biofilm. Moreover, it is frequently multiresistant to antibiotics. In this context, the development of additional or alternative antibacterial therapies targeting the biofilm is a priority. Method. The aim of this study was to evaluate in vitro the activity of phage lysin exebacase (CF-301) against biofilms formed by 19 S. epidermidis clinical strains responsible for PJI. We determined the remaining viable bacteria inside the biofilm (counting after serial dilution and plating) and the biomass (bacteria and extracellular matrix, using crystal violet staining) after 24h of exposition to exebacase at different concentrations, alone (0.05; 0.5; 5; 50 and 150 mg/L) or in combination (5, 50 and 150 mg/L) with antibiotics commonly used to treat multi-resistant S. epidermidis PJI (rifampin (1 mg/L), vancomycin (10mg/L) and daptomycin (10mg/L)). In this study, synergy was defined as a significantly higher effect of the association in comparison to the sum of the effect of each molecule. Results. Exebacase showed a dose-dependent reduction of biomass, ranging from 11 % at 0.5 mg/L to 66 % at 150 mg/L. Exebacase showed a significant bactericidal activity at 50 and 150 mg/l, with a mean decrease of the inoculum of 0.94 and 1.7 log, respectively. In addition, synergistic effects were observed in association with i) rifampin (1 mg/L) showing a mean decrease up to 84% of the biomass and 3.5 log CFU at 150 mg/L of exebacase, ii) vancomycin (10 mg/L) showing a mean decrease up to 81% of the biomass and 2.82 log CFU at 150 mg/L of exebacase, iii) and daptomycin (10 mg/L) showing a mean decrease up to 85% of the biomass and 3.1 log CFU at 150 mg/L of exebacase. Conclusions. Exebacase showed, in vitro, synergistic activity with antibiotics against S. epidermidis biofilms. It is a promising adjuvant therapy to rifampin, vancomycin and daptomycin in the context of PJI. Further studies are needed, in vitro to understand the mechanism of action on S. epidermidis biofilm and the heterogeneity of strain behaviour and in vivo to confirm the present data

Aims. The current global pandemic due to COVID-19 is generating significant burden on the health service in the UK. On 23 March 2020, the UK government issued requirements for a national lockdown. The aim of this multicentre study is to gain a greater understanding of the impact lockdown has had on the rates, mechanisms and types of injuries together with their management across a regional trauma service. Methods. Data was collected from an adult major trauma centre, paediatric major trauma centre, district general hospital, and a regional hand trauma unit. Data collection included patient demographics, injury mechanism, injury type and treatment required. Time periods studied corresponded with the two weeks leading up to lockdown in the UK, two weeks during lockdown, and the same two-week period in 2019. Results. There was a 55.7% (12,935 vs 5,733) reduction in total accident and emergency (A&E) attendances with a 53.7% (354 vs 164) reduction in trauma admissions during lockdown compared to 2019. The number of patients with fragility fractures requiring admission remained constant (32 patients in 2019 vs 31 patients during lockdown; p > 0.05). Road traffic collisions (57.1%, n = 8) were the commonest cause of major trauma admissions during lockdown. There was a significant increase in DIY related-hand injuries (26% (n = 13)) lockdown vs 8% (n = 11 in 2019, p = 0.006) during lockdown, which resulted in an increase in nerve injuries (12% (n = 6 in lockdown) vs 2.5% (n = 3 in 2019, p = 0.015) and hand infections (24% (n = 12) in lockdown vs 6.2% (n = 8) in 2019, p = 0.002). Conclusion. The national lockdown has dramatically reduced orthopaedic trauma admissions. The incidence of fragility fractures requiring surgery has not changed. Appropriate provision in theatres should remain in place to ensure these patients can be managed as a surgical priority. DIY-related hand injuries have increased which has led to an increased in nerve injuries requiring intervention

Bone non-union following fracture is a major cause of morbidity in combat casualties. The various clinical treatments used to prevent or treat non-union remain of limited efficacy. Research therefore continues in pre-clinical animal models in an attempt to identify an effective clinical treatment. The aim of this study was to systematically evaluate emerging pre-clinical therapies in order to rationalise priorities for translational research. The methodological protocol of this study was registered with the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES) and published. The review identified 3251 animal studies, 851 of which fulfilled the criteria for inclusion as detailed in the protocol. Of these, 702 of the studies described therapies that had progressed to clinical trials and were therefore excluded. The remaining 149 papers described eighteen categories of therapy that represent novel therapies yet to translate to clinical trials. These studies used a range of animal models, with heterogeneity that precluded formal synthesis and meta-analysis. This study provides a systematic evaluation of novel therapies with potential to prevent or treat non-union. It also represents a novel application of an emerging epidemiological technique to address a key priority in Combat Casualty Care research

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same. An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached. Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles. The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed. We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia

Referral patterns in spine clinic of young patients with suspected scoliosis is suboptimal with 19% of late referrals and 42% of inappropriate referrals. Patients' triage and prioritisation in spine clinic is a strategy to ensure that health care allocation is done according to the level of health needs, favoring effective management and efficient use of health care resources use. The objective of the study is to elaborate a model for triage and prioritisation of young patients in spine clinic based on expert consensus and literature on best practices. This projects was structured in three parts: 1)We documented best evidence. We conducted a review of empirical studies evaluating triage and prioritisation initiatives in order to identify key components for intervention success. 2)We elaborate a model of health care delivery with the professionals of a local paediatric spine clinic. In this model, the triage and prioritisation algorithm was developed from list of potential factors (demographics, signs and perceived symptoms, provisional diagnoses and known co-morbidities, results of preliminary physical examination and radiological findings) that was submitted to five paediatric orthopaedic surgeons for rating according to their potential relevance to orient prioritisation decisions. 3) We compared the professionals' model of health care delivery to the literature synthesis in order to propose the best model. Seven key components of triage and prioritisation systems were identified: centralised review of referral requests, list of consensual objectives criteria for triage, fast track evaluation of urgent cases, selection of cases for management at point of triage, cases prioritisation to main consultant, multidisciplinary evaluation and alternatives pathways. The consensual decision algorithm confirmed that cases who should be seen in priority are immature patients presenting with a significant trunk deformity. In addition, presence of persisting neurological symptoms, severe incapacitating pain or night pain, as well as abnormal scan or MRI findings were considered as urgent/PI priority. Cases characteristics for evaluation by nurse practitioners as well as alternative pathways of management were defined. Acceptability, compatibility, clinical relevance and discriminant capacity of the new model of health care delivery were satisfactorily demonstrated. Consensus was easily reached between the five respondents on factors supporting decisions to prioritise patients in spine clinic for suspected spinal deformity. Refinements to the initially proposed model according the identified key features from the literature, led to a final model of health care delivery that is evidence-base, feasible and coherent with the local context. Future implementation of this model should facilitate timely and appropriate health care delivery and best use of health care resources according to patients' needs

Currently 180 days is the target maximum wait time set by all Canadian provinces for elective joint replacement surgery. In Nova Scotia however, only 34% of Total Knee Arthroplasties (TKA) and 51% of Total Hip Arthroplasties (THA) met this benchmark in 2017. Surgery performed later in the natural history of disease is shown to have significant impact on pain, function and Health related Quality of Life at the time of surgery and potentially affect post-operative outcomes. The aim of this study is to describe the association between wait time and acute hospital Length of Stay (LOS) during elective hip and knee arthroplasty in province of Nova Scotia. Secondarily we aim to describe risk factors associated with variations in LOS. Data from Patient Access Registry Nova Scotia (PAR-NS) was linked to the hospital Discharge Access Database (DAD) for primary hip and knee arthroplasty spanning 2009 to 2017. There were 23,727 DAD observations and 21,329 PARNS observations identified. Observations were excluded based on missing variables, missing linkages, revision status and emergency cases. Percentage difference in LOS, risk factors and outcomes were analyzed using Poisson regression for those waiting more than 180 days compared to those waiting equal or less than 180 days. For primary TKA, 11,833 observations were identified with mean age of 66 years, mean wait time of 348 days and mean LOS of 3.6 days. After adjusting for controls, patients waiting more than 180 days for elective TKA have a 2.5% longer acute care LOS (p < 0.028). Risk factors identified for prolonged LOS are advanced age, female gender, higher surgical priority indicator, required blood transfusion, dementia, peptic ulcer disease, cerebrovascular disease, heart failure, chronic kidney disease, malignancy, ischemic heart disease and diabetes. Factors associated with decreased LOS are surgical year, use of local anesthetic, peripheral location of hospital and admission to hospital from home. For primary THA, 6626 observations were identified with mean age of 66 years, mean wait time of 267 days and mean LOS of 4 days. Patients waiting more than 180 days for THA did not show a statistically significant association with LOS. Risk factors and protective factors are the same with exception of CVD and use of local anesthetic. Our findings suggest a positive and statistically significant association for patients waiting more than 180 days for TKA and longer acute care LOS. Longer LOS may be due to deteriorating health status while placed on a surgical waitlist and may represent a delayed and indirect cost to the patient and the healthcare system. Ultimately with projected increase in demand for elective joint replacement surgeries, our findings are aimed to inform physicians and policy makers in management of surgical waitlist efficiency and cost effectiveness. For any reader inquiries, please contact . shahriar-s@hotmail.com

Aims

The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature.