Aims. The aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown. Methods. A prospective analsysis of all patients attending our hand trauma unit throughout the UK COVID-19 lockdown period (24 March to 10 May 2020) was carried out. Prospectively collected departmental data from the same period in 2019 was obtained and reviewed for comparison. The number of patients attending clinic, undergoing surgery, the type of surgical procedure, and rate of surgery was compared. Results. In all, 463 patients attended hand trauma services during the lockdown period compared to 793 in 2019 (32% reduction); 190 surgical procedures were carried out during lockdown compared to 236 in 2019 (20% reduction). Intervention rate was higher during the lockdown period (41% compared to 30%). There was no difference in the type of cases. In the first half of lockdown, 47% fewer procedures were performed than in 2019, but in the second half of lockdown 13% more procedures were carried out than the same period in 2019. Conclusion. Requirements for hand trauma surgery remain high during a pandemic lockdown. Attendances and surgical requirements can be expected to steadily return to normal levels during a prolonged lockdown period. Throughout any future lockdown period adequate surgical provision must be maintained for patients with hand injuries. Cite this article: Bone Joint Open 2020;1-10:639–643

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

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

Background: The purpose of this study is to evaluate the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with 3-dimensional imaging (SIREMOBIL ISO-C-3D) in trauma surgery. Patients & Methods: Between November, 2004 and September, 2005, the ISO-C-3D was used at our institution for intraoperative CT-quality visualization of 33 trauma cases with the fractures of calcaneus (13), tibial plateau (7), tibial plafond (6), acetabulum (4), distal radius (2) and talus (1). The mean patient age was 42 and male to female ratio 25 to 8. In 30 cases ISO-C-3D was used during the surgery after the reduction and fixation of the fracture to assess the accuracy of reduction and implant position prior to wound closure and in 3 cases the device was used before starting the operation to obtain real-time CT images which were transferred to a navigation system to perform computer navigated procedures. Results: This novel technique was highly beneficial from 4 aspects; intraoperative diagnosis, proper reduction, correct implant placement and feasibility in combining the CT images to computer navigation. In 40% of the cases (13/33) who had no regular CT scan before the surgery, intraoperative three dimensional imaging with ISO-C-3D has been a superior modality in diagnosis. In one case the reduction and implant position was corrected during the surgery after the ISO-C-3D scan. In all the procedures with ISO-C-3D navigation, satisfactory reconstruction of the articular surfaces with precise fixation was achieved. Conclusion: Intraoperative 3-dimensional visualization with ISO-C-3D provides useful information in trauma surgery which enables the surgeon to re-evaluate the injury diagnostically and to judge the reduction and implant position before wound closure. Combining the ISO-C-3D images with computer navigation makes the reduction and implant placement highly accurate

Complication rates are an increasingly topical issue. Figures are widely published in elective surgery. We were unable to find any overall rates published solely for trauma surgery involving metal implants. We wanted to identify our overall rate as a matter of good practise and to produce a figure for others to compare against. We wanted to identify the overall infection rate and study those infections in terms of fracture healing, implant survival and chronic soft tissue infection. A wound infection was any wound where there was a positive culture, prolonged pus drainage with or without a sinus or presence of pus at further surgery with or without a positive culture. Metal implants were any metalwork covered primarily or secondarily with soft tissue. 708 implants were inserted over the 11 month period studied. The causative organism was staphylococcus aureus in 65% of cases and a third of these were MRSA. Other organisms included coliforms, acinobacter, pseudomonas and bacillus. Of 52 patients who had a wound infection, 6 (11.5%) had no treatment with no detrimental effect, 34 patients had antibiotics alone and 27 had no further problems. 2 died from sepsis related causes, 3 died from other causes, 1 had delayed union but no evidence of continuing infection and 1 had chronic soft tissue discharge but bony union. 12 patients had further surgery and antibiotics. 6 retained their metal work and of these 3 died from sepsis related causes, 1 had no further problems, 1 tibial nailing became a chronic discharging osteomyelitis and 1 olecrannon fracture became an uninfected non-union. For the 6 patients who had their metalwork removed 2 died, 1 from sepsis, 2 had successful revisions and 2 were continuing treatment at most recent follow-up. Conclusion: overall deep wound infection rate was 7.3%. Most deep wound infections were treated with antibiotics alone with a satisfactory outcome. Re-operation rate for deep wound infection was 1.7%. There is very little information available on overall deep wound infection rates for implants in trauma surgery; we offer our findings as a comparison for future reference

Introduction: Trauma surgery creates enormous mental stress for operating surgeons, especially in trainees. This is responsible for sympathetic hyperactivity which can be measured by various cardio vascular variables. Air Traffic control is recognised as one of the most stressful occupations with accepted risks and incorporated remedies. We compared the stress during surgery with that experienced by air traffic controllers. Materials & Methods: The study included 40 trainee doctors. We obtained multiple readings of heart rate, diastolic and systolic Blood Pressure with ambulatory monitoring methods when they operated. This was compared to their resting measurements obtained at home. Similar measurements were performed for Air Traffic controllers, while at work and at home. Results: The heart rate and blood pressure were increased at the beginning and during surgery. Student t test was applied to compare the mean values obtained intra-operatively and in resting conditions. This suggested the increase to be statistically significant. This increase in autonomic function variables was compared with the values similarly obtained for Air Traffic Controllers. Operating surgeons manifested significant increase in comparison to the other group. Discussion: Stress can not be eliminated but can be over come with experience. Recurrent sympathetic hyperactivity may contribute to various stress related ailments. As in Air Traffic controllers, stress should be accepted as integral part of occupation. Stress relieving manoeuvres should form an important part of surgeons’ occupational health and medical school/ foundation years curriculum. Conclusions: Surgeons experience more emotional and mental stress than occupations accepted to be most stressful

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving. We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02). We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures

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

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy.

300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:

Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs.

Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D.

This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance.

Aims

Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service.

Objective. To investigate the effects of trauma and fracture surgery on leukocyte maturation and function. Background. Unbalanced inflammation triggered by trauma has been linked to multiorgan dysfunction (MOD) and death. In animal and cellular models, changes in neutrophil function and failure of monocyte infiltration and resolution have been implicated as possible causes. The investigators combine assays on neutrophil function with surface antigen expression on circulating neutrophils and monocytes. These are correlated with severity of traumatic injury, type of surgery and clinical outcome to help explain the aetiology of distant organ injury, and pose a case for damage control surgery. Results. A total of 20 patients requiring internal fixation of femoral shaft fractures, acetabular fractures and pelvic fractures were recruited. Those undergoing surgery following an interval period were used as control, with blood and plasma samples pre-operatively, and 2 and 5 days post-operatively, whilst patients with acute trauma also had an admission sample. Using flow cytometry, the neutrophils were gated on CD15+ CD14- with high side scatter whilst the monocytes were gated on CD14+ CD15- with low side scatter. Two days following surgery the neutrophils showed reduced CXCR2 expression and increased CXCR1, CD11b and IL-6R expression whilst the monocytes showed reduced CCR2 and HLA-DR receptor expression. The change in receptor expression was enhanced in the trauma patients in comparison to the control patients, and correlated with cellular function, using respiratory burst, elastase release and transmigration assays. Conclusions. This first human trial evaluating the immunologic/anti-inflammatory effects of trauma and trauma surgery on the specific antigen expression helps explain one mechanism for organ damage in the post-trauma patient

The surgical community is plagued with a reputation for both failing to engage and to deliver on clinical research. This is in part due to the absence of a strong research culture, however it is also due to a multitude of barriers encountered in clinical research; particularly those involving surgical interventions. ‘Trauma’ amplifies these barriers, owing to the unplanned nature of care, unpredictable work patterns, the emergent nature of treatment and complexities in the consent process. This review discusses the barriers to clinical research in surgery, with a particular emphasis on trauma. It considers how barriers may be overcome, with the aim to facilitate future successful clinical research.

Cite this article: Bone Joint Res 2014;3:123–9.

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device.

The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (α = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment.

This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

Graphene is a two-dimensional structure that is made of a single-atom-thick sheet of carbon atoms organised in hexagonal shapes. It is considered to be the mother of all graphite or carbon-based structures. It has shown exceptional physical and chemical properties which possess potential future applications. Graphene has an elasticity index similar to rubber and a hundred times tensile strength of steel and is even sturdier than diamonds. It is a very efficient biosensor with its exceptional electronic conductivity far greater than even copper. It is a potential future low cost material and its scalable production ability makes it even more attractive. The rediscovery of Graphene in 2008 saw few potential medical applications, specifically in the field of drug delivery, gene and cancer therapy.

Nao graphene has extensive thermal conductivity and reflexivity, which can conceivably change imaging especially muskeloskeletal imaging and notably as a contrast material. It has been found to be a safe and a cheaper IV contrast agent in USA in 2012. Being an efficient biosensor especially in conducting electricity, it could assist in prosthetic and bionic limbs or prosthesis. Its durable stubborn properties, a composition which exceeds the strength of steel and light weight structure may create a potential material to develop into a new generation of a low profile internal fixing devices like plats. Most importantly, its scaffolding cell culturing assets could change the whole concept of prosthesis from mechanical press fit fixation to more dependence on bio adhesiveness.

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery.

The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures.

Introduction

Four weeks after the earthquake in Kashmir, multidisciplinary surgical teams were organised within the UK (MiST). The aim was to help with disaster victims who had been transferred to Rawalipindi. We reviewed the work carried by one such team from the 5-18 November 2005.

Background: The experimental use of maggots (sterile larvae of Lucilia sericata) can prevent the amputation of an extremity in case of severe infection after trauma injury. Maggots destroy bacteria by secreting enzymes such as tryptase, peptidase and lipase. An alkaline environment is created by the secretion of allantoin, ammonia and calcium carbonate, which reduces bacterial growth and stimulates new formation of granulation tissue.

Material and Methods: In the period 4.1999–12.2003 42 patients (mean age 54 yrs (25–83), were included in cur prospective study for maggot treatment of severe infections after trauma (Osteomyelitis n=26, lower leg 13x, femur 6x, pelvis 4x, upper extremity 3x), necrotizing fasciitis n=7, soft tissue infection n=3, gangrene n-3, ulcus cruris n=3). Maggots were applied to the wound in a polyvinyl alcohol bag (Biobag) and were replaced every 3–4 days.

Results: The mean duration of treatment was 32,1 days (n~37) for the patients who had received one continuous treatment and 62,2 days if more treatments were applied (n=5). The average number of biobag changes per patient was 11.5 (range 4–30); the average number of maggots applied per patient was 863 (range 80–6840). In only 1 patient with osteomyelitis a lower leg amputation was necessary (1/26=3.8%) although in almost patients there was severe (multiple) co morbidity.

Conclusion: In our study the experimental use of maggots could reduce the amputation rate of limbs in case of severe infections after trauma. Our laboratory research investigations with analysis of the secreting enzymes of maggots will be presented to support that this «ancient» method has a place in modern traumatology to diminish invalidating amputations.