Aims. To assess the impact of the declaration of the state of emergency due to the COVID-19 pandemic on the number of visits to a traumatology emergency department (ED), and on their severity. Methods. Retrospective observational study. All visits to a traumatology ED were recorded, except for consultations for genitourinary, ocular and abdominal trauma and other ailments that did not have a musculoskeletal aetiology. Visit data were collected from March 14 to April 13 2020, and were subsequently compared with the visits recorded during the same periods in the previous two years. Results. The number of visits dropped from a mean of 3,212 in 2018 to 2019 to 445 in 2020. Triage 1 to 3 level visits rose from 21.6% in 2018 to 2019% to 40.4% in 2020, meaning a reduction in minor injury visits and an increase in major ones. There was a relative reduction of 13.2% in femoral fractures in the elderly. The rate of justified visits rose from 22.3% to 48.1%. Conclusion. A marked drop in the total number of visits to our traumatology ED was observed, as well as a relative increase in major injury visits and a relative fall in the minor ones. Cite this article: Bone Joint Open 2020;1-10:617–620

Aims

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support.

Aims. In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs. Methods. In this retrospective cohort study, patients were included if a radiologist diagnosed a fracture on a radiograph requested by the GP from August to October 2019 (control group) or August to October 2020 (research group), on weekdays between 8.30 am and 4.00 pm. The study compared various outcomes between groups, including the length of the initial hospital visit, frequency of hospital visits and medical procedures, extent of imaging, and healthcare expenses. Results. A total of 634 patients were included. The results show a median reduction of 25 minutes in duration of initial hospital visits, one fewer hospital visit, overall fewer medical procedures, and a decrease in healthcare costs of €303.40 per patient in the research group compared to the control group. No difference was found in the amount of imaging. Conclusion. The implementation of the new care pathway has resulted in a substantial reduction in healthcare use and costs. Moreover, the pathway provides advantages for patients and helps prevent crowding at the ED. Hence, we recommend immediately referring all minor trauma patients to the traumatology OC instead of the ED. Cite this article: Bone Jt Open 2023;4(10):728–734

Patient safety is a major concern worldwide, but particularly high rates of adverse events are reported in the surgery setting. Orthopaedic and Traumatology is the speciality most frequently involved in claims in Catalonia. The objective of the study is to perform a descriptive study of the claims regarding infection in Orthopaedic and Traumatology in Catalonia. We performed a retrospective study of the claims regarding infection in Orthopaedic and Traumatology from the prospective claims database of the Service of Professional Liability of The Catalonian Council of Official Colleges of Physicians. The time frame of data collection was from 2003 to 2013. We analyzed both the clinical and legal characteristics of the cases. During the 10-year period, 638 registered claims were related to the practice of Orthopaedic and Traumatology, and 74 (11,6%) were due to infection. The most frequent surgical procedure involved were arthroplasty (knee, hip or shoulder) (14, 18,9%), traumatic wounds and cellulitis (12, 16,2%), spine procedures (10, 13,5%) and arthroscopy (7, 9,4%). The most frequent anatomical site involved were foot and ankle (17, 22,9%), spine (15, 20,3%), knee (14, 18,9%), wrist and hand (11, 14,8%). The 68,92% of claims was solved by the courts and 29,73% by an “out-of-court” procedure. The average compensation in cases considered to have professional liability was 145.045€. Orthopaedic and Traumatology seem to be a specialty with a high risk for claims, and infection is one of the most important causes. The study of the claims can lead to improvements in prophylaxis, diagnosis and treatment of infection in Orthopaedic and Traumatology

Introduction: Fracture of the osteoporotic hip is more common in people over the age of 74. Purpose: To describe the co-operation between traumatologists and geriatric physicians in treating hip fractures among the elderly. Materials and methods: Prospective study covering the number of referrals from Traumatology to Geriatrics in one year. We obtained data on age, sex, type of fracture and surgery, geriatric assessment and repercussion of this activity on the hospital. Results: Over a period of 7 months in 2004, 120 patients were referred to Geriatrics, with a predominance of women and most with hip fractures. The intervention of the Geriatric Department consisted of detecting and compensating prior pathologies, adjusting medication, studying the fall, assessing the surgical risk and preparation for surgery, pain treatment, management of post-surgical complications (anaemia, malnutrition, pressure ulcers, infections, heart failure, etc.), early weight-bearing, detecting social risk and planning release from hospital. The repercussion of this work on the hospital translated into greater satisfaction among traumatologists, nursing staff and patients, more conditions diagnosed and treated and more complete release reports, thus improving ongoing care and shortening hospital stays. Conclusions: Collaboration between the Traumatology and Geriatric Departments in treating geriatric patients admitted to Traumatology is cost-effective because it prevents complications, rationalises treatment, improves the patients’ functional status and shortens hospitalisation stays

Purpose: To determine the degree of burnout among resident physicians in orthopaedic surgery and traumatology departments in Spanish hospitals and the influence of various factors. Materials and methods: Descriptive crossover study. The study population included all the resident physicians in orthopaedic surgery and traumatology departments in Spain. We sent an anonymous self-administered questionnaire, the Maslach Burnout Inventory, which assesses emotional exhaustion, depersonalisation and personal accomplishment, in addition to a number of sociodemographic, occupational and personal variables by means of a questionnaire. Results: Replies were received from 63 orthopaedic surgery and traumatology resident physicians (8%). 47.6% of the participants presented a high degree of emotional exhaustion, 66.6% a high degree of depersonalisation and 38.1% a low degree of personal accomplishment. Among the variables studied we found a high degree of burnout related, among others, to female sex, poor department organisation, little appreciation of the resident’s work and little free time for family. 32.8% of the respondents would choose the same medical specialisation but in a different hospital, as compared to 62.3% who would choose the same specialisation and the same hospital. Conclusions: The levels of burnout among resident physicians in orthopaedic surgery and traumatology departments in Spain are higher than among associate physicians in the same departments in Spain and than those found in two earlier studies among primary care physicians in Spain and among several medical specialisations internationally. Training activities are needed to alleviate this problem

Purpose: We report the results of a study using fluoronavigation for distal locking of tibial and femoral nails and for screw fixation of femoral neck fractures in adults. We compared the duration of radiation exposure with the manual methods. Material and methods: Among a cohort of 220, 32 were selected randomly for the distal locking or cervical screwing using fluoronavigation. The series included 22 tibial nails, 3 femoral nails, and seven femoral neck fixations. The Medtronic ION navigation system was used. The computerised system recognises the relative spatial positions of the patient, the fluoroscope and the instrument. Data are transmitted via an optical camera. Results: We noted overall operative time and duration of radiation exposure by type of fracture. The duration of fluoroscopy ranged from 0.6 to 1.4 minutes for a tibial nailing using the conventional technique and 0.5 to 1 minute with fluoronavigation. For triple screwing, the fluoroscopy time was 1 minute 25 seconds. A total of 73 screws were inserted: 72 in correct position (one patient moved during the intervention). There were no nosocomial complications and no cases of compartment syndrome. Discussion: Repeated exposure to x-rays can be a limiting factor for locked nailing. It takes only a short time to install the material and learn the software. During this first experience, the already short radiation exposure was divided in half despite the fact that each screw was controlled separately, which with experience would not be necessary. Improvements in the software will allow controlling the rotation of the limb and avoid length discrepancies. Conclusion: In the traumatology unit, fluoronavigation is not a gadget to produce unnecessary virtual images. On the contrary, it improves safety for both the patient and the surgical team. This study demonstrates that patients can benefit from less radiating minimally invasive surgery allowing more precise insertion of the locking screws to avoid material failure. Future developments should improve the quality of the anatomic results of locked nailing and allow wider indications

1. The history of microvascular surgery is reviewed; the necessary instruments and the technique of suture are described. 2. Modern trends in the experimental and clinical applications in orthopaedic surgery and traumatology are discussed. 3. The authors emphasise the usefulness of this technique in tissue transplantation and in the reconstruction of microvascular injuries of the musculoskeletal system

Introduction. Trabecular bone score (TBS) is a parameter of bone microarchitecture that is determined by the level analysis of DXA images. TBS is associated with fractures in the preliminary case-control and prospective studies. The aim of this study was to assess the TBS role in the traumatology and orthopedics. Materials and methods. We've examined 176 healthy women aged 40–79 years (mean age – 53.4±0.6 yrs) and 117 men aged 40–79 years (mean age – 59.8±0.9 yrs). Bone mineral density (BMD) of whole body, PA lumbar spine and proximal femur were measured by DXA method (Prodigy, GEHC Lunar, Madison, WI, USA) and PA spine TBS were assessed by TBS iNsight® software package installed on the available DXA machine (Med-Imaps, Pessac, France). Results. We have observed a significant decrease of TBS as a function of age (F=6.56; p=0.0003) whereas PA spine BMD was significantly increasing with age (F=4.04; p=0.008) in the examined women. This contradiction can be traced to the spinal osteoarthritis and degenerative diseases progressing with age in the elderly patients. TBS was significantly lower in women with duration of PMP over 4 yrs (p=0.003) in comparison with women without menopause; BMD of spine significantly decreased in women with duration of PMP over 7–9 yrs (p=0.02). So, the TBS can detect changes in the state of bone tissue at the earlier stage than BMD. We have observed a significant decrease of TBS in men with ageing (F=2.44; p=0.05). Overall TBS values in men are lower than the age matched TBS values in women. Conclusion. TBS is an independent parameter which has a potential diagnostic value of its own, without taking into account the BMD results. The study concerning patients with osteoporosis and fractures is underway

Osteomyelitis caused by resistant bacterial strains can be dealt with antimicrobial agents which have a different mode of action compared to antibiotics. A very promising appears to be antimicrobial peptides (AMPs). We found and verified in vitro experiments that one of the most effective and least toxic antimicrobial peptides are contained in the wild bee venom. The aim of this study was to verify the efficacy of topically applied, synthetically prepared antimicrobial peptide (Hal 2/27) with carrier, originally isolated from the venom of the wild bee in experiments on laboratory rats. It was used 18 rats, which were indicated osteomyelitis of the left femurs. After a week of six rats were injected calcium phosphate carrier with AMP Hal 2/27, six rats received only a carrier without AMP and six other rats remained without further intervention. After a week, rats were sacrificed and X-ray was performed in all rats limbs. Rats who received carrier with AMP Hal 2/27 had less X-ray evidence of osteomyelitis of femurs compared to rats after administration of the carrier without AMP. Topical application of a new synthetic antimicrobial peptides isolated from wild bee venom (Hal 2/27) using local carriers seems to be a promising way to treat and prevent infectious complications in orthopedics and traumatology. Internal grant of University Hospital Motol, Advanced Therapies, NO: 9777 and Internal grant of University Hospital Motol, NO 6010

Purpose: With the growing risk of nosocomial infections, one might expect to see a reinforcement of septic isolation wards in orthopaedics and traumatology units. The question is however being revisited because of several factors. 1st: General Orthopaedics Units are practically the only hospital units caring for a minority of septic patients with often resistant germs and a majority of non-septic patients in the same setting. 2nd: The growing number of single-patient rooms procures confidence (whether justified or not). 3rd: Hygiene specialists are particularly wary of occult carriers of resistant bacteria and apply a single set of protective measures for all patients. 4th: Economic performance is given priority. Material and methods: We studied 1) the current situation in Orthopaedic units in University Hospitals in France and 2) the statistics from the Besançon University Hospital Hygiene Unit and from data in the literature. Results: 1) Interrogation of the 71 University Orthopaedics Units in France revealed that: 11 units have strict isolation wards; 40 have incomplete isolation wards; 20 make no distinction between septic and non-septic patients. 2) According to the Hygiene Unit statistics, the epidemiological load of S. aureus meti-R (SAMR), strains often implicated in orthopaedic infection, is much higher in the University Hospital polyvalent wards than in the Orthopaedic septic ward. Contamination between septic patients is low. Furthermore, hand-borne and airborne contamination are not controlled in wards other than septic wards. Data in the literature are not in agreement concerning this new trend in prevention by isolation. Discussion: a) One argument retained by all is that septic wards have an advantage in terms of efficacy and concentration of preventive measures. b) The growing workload in mixed units hinders strict application of preventive measures. c) A large number of temporary personnel (trainees, temporary employees, personnel untrained in sepsis prevention) are present in polyvalent units. d) Standardisation of preventive measures leads to an average level of prevention which lengthens the duration of care for non-septic patients and simplifies care for septic patients. e) The financial argument is impertinent compared with the consequences of contamination. Furthermore, a departmental structure would allow common use of the septic ward. Conclusion : Septic isolation wards (or a septic department) should be preserved. The orthopaedic surgeon, as a responsible actor in the fight against nosocomial infections, should in concert with the consulting hygienist, oppose purely administrative decisions

Purpose of the study: Dementia in the elderly subject aged over 75 years is currently an important public health problem. An important part of the activity in orthopaedic surgery involves this age group. In 2007, 16,812 elderly persons aged over 75 years were hospitalised in our University Hospital (769 in orthopaedic surgery): 1380 patients were considered demented (40 in orthopaedic surgery). The purpose of this work was to evaluate the cognitive function of this population in a teaching hospital unit of orthopaedic and traumatology surgery where the prevalence of dementia appears to be underestimated. Material and methods: Data were collected over a period of four years. This study concerned 113 patient, including 83 women, mean age 81.8 years (range 75–92). The reason for hospitalisation was predominantly fracture of the proximal femur (73%); thirty patients had hip, knee or shoulder arthroplasty and 24 other situations. The Mini Mental State Examination (MMSE) was performed. Results: The MMSE could be interpreted for 100 patients: < 24 for 33, 24 to 26 for 29 and > 27 for 38. Among the 24 patients with no cognitive disorder known before hospitalization (nine patients known to be demented were removed from the analysis) and for whom the MMSE was completed entirely, the most frequent alterations were noted for attention, calculation, and recall-memory items. Discussion: Finally, one-third of the subjects aged over 75 years and hospitalized in our unit presented signs of altered cognitive function according to the MMSE(< 24). This score is one of the criteria for frailness of the elderly subject. This population has an unstable precarious medicosocial status with defective adaptation to stress and change in environment. These persons are exposed to a high risk of morbidity, mortality, dependence, longer hospital stay and institutionalization. The purpose of this screening is to improve management for these patients by proposing more specifically adapted care. Conclusion: It is thus indispensable to screen for cognitive disorders systematically in patients aged over 75 years hospitalized in a surgery unit. The MMSE score can be used for this purpose. This work is in favour of a physician or better a geriatrician within the unit who could be financed directly by his-her own sector of activity

Despite biomechanical well established implants and improved operation techniques we still have a too high rate of complications in orthopaedic and trauma surgery like non-union, implant loosening or implant associated infections. The development of bioactive implants could improve the clinical outcome.

Growth factors are important regulators of bone metabolism. During fracture healing many growth factors or cytokines were locally released at the facture site. In several studies, different growth factors demonstrated osteoinductive and fracture stimulating properties.

In vitro and in vivo studies showed a stimulating effect of Insulin-like growth factor-I (IGF-I), Transforming growth factor-A71 (TGF-A71) and Bone morphogenetic protein-2 (BMP-2) on osteo- and chondrogenetic cells. The exact effectiveness and the interaction of these growth factors during fracture healing is not known so far. Further, the local application of these factors for therapeutically use in fracture treatment is still a problem.

A biodegradable poly(D,L-lactide)-coating of implants allows the local and controlled release of incorporated growth factors directly at the fracture site. The coated implant serves on the one hand for fracture stabilization and on the other hand as a drug delivery system. The coating has a high mechanical stability. The incorporated growths factors remain biologically active in the coating and were released in a sustained and controlled manner.

To investigate the effect of locally released growth factors IGF-I, TGF-A71 and BMP-2 and the carrier PDLLA on fracture healing, standardised closed fracture models were developed with a close relationship to clinical situation. Further, possible local and systemic side effects were analysed.

The results demonstrated a significantly higher stimulating effect of IGF-I on fracture healing compared to TGF-A71. The combined application of both growth factors showed a synergistic effect on the mechanical stability and callus remodeling compared to single treatment.

The local release of BMP-2 also enhanced fracture healing significantly – comparable to combination of IGF-I and TGF-A71. However, a higher rate of mineralisation was measurable outside the fracture region using BMP-2 in a rat fracture model.

Using a large animal model on pigs with a 1 mm osteotomy gap, the effectiveness of locally released growths factors could be confirmed. Further, the PDLLA-coating without any incorporated growth factors demonstrated a significantly effect on healing processes in both models. These investigations showed, that the local release of growth factors from PDLLA coated implants significantly stimulate fracture healing without any local or systemic side effects.

Comparing systemic with local stimulation techniques, we found an improvement of fracture healing by systemic administration of growth hormone and local application of IGF-I and TGF-A71. However, the combined use of both simulation techniques did not lead to a further increase of healing processes.

Investigations on the effectiveness and the interaction of growth factors during fracture healing demonstrated an dramatic effect in the early phases of healing processes. The growth factors stimulate the differentiation of osteoblasts with a higher production of collagen I in vitro and increase osteogenesis and vascularisation of the fracture callus in vivo.

Further applications of the coating technology are the use of PDLLA and growth factor coated cages for the stimulation of intervertebral fusion and the use of PDLLA and Gentamicin coated implants in order to prevent implant associated infections.

The first patients with open tibia fractures were treated with PDLLA and Gentamicin coated IM nails.

Purpose of the study: We describe a surgery navigation system based on virtual fluoroscopy images established with a 3D optic localizer. The purpose of this work was to check the accuracy of the system for posterior spinal implants in comparison with conventional surgery. Duration of radiation and duration of surgery were compared.

Material and methods: A 3D optic localizer was used to monitor the position of the instruments in the operative field, as well as the fluoroscopy receptor. The surgeon took two views, ap and lateral, with a total exposure of two seconds. The C arm was then removed. After image correction, the ap and lateral views were displayed on the work station screen where the computer superimposed to tools on each image. Twenty osteosynthesis procedures for implantation of pedicular screws via a posterior approach to the thoracolumbar spine were performed with this virtual fluoroscopy technique (20 patients, 68 screws). During the same study period, twenty other procedures were performed with the conventional technique (ap and lateral x-ray with the C-arm after drilling the pedicle, 20 patients, 72 screws). The position of the spinal implants was compared between the two series on the ap and lateral views and postoperative CT. Similarly time of exposure to x-rays and duration of the surgical procedure were recorded.

Results: The rate of strictly intrapedicular implantation was less than 8% (5/68 screws) in the virtual fluoroscopy series versus 15% (11/72 screws) in the conventional series. Time of exposure to radiation was significantly lower in the virtual fluoroscopy series with a 1 to 3 improvement (3.5 s versus 11.5 s on average) over the conventional method. With training, this method is not more time consuming (10 min per screw for the conventional method versus 11.25 min for virtual fluoroscopy).

Discussion and conclusion: Compared with conventional fluoroscopy, the virtual technique enables real time navigation while significantly reducing the dose of radiation, both for the patient and the surgery team. There are two types of advantages of virtual fluoroscopy over CT-based systems: first virtual fluoroscopy is immediately available without specific preoperative imaging and secondly it provides real non-magnified images acquired once during the procedure, after which the C-arm is removed. 3D virtual fluoroscopy is probably the next step but requires further experience.

Aims: This presentation deals with our clinical experience based on experimental studies when using bioabsorbable fixation devices in bone, joint and ligament surgery. These devices were clinically introduced by us in the treatment of fractures in the extremities in the mid – 1980’s. Our own list of publications consists of 1137 publications since 1978 including, 26 academic dissertations. Before and during our clinical studies over 6500 animals were operated on in our experimental studies. Macroscopic, radiographic, microradiographic, histologic, histomorphometric and fluorochrome studies were done. Methods: The strength, strength retention, degradation, bone changes, healing of fractures, and injuries, and the fixation properties of the implants were investigated in vivo. Results: In Kuopio (814) and in Helsinki (3555) 4369 operations were done using bioabsorbable self-reinforced (SR) fixation implants mainly polyglycolide or poly-L-lactide during 1984–2001. In Helsinki there were 2766 trauma operations and 789 orthopaedic operations. The postoperative clinical course was uneventful in 82% of the patients. The complications included wound infection in 4.0%, failure of fixation in 3.9%, a non-infectious foreign-body reaction (sinus) in 1.9% (with SR-polyglycolide implants) but not with SR-polylactide implants. Conclusions: Due to the biodegradibility of the devices, implant removal procedures were avoided.

Compartment syndrome (CS), a serious complication in paediatric trauma, can be prevented by timely diagnosis and adequate therapy.

From 1990 to 2000 we treated 22 patients with suspected CS in the arm. Incision into the intrafascial spaces of nine forearms and three hands confirmed the diagnosis. In 10 patients, fracture had caused the syndrome, and in two, the cause was contusion. In two patients the CS resulted from incorrect treatment procedures.

We also treated 22 patients with suspected CS in the lower limb. The diagnosis was confirmed in 15. Incision into the intrafascial spaces was performed during treatment, 13 times on the crus and twice on the femur. Fractures were always the primary cause.

In the upper limb outcomes were good. One patient developed a Volkman’s contracture but this was only disfiguring. Some patients treated for lower limb CS had cosmetic after-effects, but only one patient, in whom CS was diagnosed late, had functional after-effects.

We advocate permanent monitoring of intrafascial pressures, using piezoelectric sensors, and timely performance of adequate dermofasciotomies.