Purpose

Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI.

Aims

The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care.

Aims

The aim of this study was to compare the cost-effectiveness of treatment with an osseointegrated percutaneous (OI-) prosthesis and a socket-suspended (S-) prosthesis for patients with a transfemoral amputation.

Aims

This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Aims

This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures.

Aim

There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients.

Aims

To evaluate interobserver reliability of the Orthopaedic Trauma Association’s open fracture classification system (OTA-OFC).

Aims

The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip.

Aims

The aim of this study was to investigate the effect of a posterior malleolar fragment (PMF), with < 25% ankle joint surface, on pressure distribution and joint-stability. There is still little scientific evidence available to advise on the size of PMF, which is essential to provide treatment. To date, studies show inconsistent results and recommendations for surgical treatment date from 1940.

Aims

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

Aims

To synthesise the literature and perform a meta-analysis detailing the longitudinal recovery in the first two years following a distal radius fracture (DRF) managed with volar plate fixation.

Aims

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

Limb length deficiency, secondary to trauma or infection, is a common reason for referral to our tertiary service. After experiencing troubles with the Intramedullary Skeletal Kinetic Distractor (ISKD), we changed implant to the magnet operated Precice nail. We evaluated the safety and reliability of this novel device and compared it to our early ISKD results.

To minimise variables, we selected femurs only. In total, we reviewed medical and radiographic records of 20 cases (8 ISKD, 12 Precise) from 2010–2015. At each postoperative visit, the accuracy and precision of distraction and complications were recorded. Accuracy reflected how close the measured lengthening was to the prescribed distraction at each postoperative visit. Precision reflected how close the repeated measurements were to each other over the course of total lengthening period. No patients were lost to follow-up (1–3.5 years).

With the Precice nail (2012–2015), 11/12 were male and 10/12 were caused by trauma. The mean age was 34. Mean total lengthening was 38mm (range, 29–53mm), with an accuracy of 98percnt; and precision of 92percnt;. All patients achieved target lengthening at a rate of 1mm lengthening per day. In one case, the Precice nail fractured and this was revised successfully. With the ISKD group (2010–2012), 8/8 had complications (magnet jamming, nail breakage, equinus contractures and claw toes), with 25percnt; achieving accurate lengthening and precision of 38percnt;.

Our results so far have justified our change in implant choice and, in our experience, support the Precice nail as being safe and precise.

High tibial osteotomy (HTO) is a common procedure for treating medial compartment knee arthritis. The main goal is to reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral compartment and thus delaying the need of total knee replacement (TKR) by slowing or stopping destruction of medial compartment.

Between 2002 and 2010, 34 HTO's were carried out in 32 patients (Mean age 44.2). Results were reviewed in 23 patients with an average follow-up of 10.2 years (range 6–14 years). Oxford knee score (OKS) assessment was carried out on those patients. Of the remaining 11 patients, one was excluded, 2 were lost to follow-up, and 2 had died. Five cases had TKR at an average 8.8 years since having HTO.

OKS results revealed nine cases (39.1percnt;) scored (40–48) which indicate satisfactory joint function and don't require treatment. Three cases (13percnt;) scored (30–39) indicating mild to moderate arthritis. Six cases (26.1percnt;), scored (20–29) indicating moderate to severe arthritis. Five cases (21.8percnt;) scored (0–19) indicating severe arthritis.

Only five patients (14.7percnt;) had TKR (6–14) years after there HTO. The majority of cases had an OKS suggesting satisfactory joint function. Even those with scores suggesting moderate to severe arthritis were able to function normally for more than 6 years.

The successful outcome of HTO can be maintained for more than 6–16 years. We conclude that HTO should be recommended for the treatment of medial compartment arthritis of the knee in young and active patients for symptomatic improvement and maintenance of activity levels.

Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence surgical outcome following Morton's neuroma excision.

Over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively. Patient demographics were recorded in addition to co-morbidities, deprivation, associated neuroma excision and other forefoot surgery.

Obesity, deprivation and revision surgery proved to statistically worsen MOXFQ outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). Deprivation significantly worsened the mental component of the SF12 (p=0.043) and depression the physical component (p=0.026). No difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5percnt; of deprived patients were dissatisfied with their surgery compared to 7percnt; of the remaining cohort.

Patient reported outcomes following resection of symptomatic Morton's neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. Surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome.

Osteoporosis is a major healthcare burden, responsible for significant morbidity and mortality. Manipulating bone homeostasis would be invaluable in treating osteoporosis and optimising implant osseointegration. Strontium increases bone density through increased osteoblastogenesis, increased bone mineralisation, and reduced osteoclast activity. However, oral treatment may have significant side effects, precluding widespread use. We have recently shown that controlled disorder nanopatterned surfaces can control osteoblast differentiation and bone formation. We aimed to combine the osteogenic synergy of nanopatterning with local strontium delivery to avoid systemic side effects.

Using a sol-gel technique we developed strontium doped and/or nanopatterned titanium surfaces, with flat titanium controls including osteogenic and strontium doped media controls. These were characterised using atomic force microscopy and ICP-mass spectroscopy. Cellular response assessed using human osteoblast/osteoclast co-cultures including scanning electron microscopy, quantitative immunofluorescence, histochemical staining, ELISA and PCR techniques. We further performed RNAseq gene pathway combined with metabolomic pathway analysis to build gene/metabolite networks.

The surfaces eluted 800ng/cm2 strontium over 35 days with good surface fidelity. Osteoblast differentiation and bone formation increased significantly compared to controls and equivalently to oral treatment, suggesting improved osseointegration. Osteoclast pre-cursor survival and differentiation reduced via increased production of osteoprotegrin. We further delineated the complex cellular signalling and metabolic pathways involved including unique targets involved in osteoporosis.

We have developed unique nanopatterned strontium eluting surfaces that significantly increase bone formation and reduce osteoclastogenesis. This synergistic combination of topography and chemistry has great potential merit in fusion surgery and arthroplasty, as well as providing potential targets to treat osteoporosis.

Prophylactic fixation of the contralateral hip in cases of unilateral slipped capital femoral epiphysis (SCFE) remains contentious. Our senior author reported a 10 year series in 2006 that identified a rate of subsequent contralateral slip of 25percnt; when prophylactic fixation was not performed. This led to a change in local practice and employment of prophylactic fixation as standard. We report the 10 year outcomes following this change in practice.

A prospective study of all patients who presented with diagnosis of SCFE between 2004 and 2014 in our region. Intra-operative complication and post-operative complication were the primary outcomes. 31 patients presented during the study period: 16 male patients and 15 female patients. The mean age was 12.16 (8–16, SD 2.07). 25 patients had stable SCFE and 5 had unstable SCFE. Stability was uncertain in 1 patient. 25 patients had unilateral SCFE and 6 had bilateral SCFE. 24 patients who had unilateral SUFE had contralateral pinning performed. 1 unilateral SCFE did not have contralateral pinning performed as there was partial fusion of physis on contralateral side.

In the hips fixed prophylactically there was 1 cases of transient intraoperative screw penetration into the joint and 1 case of minor wound dehiscence. There were no cases or chondrolysis or AVN. There were no further contralateral slips. This change in practice has been adopted with minimal complication. The fixation of the contralateral side is not without risk but by adopting this model the risk of subsequent slip has been reduced from 25percnt; to 0percnt;.

Laminar airflow systems are universal in current orthopaedic operating theatres and are assumed to be associated with a lower risk of contamination of the surgical wound and subsequent early infection. Evidence to support their use is limited and sometimes conflicting. We investigated whether there were any differences in infection rates (deep and superficial) between knee and hip arthroplasty cases performed in non-laminar and laminar flow theatres at 10 year follow-up.

Between 2002 and 2006, 318 patients underwent knee and hip arthroplasty in a non-laminar flow theatre. Prospectively collected local arthroplasty audit data was collected including superficial and deep infection, revision for infection and functional outcomes. A cohort of patients from the same time period, who underwent knee and hip arthroplasty in a laminar flow theatre, were matched for age, sex, body mass index (BMI), operative approach, implant and experience of surgeon.

Superficial infection rates were lower overall in the non-laminar flow theatre (2.2percnt; versus 4.7percnt;), with a significantly lower superficial infection rate for knee arthroplasty performed in the non-laminar flow theatre (2percnt; versus 6.9percnt;). The deep infection rates were similar (1.3percnt; vs 1.9percnt;) for both laminar and non-laminar flow theatre respectively. Revision rates for infection were similar between both groups (0.9percnt; in non-laminar flow theatre vs 0.3percnt; in laminar flow)

Whilst the causes of post-operative surgical site infection are multifactorial, our results demonstrate that at long –term follow-up, there was no increased risk of infection without laminar flow use in our theatre.

The aim of the study was to describe the failure rate of locking plates used for internal fixation of distal femoral fractures and to identify independent predictors of failure.

A consecutive series of 147 patients presenting to the study unit during an 8 year period with a distal femoral fracture were identified from a prospectively compiled trauma database. There were 117 females and 30 males, with a mean age of 70.7 years (13 to 99 years), of which 77 were periprosthetic fractures and 70 were supracondylar fractures around native knees.

There were 35 failures of fixation. The commonest cause was non-union (n=31). The survival of the plate 2 years post-surgery was 74percnt; (95percnt; CI 64percnt; to 84percnt;), which remained static to a mean follow of 5 years. There was no difference in failure of fixation according to gender (p=0.32) or if there was a periprosthetic fracture (p=0.8). Younger age (61.8 vs. 73.6 years, p=0.004), increasing level of comorbidity (p=0.02), and fracture comminution (p=0.001) were all significant predictors of failure of fixation. Cox regression analysis confirmed younger age (p=0.04), increasing comorbidity (p=0.002), and fracture comminution (p=0.002) as independent predictors of failure of fixation and non-union after adjusting for confounding.

The failure of locking plates for distal femoral fractures occurs in more than one in five patients. The independent predictors could be used to identify those patients at greatest risk of failure of the locking plate, who may benefit from alternative methods of fixation, primary bone grafting, or interventions that may aid union.

‘Primum non nocere’ is one of the most well known moral principles associated with the medical profession. Often, in our bid to maintain and improve quality of life, we neglect to recognise those patients who are in fact nearing the end of theirs. Thus, our aim was to ascertain if we are recognising the ‘dying’ orthopaedic patient and whether key elements of management in accordance with SIGN are being addressed.

All hip-fracture deaths occurring at a District General Hospital over a 4-year period (2012–2015) were included. Paper and electronic notes were used to record patient demographics, days from admission to death, diagnosis of ‘dying’ and discussions regarding DNACPR and ceiling of care. Total numbers of investigations undertaken during the week prior to death were noted.

89 hip-fracture deaths occurred between 2012–2015, of which 57 were female with a mean age at death of 84 years. The number of days post-admission to death was 17.5 (range 0–109). 45 patients had a new DNACPR recorded and 13 were longstanding. 43 patients (48.3%) were diagnosed as dying at a mean of 7.2 days following admission, 31 of whom (72.1%) had ceiling of care discussed. Of this cohort, 32 had futile investigations during their last week of life and astoundingly 10 on the day of death.

Although some effort is being made to recognise the ‘dying’ orthopaedic patient, further work is needed to establish a clear ceiling of care pathway, which maintains and respects patient comfort and dignity during their last days of life.

The fingers and thumb are the second most common site for dislocation of joints following injury (3.9/10,000/year). Unlike fractures, the pattern and patient reported outcomes following dislocations of the hand have not previously been reported.

All patients presenting with a dislocation or subluxation of the fingers or thumb were included in this cohort study (November 2008 and October 2009). Patient demographic and injury data were obtained and dislocation pattern confirmed on radiographs. Patient reported outcomes were obtained using the Michigan Hand Outcome Questionnaire (MHQ).

There were 202 dislocations/subluxations recorded. MHQ scores were obtained at 3–5 years for 74percnt; patients. The average age at injury was 40 years, 76percnt; (146) patients were male and 11percnt; (23) injuries were open. 50percnt; (101) of the dislocations were dorsal, 28percnt; (57) were associated with fractures and 4percnt; (9) were recurrent.

There were significant associations between: 1, Direction of dislocation and finger involved (p=0.03); 2, Joint and mechanism of dislocation (p=0.001); 3, Mechanism and direction of dislocation (p=0.008). Older patients had significantly worse outcomes (p<0.001).

This is the first study to assess the epidemiology and patient reported outcomes following dislocation of the fingers and thumb allowing us to better understand these injuries.

The arcOGEN study identified the 9q33.1 locus as associated with hip osteoarthritis (OA) in females. TRIM32 lies within this locus and may have biological relevance to OA; it encodes a protein with E3 ubiquitin ligase activity.

Sanger sequencing of TRIM32 in the youngest 500 female patients with hip OA from the arcOGEN study identified genetic polymorphisms in the proximal promoter, and 3'untranslated region of TRIM32 that are disproportionately represented in female patients with hip OA compared to the control population.

Reduced expression of TRIM32 was identified in femoral head articular chondrocytes from patients with hip OA compared to control patients. Trim32 knockout resulted in increased aggrecanolysis in murine femoral head explants. Murine chondrocytes deficient in Trim32 exhibited increased expression of mature chondrocyte markers following anabolic cytokine stimulation, and increased expression of hypertrophic chondrocyte markers following catabolic cytokine stimulation.

Trim32 knockout mice demonstrated increased cartilage degradation and tibial subchondral bone changes after surgically-induced knee joint instability. Increased cartilage degradation and medial knee subchondral bone changes were also identified in aged Trim32 knockout mice.

These results further implicate TRIM32 in the genetic predisposition to OA, and indicate a role for TRIM32 in the joint degeneration evident in OA. These results support the further study of TRIM32 in the pathophysiology of OA and development of novel therapeutic strategies to manage OA.

Total Hip Arthroplasty (THA) is one of the most successful and cost-effective treatments available for painful hip arthritis. Unfortunately, dislocation following primary THA is one of the most common complications, occurring in approximately 0.50–10percnt; cases. However, there is little literature that investigates the effects that dislocation has on the patient's overall function and satisfaction.

We reviewed 229 THA patients that had sustained dislocation from a prospective database, consisting 156 single dislocations and 73 with two or more. Patient outcomes were compared with a matched control group of 196 patients without dislocation in the same follow-up period. Harris Hip Score (HHS) and patient satisfaction were recorded pre-operatively and at one, five and ten years post-operatively. Mann-Whitney test compared HHS between control and dislocation groups, Chi-Square test compared patient satisfaction and implant survival.

Total HHS and functional component were significantly lower in the dislocation group at one, five and ten years (p<0.05). HHS Pain component revealed a significant difference but only at one and three years (p<0.05). Patient satisfaction only showed a significant difference at one-year review. Dislocation rates were significantly higher in females. Implant survivorship was significantly lower in the dislocation group at 15-years.

Hip-function and implant survival is significantly reduced following prosthesis dislocation, however patient satisfaction and pain levels appear unaffected at long-term follow-up.

Tranexamic Acid (TXA) is widely used to decrease bleeding by its antifibrinolytic mechanism. Its use is widespread within orthopaedic surgery, with level one evidence for its efficacy in total hip and knee replacement surgery; significantly reducing transfusion rates without increased thromboembolic disease. There is limited evidence for its use during hip fracture surgery, and we therefore sought to investigate its effects with a prospective cohort study.

We recorded intra-operative blood loss, pre and post-operative haemoglobin and creatinine levels, post-operative complications and mortality in all hip fracture patients over a six month period. During this time, we introduced one gram of TXA into our standardised hip fracture theatre checklist. It was subsequently given to all patients unless contra-indicated.

A total of 99 patients were included. 90-day mortality in the control group was 16%, there was no mortality in the TXA group (p<0.05). 14 patients required a transfusion in the control group and 3 in the TXA group (19% vs 11% transfusion rate, 0.36 units RCC vs 0.22 per patient respectively) Mean blood loss was 338 vs 235mls, Haemoglobin drop 23 vs 18g/dl control and TXA groups respectively.

We have demonstrated a significantly lower mortality rate with TXA. We have also shown lower rates of transfusion, blood loss and recorded haemoglobin drop with the use of TXA. We intend to continue this study to demonstrate this significantly, and fully clarify the safety profile of TXA in this frail cohort of patients.

The Low Contact Stress (LCS) mobile-bearing total knee replacement (TKR) was designed to minimize polyethylene wear, aseptic loosening and osteolysis. However, registry data suggests there is a significantly greater revision rate associated with the LCS TKR.

The primary aim of this study was to assess long-term survivorship of the LCS implant. Secondary aims were to assess survival according to mechanism of failure and identify predictors of revision.

We retrospectively identified 1091 LCS TKRs that were performed between 1993 and 2006. There was incomplete data available 33 who were excluded. The mean age of the cohort was 69 (SD 9.2) years and there were 577 TKRs performed in females and 481 in males. Mean follow up was 14 years (SD 4.3).

There were 59 revisions during the study period: 14 for infection, 18 for instability, and 27 for polyethylene wear. 392 patients died during follow up. All cause survival at 10-year was 95% (95%CI 91.7–98.3) and at 15-year was 93% (95%CI 88.6–97.8). Survival at 10-years according to mechanism of failure was: infection 99% (95%CI 94–100%), instability 98% (95%CI 94–100%), and polyethylene wear 98% (95%CI92–100). Of the 27 with polyethylene wear only 19 had associated osteolysis requiring component revision, the other 8 had simple polyethylene exchanges. Cox regression analysis, adjusting for confounding variables, identified younger age was the only predictor of revision (hazard ratio 0.96, 95%CI 0.94–0.99, p=0.003).

The LCS TKR demonstrates excellent long-term survivorship with a low rate of revision for osteolysis, however the risk is increased in younger patients.

The aim of this prospective randomized controlled trial was to compare patient reported and functional outcomes, complications and costs for displaced olecranon fractures managed with either tension band wire (TBW) or plate fixation. We performed a registered prospective randomized, single blind, single centre trial in 67 patients aged between 16–74 years with an acute isolated displaced fracture of the olecranon. Patients were randomised to either TBW (n=34) or plate fixation (n=33). The primary outcome measure was the Disability Arm Shoulder and Hand (DASH) score at one-year.

The baseline demographic and fracture characteristics of the two groups were overall comparable. The one-year follow-up was 85percnt;. There was a significant improvement in elbow function over the 12 months following injury in both groups (p<0.001). At one-year following surgery the DASH for the TBW group was not statistically different to the plate fixation group (12.8 vs 8.5; p=0.315). There was no significant difference between groups in terms of range of movement, Broberg and Morrey Score, Mayo Elbow Score or the DASH at all assessment points over the one-year following injury (all p≥0.05). Complication rates were significantly higher in the TBW group (63percnt;vs38percnt;; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50percnt;vs22percnt;; p=0.021).

In active patients with an isolated displaced fracture of the olecranon, no difference was found in the patient reported outcome between TBW and plate fixation at one year following surgery. The complication rate is higher following TBW fixation due to a high rate of symptomatic metalwork removal.

Training time in Trauma & Orthopaedics is pressured. In this action research project, we develop a feedback/self-reflection model for trainers and trainees, emphasising the contribution both groups make to training, to maximise cohesion and efficacy.

Starting in 2013, trainees completed anonymous feedback forms after each 6-month post. The 18-point quantitative questionnaire covers four training domains: WBA engagement, teaching/feedback, research/audit, operative training.

Consultant trainers completed a once-off corresponding 18-point self-reflection questionnaire. Additionally, trainers were asked for their expectations of and advice for trainees.

Individual trainer profiles were generated from trainee feedback questionnaires, allowing comparison between trainer-group-average, trainer-specific and trainer-self-reflection scores across 18 fields. Trainer profiles were uploaded to ISCP and used for recognition of trainer status for SOAR. This data provided basis for local service provision review with amendments to maximise training efficacy.

Results of thematic analysis of trainer feedback was shared with the trainee group. This and subsequent group self-reflection formed the basis of our ‘Trainee Charter’.

Trainee feedback illustrates high levels of satisfaction with local training (average global score 4.2/5). Strengths included ‘feedback’ and ‘operative teaching’; relative weaknesses included ‘research time’ and ‘OPD teaching’.

The ‘Trainee Charter’ details specific desirable behaviours that embody eight trainee-qualities consistently identified by trainers as important, including ‘honesty’ and ‘being organised’. The charter emphasises trainee contribution to training.

For the first time, trainers have the benefit of serial and individualised feedback. Trainees are better informed and empowered in relation to maximising their own training. Most importantly, both halves of the training-team are explicitly acknowledged.

There are concerns regarding the rates and significance of DVT and PE following ankle fracture with published rates of VTEs varying widely. This study aimed to identify the incidence of VTEs in patients with ankle fractures and to compare this to the background risk of VTEs in these patients and the population.

1,283 consecutive patients with ankle fractures presenting to our trauma centre over a twenty-month period were studied prospectively. Patients with conservatively-managed ankle fractures were encouraged to mobilise weight-bearing but not provided with chemical thromboprophylaxis, whilst operatively-managed fractures were only prescribed chemical thromboprophylaxis during their inpatient stay. Both hospital and national episode data were searched to identify VTEs between 1981 and 2014.

Over this 33-year period there were 17 PEs and 5 DVTs. Of these, 50percnt; occurred prior to the ankle fracture, 23percnt; greater than one year after the fracture and only 27percnt; in the 90 days following injury, with no fatal PEs in this cohort. The incidence of VTEs among conservatively-managed ankle fractures within 30 and 90 days was 1.1 and 3.3 per thousand patients respectively. Operatively-managed fractures were at greater risk, with 5.2 per thousand patients at 30 days and 7.8 at 90 days.

We have found that the incidence of VTEs is very low after ankle fracture: approximately five times lower than after major joint arthroplasty. The efficacy of chemical thromboprophylaxis remains controversial, and given that the rate of major haemorrhagic complications is 2percnt;, it remains to be determined whether this is appropriate after ankle fracture.

Enterococcus faecalis is a rare but recognized cause of prosthetic joint infection. It is notorious for formation of biofilm on prosthetic surfaces. We hypothesized that a ‘serum factor’ was responsible for transformation of E. faecalis from its planktonic form to a biofilm existence upon making contact with prostheses. Using a novel ‘proteomic approach’, we studied the protein expression profiles of this bacterium when grown on an artificial surface in a serum environment against a control.

E.faecalis 628 transconjugant formed by conjugation clinical strain (E55) and laboratory strain (JH2-2) was used to inoculate each of rabbit serum (RS) and Brain Heart Infusion (BHI) agar as a control and grown for 24 hours. Proteins were harvested for analysis in fractions including cell surface, membrane and cytosolic proteins. Recovered proteins were separated using 2-dimentional polyacrylamide gel electrophoresis (2D PAGE). Gels were stained and spots of interest harvested. These were analyzed using MALDI mass spectrometry followed by peptide mass fingerprinting using online database searches.

Two surface exclusion proteins Sea1 and PrgA were only expressed from the serum culture. These proteins are both encoded by genes very close to the gene for enterococcal aggregation substance PrgB, which plays an integral role in biofilm formation. PrgA and PrgB are both encoded by the prgQ operon and hence expressed simultaneously upon activation of the operon.

This tendency for serum only protein expression suggests the possibility of a pheromone-like activator in serum that could be a potential therapeutic target for management of biofilm associated E. faecalis prosthetic infections.

Nasal carriers of methicillin sensitive Staphylococcus aureus (MSSA) have an increased risk for health-care associated infections. There is currently no national screening policy for the detection of MSSA in the UK. This study aimed to: evaluate the diagnostic performance of molecular and culture techniques in MSSA screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on MSSA detection in orthopaedic patients. Paired nasal swabs for PCR assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint replacement surgery.

The prevalence of MSSA nasal colonisation was found to be between 22.4–35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p=0.005), failing to identify its presence in ∼1/3 of patients undergoing joint replacement surgery.

Modelling these results to national surveillance data, it was estimated that 800–1200 MSSA surgical site infections could be prevented annually in the UK by using alternative diagnostic methods to direct culture in pre-operative MSSA screening and eradication programmes.

There is much debate regarding the use of continuous-compartment-pressure-monitoring (CCM) in the diagnosis of acute compartment syndrome (ACS).

We retrospectively reviewed the management of all patients (aged 15 and over) who were admitted with a fracture of the tibial diaphysis, across 3 centres, during 2013–2015. Patient demographics, pre-existing medical problems, initial treatment, subsequent complications, methods of compartment monitoring, and follow-up were all included in the data collection. We separated patients into monitored (MG) and non-monitored groups (NMG), and compared the outcomes of their treatment. Data analysis was performed using SPSS and statistical significance was set as p < 0.05.

287 patients were included in this study (116 NMG vs. 171 MG). There were no significant differences observed in age, sex, previous medical problems, length of stay, AO classification of fracture and post-operative complications between the groups. 21 patients were suspected to have developed ACS (n=8 NMG 6.9percnt;, n=13 MG 7.6percnt;) and were treated with acute decompression fasciotomies. The average time from admission to fasciotomy was 20.3 hours (21.25hrs NMG, 19.5hrs MG p=0.448). There was no significant difference in the average length of hospital stay and documentation of complications at follow up between the 2 groups. There were no reported cases of soft tissue infections associated with the use of CCM.

This study illustrates that CCM does not increase the rate of fasciotomies in this patient group, or reduce the time to fasciotomy significantly. There was no evidence to suggest that use of CCM is associated with superficial or deep infection.

Proliferation of synovial Mesenchymal Stromal/Stem Cells (MSCs) leads to synovial hyperplasia (SH) following Joint Surface Injury (JSI). Uncontrolled Yap activity causes tissue overgrowth due to modulation of MSC proliferation. We hypothesised that YAP plays a role in SH following JSI.

A spatiotemporal analysis of Yap expression was performed using the JSI model in C57Bl/6 mice. Synovial samples from patients were similarly analysed. Gdf5-Cre;Yap1fl/fl;Tom mice were created to determine the effect YAP1 knockout in Gdf5 lineage cells on SH after JSI.

In patients, Yap expression was upregulated in activated synovium, including a subset of CD55 positive fibroblast-like synoviocytes in the synovial lining (SL). Cells staining positive for the proliferation marker Ki67 expressed active YAP.

In mice, Yap was highly expressed in injured knee joint synovium compared to controls. Yap mRNA levels at 2 (p<0.05) and 8 days (p<0.001) after injury were increased.

Conditional Yap1 knockout in Gdf5 progeny cells prevented hyperplasia of synovial lining (SL) after JSI. Cellularity was significantly decreased in the SL but not in the sub-lining of injured Yap1 knockout- compared to control mice. The percentage of cells in synovium that were Tom+ increased in response to JSI in control and haplo-insufficient but not in YAP1 knockout mice (p<0.05).

Modulation of YAP and proliferation of MSCs in the synovium after JSI provides a system to study the role of SH after trauma in re-establishing joint homeostasis and is a potential novel therapeutic target for the treatment of post traumatic OA.

Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy seen in clinical practice. Approximately 34% of CTS patients undergo carpal tunnel decompression (CTD) surgery, in the UK. We investigated the change in epidemiology of CTD based on sex, age, socio-economic deprivation and geographical location, in Scotland, over the last 20 years.

76,076 CTD were performed between 1996–2015 (71% female, M:F ratio 1:2.4). The overall incidence rate of CTD was 73/100,000 person years. The mean age was 50–59 years old for both sexes. Socio-economic deprivation was associated with higher incidence rates of CTD (most deprived 89/100,000 person years and least deprived 64/100,000 person years) (p<0.01). NHS health boards with low populations and a more rural location had higher incidence rates; mean 98/100,000 person years (range 4–238/100,000 person years) compared to high population heath boards in urban locations; mean 74/100,000 person years (range 4–149/100,000 person years) (p<0.01). There has been a significant increase in number and overall incidence of CTD, in Scotland, during the study period: in 1996, 1,156 CTD performed (incidence 23/100,000 person years) vs. 2015, 5,292 CTD performed (incidence 87/100,000 person years) (p<0.01).

We conclude that middle aged females are still the most common demographic undergoing CTD but the incidence rate is increasing over time. There appears to be an association between CTD and socio-economic deprivation. The incidence of CTD, and change over time, differs between health boards.

Aims

To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.

This study aimed to evaluate the effect of clavicular shortening, measured by three-dimensional computerized tomography (3DCT), on functional outcomes and satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury.

The data used in this study were collected as part of a multicenter, prospective randomized control trial comparing open reduction and plate fixation with nonoperative treatment for displaced midshaft clavicle factures. Patients who were randomized to nonoperative treatment and who had healed by one year were included. Clavicle shortening relative to the uninjured contralateral clavicle was measured on 3DCT. Outcome analysis was conducted at six weeks, three months, six months and one year following injury and included the Disabilities of the Arm, Shoulder and Hand (DASH), Constant and Short Form-12 (SF-12) scores, and patient satisfaction.

48 patients were included. The mean shortening of injured clavicles, relative to the contralateral side, was 11mm (+/− 7.6mm) with a mean proportional shortening of 8percnt;. Proportional shortening did not significantly correlate with the DASH (p>0.42), Constant (p>0.32) or SF-12 (p>0.08) scores at any time point. There was no significant difference in the mean DASH or Constant scores at any followup time point both when the cut off for shortening was defined as one centimeter (p>0.11) or two centimeters (p>0.35). There was no significant difference in clavicle shortening between satisfied and unsatisfied patients (p>0.49).

This study demonstrated no association between shortening and functional outcome or satisfaction in patients with healed, displaced, midshaft clavicle fractures up to one year following injury.

Two-stage revision is the gold standard for managing infected total hip and knee arthroplasties. The aim was to assess the effect of duration between stages on reinfection rate at one year.

A systematic review and meta-analysis was conducted on all studies investigating reinfection rate with documented interval between first and second stages. Total hip (THR) and total knee replacements (TKRs) were included but analysed separately. The effect size of studies was stratified according to sample size then with study quality.

All papers up until November 2015 (including non-English language) were considered. From 3827 papers reviewed, 38 cohorts from 35 studies were included, comprising 23 THR and 15 TKR groups. Average study quality was 5.6/11 (range 3–8). Funnel plots calculated to assess for bias indicated significant asymmetry at lower sample sizes in both groups.

In the TKR group, studies with 0–3 months between stages showed a significantly lower reinfection rate than 3–6 months (9.5% 21/222 vs 20.7% 28/135, p<0.01). A similar trend was seen in the THR group (6.1% vs 10.7%, p<0.05). No difference was observed for either group between 3–6 and 6–9 months.

There is no consensus regarding the appropriate duration between surgeries in two-stage revisions for infection. Studies stratified by sample size and quality indicate an increased reinfection rate past three months. Published guidance is no substitute for clinical decision-making but the conclusions from this study are to recommend against routine delay of more than 3 months between first and second stage revisions for infected THR and TKR.

Kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of insertion could provide such advantages.

Three concurrent studies were performed to assess the viability of bioabsorbable pins across the growth plate. (1) An epidemiological study to identify Kirschner wire infection rates. (2) A mechanical assessment of a bioabsorbable pin compared to Kirschner wires in a simulated supracondylar fracture. (3) The insertion of the implants across the physis of sheep to assess effects of the bioabsorbable implant on the growth plate via macroscopic, pathohistological and micro-CT analysis.

An infection rate of 8.4% was found, with a deep infection rate of 0.4%. Mechanically the pins demonstrated comparable resistance to extension forces (p=) but slightly inferior resistance to rotation (p=). The in vivo component showed that at 6 months: there was no leg length discrepancy (p=0.6), with micro-CT evidence of normal physeal growth without tethering, and comparable physeal width (p=0.3).

These studies combine to suggest that bioabsorbable pins do not represent a threat to the growth plate and may be considered for physeal fracture fixation.

Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion.

A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected.

The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs.

We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program.

Following the neonatal examination the 6–8 week ‘GP check’ forms the second part of selective surveillance for developmental dysplasia of the hip (DDH) in the UK. We aim to investigate the effectiveness of this 6–8 week examination for DDH.

This is a observational study including all infants born in our region over 5 years. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment record for early and late DDH as well as referrals for ultrasound (US) following the 6–8 week check were analysed. The attendance at the 6–8 week examination in those patients who went on to present with a late DDH was also analysed.

23112 live births, there were 141 confirmed cases of DDH. 400 referrals for ultrasound were received from GP; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended the 6–8 week examination and no abnormality had been identified. The sensitivity of the examination was 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%

For many years the 6–8 week ‘check’ has been thought of as a safety net for those children with DDH not identified as neonates, however we found that 4 out of every 5 children with DDH were not identified. It is essential efforts are made to impove detection as the long term consequences of late presentation can be life changing.

Increasing demands on our emergency department (ED) has resulted in the reduction of manipulations (MUAs) at the ‘front door’. We hypothesised that MUAs undertaken in theatre is rising with adverse financial implications. We performed a retrospective audit of operating lists in our institution from 2013–2016. Cost estimates were determined by our finance department. We used the NICE guidelines on management of non-complex fractures (NG38 Feb2016) as our audit standard.

Data on 1372 cases performed over a three-month representative period during 2013–2016 was analysed. MUAs were 13% of the total theatre workload, with an annual increase in volume noted. Additionally, simple displaced distal radius fractures were routinely receiving a MUA (with or without K-wires) as a primary procedure in theatre. When this workload is combined it makes up 22% of the total theatre workload. Average theatre time was 57 minutes per case. Delays to definite procedure ranged from 8 to 120 hours. Cost of hospital admission and theatre utilisation was approximately £1000 per patient. Conversely, the cost of a MUA in the ED was estimated at £150. Given that we currently undertake around 15 manipulations in theatre a month, performing such work in the ED it would save approximately £153,000 a year to our health board.

This audit identifies that MUAs of common orthopaedic injuries undertaken in theatre can lead too significant clinical and financial costs. We have proposed a strong financial argument to management for a twice weekly ‘manipulation list’ in the ED which is currently under review.

Evidence suggests as little as 32percnt; of those with a displaced intracapsular hip fracture who meet the NICE eligibility criteria currently undergo a total hip replacement (THR). The reason for this discrepancy is not clear. This study therefore set out to examine the reasons behind this lack of adherence to these guidelines through the use of a questionnaire to current Trauma & Orthopaedic surgery consultants across Scotland.

An invitation to take part in the survey was distributed through the Scottish Committee for Orthopaedics & Trauma (SCOT) email address list. A series of 10 questions were designed to determine the background of participants, their experience at performing hip fracture surgery (including THR) and their thoughts regarding its use in the hip fracture setting. Results were collated at the end of the study period and quantitatively analysed where possible.

There were 91 responses in total. 53percnt; of individuals said they would offer those meeting the NICE criteria a THR less than 76percnt; of the time. The most commonly used alternative was a cemented bipolar hemiarthroplasty (51percnt;). Hip surgeons were more likely to perform or supervise THR for hip fracture than non-hip surgeons (p<0.0001). There were a wide variety of reasons why people would not offer a THR including dislocation rate, technical complexity and inadequate evidence for use.

Overall this study highlights current trends and barriers in the provision of THR to hip fracture patients. This knowledge can be used to ascertain research priorities to maximise the quality of care in this setting.

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms.

All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams.

36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality.

Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes.

Aims

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

Aims

This study assessed the association of classes of body mass index in kg/m² (classified as normal weight 18.5 kg/m² to 24.9 kg/m², overweight 25.0 kg/m² to 29.9 kg/m², and obese ≥ 30.0 kg/m²) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures.

Aims

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.

Aims

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

Aims

We aimed to characterise the effect of expeditious hip fracture surgery in elderly patients within 24 hours of admission on short-term post-operative outcomes.

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

Aims

This is a prospective randomised controlled trial comparing the functional outcomes of plate fixation and elastic stable intramedullary nailing (ESIN) of completely displaced mid-shaft fractures of the clavicle in the active adult population.

Aims

Surgical site infection can be a devastating complication of hemiarthroplasty of the hip, when performed in elderly patients with a displaced fracture of the femoral neck. It results in a prolonged stay in hospital, a poor outcome and increased costs. Many studies have identified risk and prognostic factors for deep infection. However, most have combined the rates of infection following total hip arthroplasty and internal fixation as well as hemiarthroplasty, despite the fact that they are different entities. The aim of this study was to clarify the risk and prognostic factors causing deep infection after hemiarthroplasty alone.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Aims

Hip hemiarthroplasty is a standard treatment for intracapsular proximal femoral fractures in the frail elderly. In this study we have explored the implications of early return to theatre, within 30 days, on patient outcome following hip hemiarthroplasty.

Aims

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

Background

Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up.

Background

With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre.

To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications.

We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months). Delayed union was associated with higher grade injuries, those treated with elastic nails demonstrated the longest union time (ave 7.3 months). 21/44 (47.7%) patients had complications, with pin site infection being the most commonly seen. 18% patients suffered a major complications needing further surgery.

Various fixation methods can be successfully used to treat these fractures. They demonstrate a high complication rate and often require multiple surgeries, with union taking an average of 6 months. Mono-lateral fixators demonstrate a high revision rate, particularly if the fracture is not well reduced.

Aims

Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome.

Introduction

Open fractures are managed in the UK guided by standards issued by the BOAST-4 standards. A study was undertaken to evaluate compliance with these standards in a regional trauma unit (MTU), and compared following upgrading to a Major Trauma Centre (MTC).

Introduction

The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower limb lengthening. To assess macroscopic and microscopic changes to the implants and assess differences following design modification, with identification of potential surgical, implant and patient risk factors.

Introduction

The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator.

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care.

All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research.

There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles.

The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment.

Background

Severe infantile Blount's disease can result in a multiplanar deformity of the proximal tibia with both intra-articular and metaphyseal components. Correction can represent a significant surgical challenge. We describe our results using the Taylor spatial frame for acute tibial hemiplateau elevation combined with gradual metaphyseal correction in patients with severe infantile blounts with an associated physeal bony bar.

Introduction

Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation.

Background

Chronic acquired radial head dislocations pose a complex problem in terms of surgical decision making, especially if surgery has already previously failed. There are several underlying causes that should be investigated, including previous trauma resulting in a missed Monteggia fracture.

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit.

An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended.

Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment).

We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100).

Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment.

Level of evidence: IV (case series)

Aims

To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union.

Purpose

Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had severe tibia plateau fractures which were treated with circular ilizarov frame.

BACKGROUND

Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures.

Introduction

Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications.

Introduction

Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives.

Purpose

This study compares outcomes in patients with complete congenital fibula absence treated with an amputation protocol to those using an extension prosthesis.

Care of complex and open fractures may provide better results if undertaken in larger units, typically Major Trauma Centres (MTCs) or Orthoplastic units. Some ‘complex injuries’ may still be admitted to units lacking specialist services potentially delaying definitive treatment. The aim of this study was to analyse the referral pattern for acute inpatient transfer in an adult limb reconstruction unit for one calendar year.

Prospectively collected data from an electronic database for 2016 was reviewed. All records were evaluated for, diagnosis, time from injury to referral, nature of initial treatment, time to transfer, details of definitive surgery, and time to repatriation.

There were 91 formal electronic referrals, 84 of which considered appropriate for inpatient transfer. 74 were for fresh complex fractures, including 22 pilon fractures and 23 bicondylar tibial fractures. Median delay to request transfers for acute trauma was 3 days (0d-19d), delay from referral to transfer was 8.5 days (1d-31d) and delay from date of injury to definitive surgery was 13 days (1d-52d). 9 patients with Grade 3 open fractures and had primary debridement at the referring institution with a median delay to definitive orthoplastic surgery of 9 days (5d-20d). Only 17 of 61 per-articular fractures had spanning external fixation at the referring institution. Delay to repatriation was 8 days (0d–72d).

This study demonstrates organisational failures in acute orthopaedic care: open fractures not being primarily treated in orthoplastic centres or MTCs, delays in transfers due to bed-blocks, and significant delays in repatriation. It also demonstrates scope for improvement in clinical practice, and in particular, the need to reinforce the advantages of spanning external fixation of periarticular fractures.

Our data serves to highlight continuing problems in delivery of acute fracture care, despite widely publicised recent national guidelines.

The Fassier-Duval (FD) rod, which offers a single-entry design and allows elongation for growth, has been widely adopted in paediatric deformity correction over the past decade, although evidence is limited in literature regarding the associated complications from its use.

All FD roddings carried out in a Scottish tertiary referral centre were identified. The electronic records and radiographs of each procedure were reviewed. The follow-up duration, indications for surgery, complications arisen and further operations were recorded.

21 procedures in 11 patients were identified between 2009–2016. The mean age at operation was 6 years and 2 months. The median follow-up period was 3 years and 9 months. The main underlying pathology was osteogenesis imperfecta (71.4%, n=15). The main indication of surgery was deformity correction (61.9%, n=13). 11 (52.4%) FD roddings were for femur and the remainder were for tibia. The commonest complication was proximal migration (n=6, 28.6%). In our cohort we did not have negative telescoping or non-union. Two procedures (9.5%) were complicated by deep infections which were successfully treated. There were 3 further operations (14.3%), including one revision to a locked intramedullary nail for fracture and one below knee amputation for recurrent pseudarthrosis.

We compared our results with those from Birke and co (J Paediatr Orthop 2011) from Australia. Our results are comparable and with a longer follow-up period.

Although FD rodding allows children to maintain their mobility and prevent fractures, there are significant complications associated with its use. We hope in the future other centres can publish their results to allow improvements in surgical practice and implant design.

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Aims

The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis.

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

Aims

The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration.

Objectives

Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs.

Aims

The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.

Aims

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients.

Aims

Our aim was to analyse the long-term functional outcome of two forms of surgical treatment for active patients aged > 70 years with a displaced intracapsular fracture of the femoral neck. Patients were randomised to be treated with either a hemiarthroplasty or a total hip arthroplasty (THA). The outcome five years post-operatively for this cohort has previously been reported. We present the outcome at 12 years post-operatively.

Aims

Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used.

Aims

The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery.

Aims

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip.

Aims

To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT).

Fractures of the hip are common, often occurring in frail elderly patients, but also in younger fit healthy patients following trauma. They have a significant associated mortality and major social and financial implications to patients and health care providers. Many guidelines are available for the management of these patients, mostly recommending early surgery for the best outcomes. As a result, healthcare authorities now put pressure on surgical teams to ‘fast track’ patients with a fracture of the hip, often misquoting the available literature, which in itself can be confusing and even conflicting.

This paper has been written following an extensive review of the available literature. An attempt is made to clarify what is meant by early surgery (expeditious versus emergency), and we conclude with a personal view for the practical management of these patients of variable age, fitness and type of surgery performed within services that are often under considerable pressure of finance and available operating theatres and qualified staff.

Cite this article: Bone Joint J 2016;98-B:1573–81.

Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate.

All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included.

124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus.

In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR.

Competition ratios for Core Surgical Training (CST) and Higher Specialist Training in Trauma & Orthopaedic (T&O) surgery have decreased over the last 5 years. Whilst multifactorial, one reason thought to contribute to career decision- making, is junior doctors' experience whilst working in that specialty. This study aimed to identify ‘who’ is currently working on the “1st on call” tier in T&O in the UK, and what clinical activities are undertaken.

Collaborators were recruited between 12/09/2015 – 17/01/2016 via the BOTA networks. Data was prospectively collected between 18/01/2015 and 22/01/2015. Each collaborator completed a coded clinical activity diary for all doctors on the “1st on call” rota for T&O in their hospital. Activity parameters included doctor grade, rota gaps, operative and clinic exposure, on call activity, and ward cover.

221 collaborators submitted clinical activity data regarding 933 junior doctors from 100 T&O departments in the UK. 30 rota gaps were identified. The mean number of junior tier doctors was 9 (range 1–23). The “Lost Tribe” comprised Foundation Year 2 (26%), Core Surgical Trainee (19%), Trust Grade (20%), and locum doctors (13%), amongst other grades. During the study period, 2.5% of the ‘Lost Tribe’s' time was allocated to clinic, 2.7% to theatre, 27% to ward cover and 34.6% to zero sessions.

Doctors-in-training make up a minority of the workforce and as such, the T&O profession need to do more to ensure that junior doctors are exposed to clinics and operative lists to specifically address the balance between training and service delivery.

There is limited long term evidence to support instrumented fusion as an adjunct to decompression for foraminal stenosis in the presence of single level degenerative disc disease.

We report the long term outcome of a prospective randomised controlled trial. Forty-four patients with single-level disc disease were randomly assigned to three groups (spinal decompression (Group 1), decompression and instrumented posterolateral fusion (Group 2), or decompression and instrumented posterolateral fusion plus transforaminal interbody fusion (Group 3). Spinal disability (Dallas, Roland Morris, and Lower Back Outcome Score [LBOS]), and quality of life (EuroQol (EQ) and short form (SF-) 36 questionnaires) were assessed before and at after surgery by independent researchers.

At mean of 15 years follow up 33 (75%) patients were available for assessment. All groups observed a significant improvement in the EQ-5D at final follow up. Group 1 demonstrated significantly better functional outcome at final follow up according to the Dallas, Roland Morris, LBOS, and EQ-5D (3L and VAS) scores when compared to the other two groups (p<0.01). The SF-36 score demonstrated that group 1 had significantly better generic health scores compared to groups 2 and 3. Regression analysis was used to adjust for the differences in general health between the groups and demonstrated no significant difference between the groups in the spine specific scores: Dallas (p>0.15), Roland Morris (p>0.37), or the LBOS (p>0.32).

Fusion in combination with decompression for the treatment of foraminal stenosis and single level degenerative disc disease offers no long term functional benefit over decompression in isolation.

Risk of revision following total knee replacement is relatively high in patients under 55 years of age, but little is reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction following TKR in patients younger than 55 years of age.

We assessed 177 TKRs (157 consecutive patients) from 2008 to 2013. Data was collected on age, sex, implant, indication, BMI, social deprivation, range of motion, and prior knee surgery in addition to Oxford Knee Score (OKS) and SF-12 score. Postoperative data included knee range of motion, complications, and OKS, SF-12 score and satisfaction measures at one year.

Overall, 24.9% of patients (44/177) were unsure or dissatisfied with their TKR. Significant predictors of dissatisfaction on univariable analysis (p<0.05) included: Kellgren-Lawrence grade 1/2 osteoarthritis; indication; poor preoperative OKS; postoperative complications; and poor improvements in OKS and pain component score (PCS) of the SF-12. Odds ratios for dissatisfaction by indication compared to primary OA: OA with previous meniscectomy 2.86; OA in multiply operated knee 2.94; OA with other knee surgery 1.7; OA with BMI>40kgm-2 2; OA post-fracture 3.3; and inflammatory arthropathy 0.23. Multivariable analysis showed poor preoperative OKS, poor improvement in OKS and postoperative stiffness, particularly flexion of <90°, independently predicted dissatisfaction (p<0.005).

Patients coming to TKR when under 55 years of age differ from the ‘average’ arthroplasty population, often having complex knee histories and indications for surgery, and an elevated risk of dissatisfaction.

There is comprehensive data addressing the 6 to 18-month survival in patients with pathological neck of femur (NOF) fractures due to bony metastases. However, little is known about early mortality in this group. The aim was to quantify 30 and 90-day mortality in patients with pathological NOF lesions/fractures and identify biochemical markers associated with early death.

Orthopaedic trauma lists over one year were used to identify patients with a pathological NOF fracture/lesion.

33 patients had a metastatic NOF fracture/lesion and were compared to a control group of age and gender-matched non-pathological NOF fractures. Time from referral to surgery was higher in patients with a pathological fracture compared to a pathological lesion (average 7.4 and 0.6 days, p<0.05). 30 and 90-day mortality was higher in the metastatic group compared to controls (15% 5/33 vs 9% 3/33 p<0.05, and 42% 14/33 vs 12% 4/33 p<0.01, respectively).

Patients with early mortality had lower average sodium (135 vs 138, p<0.05), creatinine (48 vs 62, p<0.05) and APTT (27 vs 32, p<0.05). They had a higher average WCC (11.3 vs 7, p<0.05) and CRP (55 vs 18, p<0.01). Metastatic patients with early mortality had lower albumin (20 vs 30, p<0.01) and haemoglobin (102 vs 121, p<0.01), which were higher in the control NOF group with early mortality (albumin 28 and haemoglobin 118 respectively, p<0.05).

Patients with pathological NOF lesions have multiple biochemical abnormalities associated with early mortality. A prospective study is proposed to assess whether correction of these abnormalities can improve survival in this group.

The use of Birmingham hip resurfacing (BHR) remains controversial due to the increased revision rate in female patients. We compared the outcomes of BHR in female patients to an age matched total hip arthroplasty(THA) cohort. We reviewed the pain, function and total Harris Hip Scores(HHS), and Kaplan-Meir survivorship for BHR and THA cohorts from a prospective regional arthroplasty database.

There were 234 patients in each cohort, with mean age of 51 years. The BHR cohort had significantly better function and total HHS at all points of the 5-year study, but not for the post-operative pain score. The 5-year revision rate for the BHR cohort was significantly higher than the THA cohort (6.8% vs 3.4%, p=0.001). The main reason for revision in the BHR cohort was aseptic loosening (n=8), followed by metallosis (n=3). The 5-year Kaplan-Meier survivorship was 92.6% (95% CI±1.7%) and 96.4% (95% CI±1.3%) for the BHR and THA cohort (p=0.001).

BHR can give significantly better functional outcomes than THA. The vast majority of female patients were happy with BHR and did not need further surgery at the 5-year stage. This is somewhat at odds with the recent reputation of the procedure. The 10-year result of the same cohort is warranted to provide further data. Our study is not a recommendation to still offer BHR to female patients, but rather to inject a note of realism into the debate. There are implications for future implant development in that these results do validate resurfacing as a functionally valuable option for active patients.

Scar tissue formation secondary to acute muscle injury, surgical wounding and compartment syndrome can result in significant functional impairment and predispose to further injury. The source of fibroblasts, and the molecular mechanisms driving their activation and persistence in skeletal muscle fibrosis are not known. We hypothesized that cells expressing PDGFRβ become fibroblasts in response to injury and that targeting αv integrins in these cells reduces skeletal muscle fibrosis.

We used double-fluorescent reporter mice to demonstrate that cells expressing PDGFRβ become activated myofibroblasts in response to cardiotoxin (CTX) induced skeletal muscle injury. Following injury, PDGFRβ+ cells moved from perivascular locations into the interstitium in a distribution characteristic of fibroblasts, and showed marked induction of fibroblastic genes including αSMA and collagen1 (all p<0.0001). To confirm that αv integrins present on PDGFRβ cells critically regulate skeletal muscle fibrosis we used Itgavflox/flox;PDGFRβ-Cre mice (transgenic mice in which αv integrins are ‘knocked-down’ in PDGFRβ+ cells). These mice were significantly protected from CTX induced fibrosis (p<0.01). To demonstrate potential clinical utility of targeting αv integrins, we used a small molecule inhibitor of αv integrins (CWHM12). Treatment with CWHM12 significantly reduced fibrosis when delivered from the time of injury (p<0.01) and when delivered after the fibrotic response had become established (p<0.01).

We have identified a core pathway regulating fibrosis in skeletal muscle. Pharmacologic inhibition of αv integrins has potential clinical utility in the treatment and prevention of skeletal muscle fibrosis.

Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation.

A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input.

56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks.

The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients.