The Victorian state government introduced a trial electronic scooter sharing scheme on 1st February 2022 in inner city Melbourne. Despite epidemiological data from other jurisdictions that show these devices are associated with significant trauma. This is a descriptive study from the largest trauma centre in Victoria demonstrating the “scope of the problem” after introduction of this government-approved, ride sharing scheme. Retrospective case series. Our hospital orthopaedic department database was searched from 1/1/2021 to 30/6/22 to identify all presentations associated with electronic scooter trauma, the mechanism of injury and admission information was confirmed via chart review. Data collected included: mode of arrival, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, list of injuries, operations undertaken, surgical procedures, discharge destination, death. In the 12 months prior to and 5 months since introduction of the ride share scheme, 43 patients were identified. 18 patients (42% of our cohort) presented in the 5 months since ride sharing was introduced, and 25 patients in the preceding 12 months. 58% were found to be alcohol or drug affected. All patients were admitted to hospital, 14% of which included ICU admission. 44% were polytrauma admissions. Median hospital length of stay was 2 days. The longest individual hospital stay was 69 days. No patients in this series died. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. Mean Injury Severity Score was 10. Despite data demonstrating their danger in other jurisdictions, the Victorian state government approved a trial of an electronic scooter ride share scheme in inner Melbourne in February 2022. These devices are associated with a significant trauma burden and the rate has increased since the introduction of the ride-sharing scheme. This data may be combined with other hospital data and could be used to inform policy makers.
Complications are an inevitable part of orthopaedic surgery, how one defines complications can have an impact on the ability to learn from them. A group of general surgeons headed by Clavien and Dindo Our aim was to evaluate a modification of this classification system and its use over a 12-month period at our institution via our departmental audits, our hypothesis being that this would direct appropriate discussion around our complications and hence learning and institutional change. A modified Clavien-Dindo Classification was prospectively applied to all complications recorded in the Orthopaedic departmental quarterly audits at our institution for a 12-month period (4 audits). The audit discussion was recorded and analysed and compared with the quarterly complication audits for the preceding 12-month period. The modified Clavien-Dindo classification for surgical complications was applicable and reproducible to Orthopaedic complications in our level 1 trauma centre. It is a transparent system, objective in its interpretation and avoids the tendency to down-grade serious complications. It was easy to apply and directed discussion appropriately at our quarterly audit meetings on complications where there was a preventable outcome or important learning point. In particular modifications to VTE and Death classes allowed the unit to focus discussion on cases where complication was preventable or unexpected. The modified Clavien-Dindo classification system is an easy to use and reproducible classification system for Orthopaedic complications in our unit it directed audit discussion towards cases where complications were preventable or had a learning point.
Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA). A 22-year-old male professional motorbike rider presented with an anterior left hip dislocation that occurred during a race. A CT scan after a closed reduction revealed a large osteochondral impaction fracture/defect that was addressed via partial resurfacing using the HemiCAP System. A 34-year-old male presented with an anterior left hip dislocation after a motor vehicle accident and underwent a closed reduction. CT showed a loose osteochondral fragment, that was fixed back with headless screws, and an adjacent defect was addressed with a HemiCAP implant. Both patients were kept non weight-bearing for two months and had an uneventful recovery. Patient 1 was last reviewed at our institution one month post-operatively with a pain-free hip. His follow-up is being continued interstate and at telephone interview, 18 months after surgery, he had returned to full function and resumed riding on the professional racing circuit. Patient 2, at three-month review, had a pain-free hip with a full range of motion. CT scan showed excellent joint surface congruity at the implant articular surface junction. We report the use of the HemiCAP System as a novel method of treating osteochondral defects, which has never been reported before. There has only been one other reported case of using a HemiCAP in an osteoarthritic femoral head. This is a short follow-up with only two patients treated; however we are encouraged by the results so far, as there are no other satisfactory alternative treatment options.Patient 1
Patient 2
Despite the publication of numerous studies, controversy regarding the non- operative treatment of type II dens fractures remains. The halo-thoracic vest (HTV) and cervical collar are the most commonly used devices. We sought to compare the outcomes of patients managed with these devices in terms of non-union risk factors and associated complication rates. This study was a retrospective review of adult patients with type II dens fractures treated non-operatively at a level one trauma centre between 2001 and 2007. The patients were identified using a hospital trauma database. Each patient included in the study had a minimum follow up of six months. Patient medical records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union, measured at three months. A p-value of < 0.05 was considered statistically significant. Sixty-seven patients were included. Thirty-five patients were treated using a HTV and 32 with a collar. Non-union was found to be associated with increased time in HTV or collar (p = 0.011) and with a mechanism of injury involving a low fall (p = 0.008). In addition, the proportion of patients with stable union at three months was 60% for the HVT group versus 35% for the cervical collar group (p = 0.10). There were trends to support an increased risk of non-union with a patient age of greater than or equal to 65 years at the time of presentation (p = 0.13) as well as with a fracture displacement of greater than or equal to 2 mm at time of presentation (p = 0.17). Clinically significant complications of the HTV were of greater prevalence than those experienced by collar patients. Sixty percent of HTV patients suffered one or more complications compared with 6% of collar patients. We were unable to demonstrate any clear advantage or disadvantage of either device. Further investigation of mortality would be beneficial, particularly in the patient group injured with a mechanism involving a low fall (which tends to include more elderly patients).
The Orthopaedic Unit at The Alfred has been using an external fixator in a novel configuration for protecting lower limb wounds after free flap surgery (sometimes even in the absence of a concomitant bony injury). This soft-tissue frame allows the limb to be elevated without contact so that there is no pressure on the flap and its pedicle. Thus, optimising the arteriovenous circulation. We report our initial experience with these soft tissue frames. The soft tissue frame is not necessarily applied for definitive fracture care, but constructed or modified to optimise elevation of the leg, remove direct pressure from the soft tissues, and stabilise the muscles adjacent to the flap. All ankle-spanning frames held the foot in a plantargrade position to optimise blood flow and recovery (prevent equinus), and minimise intra-compartmental pressure. During 2007, the Plastic Surgery Unit performed 23 free flaps to the lower limbs of 22 patients. Five of these patients had a soft-tissue frame constructed. One patient had a frame applied purely to manage the soft tissue injury, and the other four, who required an external fixator for a bony injury, had their frame modified. Four of the five patients study patients were injured in motor vehicle accidents and one was injured in a simple fall. All five free flaps survived and none required any further surgery. No patients suffered complications (such as bleeding, pin-track infections, or osteomyelitis) related to the soft tissue frame. We strongly recommend considering an external fixator in a modified configuration after lower limb free flap surgery. Constructing a soft tissue frame has no added risks if the fixator is already required. In the case where there is no bony injury, a soft tissue frame has the benefits of providing optimal flap conditions and maintaining anatomical joint alignment. However, this must be balanced against the small risk associated with the insertion of pins (such as infection) and the need for an extra procedure to remove the frame. As always, treatment must be tailored to the individual patient.
Despite increasing use of vena cava filters (VCFs) for pulmonary embolism (PE) prophylaxis after major trauma, there is continued debate regarding their safety and efficacy. We aimed to evaluate the impact of prophylactic VCFs on the incidence of PE after major trauma and to describe VCF related complications. Prospectively collected data from The Alfred Hospital Trauma Registry were used to identify all major trauma patients admitted between 1 July 2001 and 1 July 2008. Data for each patient was collated from the registry. This included patient demographics, injury specific data, management details (including prophylactic VCF use) and clinical outcomes (including the occurrence of PE). Medical record and radiology chart review was used to verify all PEs. Potential PE risk factors were assessed as covariates in a univariate analysis, with PE as the dependent variable. A multivariate analysis was then performed using multiple logistic regression adjusting for baseline imbalances and known covariates. During this period, 6,344 major trauma patients were treated, with 73.2% male, mean age of 44.2 +/− 21.0 SD, 90.2% with a blunt mechanism of injury and mean ISS of 24.3 +/− 12.0 SD. Of these patients, 511 (8.1%) received prophylactic VCFs, (inserted in absence of PE) at the discretion of the treating clinician. There were 45 PE (incidence of 0.71%), of which two were fatal. Three variables were independently associated with the occurrence of PE in the multivariate analysis: (i) presence of prophylactic VCF (OR 0.28; 95%CI 0.09 - 0.89); (ii) number of injuries to the AIS body region lower limb (OR 1.31; 95%CI 1.17 - 1.47) and (iii) central venous catheterisation (OR 1.87; 95%CI 1.88 - 6.17). Data was available on the VCF database for 429 of the 511 patients with VCFs (84.0%). The mean time to prophylactic VCF insertion was 3.6 +/− 0.2 SEM days after admission. The VCF major complication rate was 2.6% (n=11), including four non-fatal PE. The technical success rate for retrieval was 92.4% (279 retrievals from 302 attempts) and the overall retrieval rate was 65.0% (279 retrievals from 429 placements). Prophylactic VCFs are associated with a reduced rate of PE when used in selected major trauma patients. In addition, prophylactic VCFs have a low major complication rate and high rate of technical success for retrieval.
