bluuebunny/crossref_metadata_2025_split huggingface dataset:
THE FITBONE LEARNING CURVE: WHEN DOES IT END?
Authors: Tissingh Elizabeth , Goodier David , Wright Jonathan , Timms Anna , Campbell Michelle , Crook Grace , Calder Peter 
Published: July 2023

IntroductionThe FitBone lengthening nail (Orthofix UK) is an intramedullary device licensed for the lengthening of long bones in adults in the UK. It contains a motor powered by electricity transmitted via an induction coil placed underneath the skin. It was developed in Germany two decades ago but uptake in the UK has only started more recently. The aim of this study was to review the first cohort of FitBone lengthening nails in a unit with significant experience of other lengthening nails (including PRECICE and Stryde).Materials & MethodsDemographic, clinical and radiological data was prospectively collected on all FitBone cases starting in February 2022. Accuracy of lengthening rate, patient satisfaction and implant issues were all considered. Complications and learning points were recorded and discussed by the multidisciplinary team involved in the patients care.ResultsEleven lengthening nails were inserted between February and November 2022 (6 right femurs, 5 left femurs). The average patient age was 31 (16–57) with 4 females and 7 males. The average lengthening achieved was 44mm (13– 70) over an average of 59 days (35 to 104). Significant technical issues were encountered in this cohort of patients including slow opening up at osteotomy site (3 requiring speeding up of programme), early consolidation (one requiring re-do osteotomy) and backing out of locking screws (3 out of 11 nails). There were also patient use concerns with difficulty using the motor and the inability to reverse the lengthening without an additional component to the motor.ConclusionsWe present the first UK cohort of patients with femoral lengthening using the FitBone implant and device. We highlight the technical and patient issues encountered during this learning curve and propose solutions to avoid these pitfalls.
CURRENT FRACTURE-RELATED INFECTION PRACTICE IN THE UK: IS THERE A CASE FOR CHANGE?
Authors: Tissingh Elizabeth , Wright Jonathan , Goodier David , Calder Peter , Vris Alex , Iliadis Alexios 
Published: July 2023

IntroductionA greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK.Materials & MethodsOrthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks.ResultsOf the 36 respondents, the majority (64%) worked in a major trauma centre. In the majority of cases, bone infection was managed by the limb reconstruction team (68%) although in most centres the wider team was often also involved including the general on call, the trauma team and the arthroplasty team. When referrals were made elsewhere, this was usually done to known individuals rather than established FRI networks. 80% of respondents said that there was a bone infection MDT in their unit and this usually met weekly. This usually included orthopaedics and microbiology but plastics in only 43% of cases and radiology in only 23% of cases. Most respondents said that the lack of funding and appropriate tariffs were the main barrier to FRI management locally (62%) and nationally (83%). Most respondents (83%) said that bone infection practice should be centralised. The overwhelming majority of this cohort (90%) said that patient outcomes would be improved by cases being managed in dedicated centres.ConclusionsThere is variation in practice for the management of bone infection in the UK. This reflects the lack of clear national guidelines and the lack of established networks for management and onward referral. There is agreement that patient outcomes would be improved by more formal networks and specialised centres but also recognition that remuneration is a significant barrier to implementing change. This survey reflects practice in units with an interest in limb reconstruction and bone infection. Further work is needed to evaluate practice across district general hospitals in the UK and to build consensus around best practice and national strategies for improved care.
MANAGEMENT OF GERIATRIC OPEN ANKLE FRACTURES
Authors: Airey Grace , Chapman James , Mason Lyndon , Harrison William 
Published: July 2023

IntroductionOpen fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC).Materials & MethodsThis cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed. Weightbearing status over the treatment course was monitored. Patient frailty was measured using the clinical frailty score (CFS).ResultsThere were 35 patients, mean age 77 years (range 65–97 years), 86% female. Mean length of admission in the MTC was 26.4 days (range 3–78). Most (94%) had a low-energy mechanism of injury.Only 57% of patients underwent one-stage surgery (ORIF n=15, hindfoot nail n=1, external frame n=4) with 45% being permitted to fully weightbear (FWB). Eleven (31.4%) underwent two-stage surgery (external fixator; ORIF), with 18% permitted to FWB. Of those patients with pre-injury mobility, 12 (66%) patients were able to FWB following definitive fixation. Delay in weightbearing ranged from 2–8weeks post-operatively. Seven patients (20%) underwent an initial Orthoplastic wound debridement. Ten patients (28.6%) required plastic surgery input (split-skin grafts n=9, local or free flaps n=3), whereby four patients (40%) underwent one stage Orthoplastic surgery.Eighteen (51.4%) patients had a CFS ≥5. Patients with a CFS of ≥7 had 60% 90-day mortality. Only 17% patients had orthogeriatrician input during admission.ConclusionsThese patients have high frailty scores, utilise a relatively large portion of resources with multiple theatre attendances and protracted ward occupancy in an MTC. Early FWB status needs to be the goal of treatment, ideally in a single-staged procedure. Poor access to orthogeriatric care for these frail patients may represent healthcare inequality.
DOUBLE-BARREL DRILL SLEEVE: A SURGICAL INNOVATION FOR PERCUTANEOUS OSTEOTOMY
Authors: Rashid Lutfi , Trompeter Alex , Saw Aik 
Published: July 2023

IntroductionOsteotomy is a key step in distraction osteogenesis. Various techniques of osteotomy have been described with its own benefits and pitfalls. Percutaneous osteotomy using multiple drill holes is one of the most widely used osteotomy techniques. It still remains a challenge however to keep the drill holes aligned prior to the osteotomy. Moreover, the efficacy of percutaneous irrigation practice to keep the temperature low during drilling with this technique is also debatable. With an aim to overcome these challenges, we are introducing a device called the Double Barrel Drill Sleeve (DBDS) to perform percutaneous osteotomies. We attempted to compare this method to the conventional multiple drill holes technique using laboratory experiments and clinical data.Materials & MethodsDBDS has two adjacent parallel barrels that can fit 3.2 to 3.5 mm diameter drill bits. It has a guide member at the drilling end that can be inserted through a pre drilled hole at the near and far cortices of a bone. This provides a constant rotating point for drilling of holes through the barrels. An osteotomy simulation was performed to compare percutaneous drilling with DBDS vis-a-vis a conventional single drill sleeve (SDS) by qualified orthopaedic surgeons, mainly to assess the drilling patterns of both techniques. Percutaneous drilling was done on PVC pipes wrapped in thick sponge to simulate tubular bone with surrounding soft tissue. We also assessed the effect of indirect irrigation on temperature during drilling using the DBDS against a control group on a cadaveric bone model. Ultimately we reviewed our patients who had undergone osteotomy for distraction osteogenesis with DBDS and the conventional technique, and compared their outcomes.ResultsCompletion time for the osteotomy simulation in the DBDS group was significantly faster than the conventional drilling group; 74 seconds to 179 seconds. There was significantly less drilling deviation from the midpoint in the DBDS group as compared to the SDS group. Mean bone temperature during drilling with indirect irrigation using DBDS was significantly lower (32.6'C) compared to the control group (48.4'C). There was no significant difference in healing index between patients treated with DBDS and the conventional method. None of these patients developed non union.ConclusionsPercutaneous drilling with DBDS was quicker and more linear compared to the conventional method. Its double-barreled feature allows effective indirect irrigation during drilling. A comparable healing index in both of the techniques shows its clinical efficacy. These attributes make DBDS a usefull tool to overcome some of the pitfalls associated with the conventional multiple drill holes technique.
FRACTURE-RELATED INFECTION: DIAGNOSIS AND MANAGEMENT AT A MAJOR TRAUMA CENTRE
Authors: Fernandes Ramon , Farid Mohammed , Desai Seema , McFadyen Iain , Maamoun Wareth , Huq Shahidul 
Published: July 2023

IntroductionFracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction.Materials & MethodsA retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management.ResultsA total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts.ConclusionsThe diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction.
CAN ARTHOPLASTY STEM INFLUENCE OUTCOME (CASINO): A RANDOMIZED CONTROLLED TRIAL OF STEM LENGTH IN CEMENTED TOTAL HIP ARTHROPLASTY
Authors: Gaston Paul , Clement Nicholas , Ohly Nicholas , Macpherson Gavin , Hamilton David 
Published: July 2023

In this RCT the primary aim was to assess whether a short (125mm) Exeter V40 stem offered an equivalent hip specific function compared to the standard (150mm) stem when used for cemented total hip arthroplasty (THA). Secondary aims were to evaluate health-related quality of life (HRQoL), patient satisfaction, stem height and alignment, radiographic loosening, and complications between the two stems.A prospective multicentre double-blind randomised control trial was conducted. During a 15-month period, 220 patients undergoing THA were randomised to either a standard (n=110) or short (n=110) stem Exeter. There were no significant (p≥0.065) differences in preoperative variables between the groups. Functional outcomes and radiographic assessment were undertaken at 1- and 2-years.There were no differences (p=0.428) in hip specific function according to the Oxford hip score at 1-year (primary endpoint) or at 2-years (p=0.767) between the groups. The short stem group had greater varus angulation (0.9 degrees, p=0.003) when compared to the standard group and were more likely (odds ratio 2.42, p=0.002) to have varus stem alignment beyond one standard deviation from the mean. There were no significant (p≥0.083) differences in the Forgotten joint scores, EuroQol-5-Dimension, EuroQol-VAS, Short form 12, patient satisfaction, complications, stem height or radiolucent zones at 1 or 2-years between the groups.The Exeter short stem offers equivalent hip specific function, HRQoL, patient satisfaction, and limb length when compared to the standard stem at 2-years post-operation. However, the short stem was associated with a greater rate of varus malalignment which may influence future implant survival.
ACETABULAR SECTOR ANGLES IN ASYMPTOMATIC AND DYSPLASTIC HIPS: DEFINING THRESHOLDS FOR DYSPLASIA
Authors: Verhaegen Jeroen , Devries Zach , Horton Isabel , Slullitel Pablo , Rakhra Kawan , Beaule Paul , Grammatopoulos George 
Published: July 2023

Traditional radiographic criteria might underestimate or fail to detect subtle types of acetabular dysplasia. Acetabular sector angles (ASA) can measure the degree of anterior and posterior coverage of the femoral head on computed tomography (CT). This study aims to determine ASA values at different axial levels in a cohort of (1) asymptomatic, high-functioning hips without underlying hip pathology (controls); and (2) symptomatic, dysplastic hips that underwent periacetabular osteotomy (PAO). Thereby, we aimed to define CT-based thresholds for hip dysplasia and its subtypes.This is an IRB approved cross-sectional study of 51 high functioning, asymptomatic patients (102 hips) (Oxford Hip Score >43), without signs of osteoarthritis (Tönnis grade≤1), who underwent a CT scan of the pelvis (mean age: 52.1±5.5 years; 52.9% females); and 66 patients (72 hips) with symptomatic hip dysplasia treated with peri-acetabular osteotomy (PAO) (mean age: 29.3±7.3 years; 85.9% females). Anterior and posterior acetabular sector angles (AASA & PASA) were measured by two observers at three CT axial levels to determine equatorial, intermediate, and proximal ASA. Inter- and intra-observer reliability coefficient was high (between 0.882–0.992). Cut-off values for acetabular deficiency were determined based on Receiver Operating Characteristic (ROC) curve analysis, area under the curve (AUC) was calculated.The dysplastic group had significantly smaller ASAs compared to the Control Group, AUC was the highest at the proximal and intermediate PASA. Controls had a mean proximal PASA of 162°±17°, with a cut-off value for dysplasia of 137° (AUC: 0.908). At the intermediate level, the mean PASA of controls was 117°±11°, with a cut-off value of 107° (AUC 0.904). Cut-off for anterior dysplasia was 133° for proximal AASA (AUC 0.859) and 57° for equatorial AASA (AUC 0.868). Cut-off for posterior dysplasia was 102° for intermediate PASA (AUC 0.933).Measurement of ASA on CT is a reliable tool to identify dysplastic hips with high diagnostic accuracy. Posterior ASA less than 137° at the proximal level, and 107° at the intermediate level should alert clinicians of the presence of dysplasia.
AUTOMATED VERSUS MANUAL COMPONENT IMPACTION IN TOTAL HIP ARTHROPLASTY: EFFECTS ON COGNITIVE FUNCTION, PHYSICAL FATIGUE, AND STRESS LEVEL
Authors: Vandeputte Frans-Jozef , Hausswirth Christophe , Dille Jeroen , Corten Kristoff 
Published: July 2023

Total Hip Arthroplasty (THA) surgery is a physical and cognitive challenge for surgeons. Data on stress levels, cognitive and physical load of orthopaedic surgeons, as well as ergonomic impact, are limited. With and without the use of an automated impaction device, operational efficiency and the surgeon's ergonomic, mental, and physical load was investigated.In a total of thirty THA procedures, a standard manual technique was compared with an automated impaction device. Three computerized cognitive tasks (Simon, pattern comparison, and pursuit rotor) and five physical tests (isometric wall-sit, plank-to-fatigue, handgrip, supra-postural task, and shoulder endurance) were used to assess psychophysiological load of the surgeon. Surgeon's cortisol concentration was evaluated from saliva samples. Postural risk was assessed by Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Efficiency was assessed by timing surgical steps and instrumentation flow.Cognitive performances after automated impaction showed faster response times and lower error rates with a greater time-on-target (+1.5 s) and a lower mouse deviation from target (−1.7 pixels). Manual impaction showed higher physical exhaustion in the isometric wall-sit test (10.6% vs. 22.9%), plank-to-fatigue (2.2% vs. 43.8%), the number of taps in the supra-postural task (−0.7% vs. −7.7%), handgrip force production in the dominant (−6.7% vs. −12.7%) and contralateral hand (+4.7% vs. +7.7%), and in shoulder endurance (−15s vs. −56s). An increase of 38.2% in salivary cortisol concentration between the midday (1.31 nmol/l) and afternoon session (1.81 nmol/l) was observed with manual impaction. After using automated impaction, salivary cortisol concentration decreased (−51.2%). Manual broaching time was on average 6′20’’ versus 7’3’’ with automated impaction. RULA of manual impaction scored 6 for cup impaction and 5 for femoral broaching, versus 3 and 3 for automated impaction, respectively. REBA of manual impaction scored 9 for cup impaction and 5 for femoral broaching, versus 4 and 3 for automated impaction, respectively.Automated impaction lowers surgeons’ cognitive and physical fatigue and leads to reduced stress and improved ergonomics without loss of surgical efficiency.
SLIDING HIP SCREW CONSTRUCTS ARE ASSOCIATED WITH EARLY MOBILIZATION, RETURN TO DOMICILE, AND SHORTER LENGTH OF STAY WHEN COMPARED TO AN INTRAMEDULLARY NAIL: RESULTS FROM THE SCOTTISH HIP FRACTURE AUDIT
Authors: Diffley Thomas , Ferry Jamie , Sumarlie Regina , Beshr Mostafa , Chen Bin , Clement Nick , Farrow Luke 
Published: July 2023

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies.A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance.13638 records were included (72% female). 9867 received a SHS (72%).No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's.There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations.Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS.Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted.
THE INCIDENCE AND RISK FACTORS FOR ABNORMAL POSTOPERATIVE BLOOD TESTS FOLLOWING PRIMARY TOTAL JOINT REPLACEMENT: A SINGLE-CENTRE RETROSPECTIVE COHORT STUDY
Authors: Orfanos Georgios , Kumar Nakulan Nantha , Lowe David , Redfern Dan , Burston Benjamin , Banerjee Robin , Thomas Geraint 
Published: July 2023

Primary total joint arthroplasty (TJA) is an increasingly common and safe way of treating joint disease. Robust preoperative assessment improved intraoperative techniques and holistic rehabilitation contribute to an uneventful postoperative period. Despite there being evidence against the utility of postoperative blood tests, it is still often part of routine practice. We aim to evaluate the usefulness of these tests by investigating their incidence following TJA as well as identifying preoperative risk factors for abnormal blood test results postoperatively especially pertaining to anaemia and acute kidney injury (AKI).This is a retrospective cohort study of patients who had elective TJA between January and December 2019 at a tertiary centre. An independent student's t-test and Fisher's exact test was used to compare variables between the normal and abnormal postoperative results groups. An analysis of variance (ANOVA) was performed to identify risk factors for an abnormal blood test result. Analyses of receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to determine cut off values that could be suggestive of abnormal test results postoperatively.The study included 2721 patients with a mean age of 69 of which 46.6% were males. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥65 years), female gender, ASA ≥ 3 as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dL), haematocrit (≤ 0.395L/L) and potassium (≤ 3.7 mmol/L) were noted as cut-offs that could be predictive of postoperative anaemia or AKI respectively.The costs outweigh the benefits of ordering routine postoperative blood tests in TJA patients. Clinicians should risk stratify their patients and have a lower threshold for ordering blood tests in patients with one or more of the risk factors we have identified. These risk factors are age (≥65 years), females, ASA ≥ 3, preoperative haemoglobin (≤ 127 g/L), haematocrit (≤ 0.395L/L), and potassium (≤ 3.7 mmol/L).