One-stage combined "fix and flap" approach for complex open Gustilo-Anderson IIIB lower limbs fractures: a prospective review of 102 cases.

BACKGROUND: Management of open fractures is challenging and requires a multidisciplinary team approach. This study aims to evaluate outcomes of open Gustilo-Anderson IIIB fractures managed at a single Ortho-Plastic centre following One-stage "Fix and Flap" approach. METHODS: Prospective data review for patients presenting with Gustilo-Anderson IIIB Fractures to our centre and managed with one-stage "Fix and Flap" approach. Postoperative outcomes are presented only for the patients who had a minimum of 12 months postoperative follow-up. RESULTS: 120 patients were included (83 males and 37 females). Mean age was 43 years (10-96). Tibia diaphysis was the most common site of injury (60%). 55.9% of injuries were road traffic accidents (RTA). 102 out of 120 patients had a minimum of 12 months follow-up (mean follow-up duration 25 months). Meantime from injury until definitive surgery was 7.71 days. Primary union achieved in 86.73%. Delayed union was encountered in 10.20%. 3.06% of patients had non-union. Limb salvage rate was 97.05% and Deep infection rate was only 0.98%. CONCLUSION: Our results showed that low infection rate, high limb salvage rate, and high union rate can be achieved in these complex injuries with meticulous technique, combined Ortho-Plastic (Fix and Flap) approach, and MDT input.

Cobalt-related cardiomyopathy: A real concern! A review of published evidence.

BACKGROUND: Cobalt (Co) toxicity-related cardiomyopathy (CMP) in hip arthroplasty has recently been reported in the literature. The purpose of this review was to identify and assess available published evidence of CMP in hip arthroplasty patients and to derive recommendations for management. METHODS: We evaluated 23 cases reported till October 2018 and stratified into three categories, based on pre-existing risk factors for CMP, histological confirmation and evidence of systemic signs of Co toxicity. RESULTS: Co toxicity was considered to be the definite cause of CMP in 8 cases and probably contributory in 13 cases. Two cases were considered to have developed CMP secondary to pre-existing risk factors. Majority of the patients had good recovery of cardiac function after hip revision and cardiac management, but five cases deteriorated and died. CONCLUSION: Although Co-related CMP has been reported in a small number of cases of hip arthroplasty, a delay or missed diagnosis may lead to significant morbidity and mortality. Timely diagnosis, removal of causative implant and avoidance of metal articulations in revision for fractured ceramic implants may help in effective management.

Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in the management of open Gustilo Anderson IIIB fractures. Prospective Review of 80 Patients from the Manchester Ortho-Plastic Unit.

BACKGROUND: This study aims to evaluate outcomes of using Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in management of Open Gustilo-Anderson IIIB Fractures. METHODS AND RESULTS: 80 patients were managed with single-stage "Fix and Flap" along with intra-operative Adjuvant Local Antibiotic Bio-Composite. Successful fracture union was achieved in 96.1% of patients, with a limb salvage rate of 96.25%. Infection rate was only 1.25%. CONCLUSION: High union rate and very low deep infection rate can be predictably achieved in complex Open Gustilo-Anderson IIIB fractures by meticulous technique, use of local adjunctive antibiotics bio-composite and a combined ortho-plastic approach.

Management of Pyogenic Spinal Infection, review of literature.

OBJECTIVE: To evaluate the available evidence for the management of Pyogenic Spinal Infection (PSI). METHODS AND RESULTS: A comprehensive search for the relevant literature published between 1990 and 2018 to evaluate the management of PSI was conducted.Nonoperative management of carefully selected patients for an adequate duration of antibiotics can result in satisfactory outcomes with low recurrence rate. When there is an indication for surgery, posterior approach, with or without debridement of infected tissue reported to be associated with good outcomes. CONCLUSION: Studies with larger sample sizes and longer duration of follow up are recommended to formulate more comprehensive evidence.

Cobalt cardiomyopathy in hip arthroplasty.

BACKGROUND: Cobalt toxicity-related cardiomyopathy in hip arthroplasty has recently been reported in the literature. The purpose of this review is to identify and assess available published evidence of cardiomyopathy in hip arthroplasty patients and to derive recommendations for management. METHODS: We evaluated 23 cases reported until October 2018 and stratified them into 3 categories, based upon pre-existing risk factors for cardiomyopathy, histological confirmation, and evidence of systemic signs of cobalt toxicity. RESULTS: Cobalt toxicity was considered to be the definite cause of cardiomyopathy in 8 cases, and probably contributory in 13 cases. Two cases were considered to have developed cardiomyopathy secondary to pre-existing risk factors. Majority of the patients had a good recovery of cardiac function after hip revision and cardiac management, but 5 cases deteriorated and died. CONCLUSIONS: Although cobalt-related cardiomyopathy has been reported in a small number of cases of hip arthroplasty, a delay or missed diagnosis may lead to significant morbidity and mortality. Timely diagnosis, removal of causative implant, and avoidance of metal articulations in revision for fractured ceramic implants may help in an effective management.

Incidence of shoulder functional morbidity following ipsilateral mastectomy and latissimus dorsi flap reconstruction.

INTRODUCTION: The aim of this study was to investigate the incidence of shoulder morbidity in our cohort of patients with latissimus dorsi flap reconstruction after mastectomy. METHODS: This is a retrospective study of prospectively collected data of 72 patients using validate Oxford shoulder score for function and quickDASH score for disability. Scores were collected preoperatively and at time of final review or study. We also reviewed patient records for patients who had a formal diagnosis of shoulder pathology. Results were analysed with student t-test. RESULTS: Analysis of scores showed a statistically significant worsening of both oxford shoulder score (p < 0.005) and quickDASH score (p < 0.005), when pre and post-operative scores were compared. Seven patients had a formal diagnosis of shoulder pathology, and all of them recovered well. There was no significant difference in oxford shoulder score or quickDASH scores between patients with or without shoulder pathology. About 40% patients had some functional loss or disability at 4 years after the surgery. CONCLUSION: Our study shows a high incidence of significant shoulder functional morbidity following latissimus dorsi flap reconstruction but number of patients requiring specific treatment is low. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Adjuvant antibiotic loaded bio composite in the management of diabetic foot osteomyelitis - A multicentre study.

BACKGROUND: Diabetic foot ulcers are associated with a high morbidity and are common cause of non-traumatic lower limb amputations. The effect of debridement and the use of an adjuvant local antibiotic carrier in the treatment of diabetic foot ulcers with osteomyelitis was evaluated. METHODS: A retrospective review of patients with diabetic foot ulceration and osteomyelitis treated by debridement with adjuvant local antibiotic was performed. Seventy patients with Texas Grade 3B & 3D lesions were included, with a mean age of 68 years. Cerament G, an antibiotic-loaded absorbable calcium sulphate/hydroxyapatite bio-composite was used along with intraoperative multiple bone sampling and culture-specific systemic antibiotics. RESULTS: Patients were followed up until infection eradication or ulcer healing. Mean follow up was 10 months (4-28months). Nine patients had Charcot foot deformity, 14 had peripheral vascular disease. 62% of patients had forefoot, 5% midfoot and 33% hind foot involvement. Fifty-three patients (87%) had polymicrobial infection. Staphylococcus aureus was the most common microorganism isolated. Infection was eradicated in 63 patients (90%) with mean time to ulcer healing of 12 weeks. Seven patients were not cured and required further treatment. Five patients had below knee amputation. CONCLUSIONS: Adjuvant, local antibiotic therapy with an absorbable bio-composite can help achieve up to 90% cure rates in diabetic foot ulceration with osteomyelitis. Cerament G can act as effective void filler allowing dead space management after excision and preventing reinfection and the need for multiple surgical procedures. LEVEL OF EVIDENCE: Level IV- case series.

Long-term results of metal on metal total hip arthroplasty in younger patients (<55yrs).

INTRODUCTION: Metal on Metal (MoM) hip arthroplasty saw a new era of popularity with development of its second generation bearing surfaces, in the first decade of this century. However, by the end of that decade, concerns had been raised due to metal debris related complications.We aimed to determine the survival of MoM stemmed hip replacement in younger population. We also studied the rate of revision related to adverse reaction to metal debris (ARMD) along with reviewing the clinical and radiological progress of MoM hip arthroplasty in younger age (<55 yrs) group. PATIENTS & METHODS: This is a retrospective cohort study of patients 55 yrs old or younger, who had metal on metal (MoM) hip arthroplasty for osteoarthritis. We had 109 procedures performed on 90 patients with a mean follow up of 10 years. All patients were reviewed as per MHRA guidelines in planned follow-up clinics. Data analyses were performed using SPSS. RESULTS: Survival of implant in our younger cohort was 88.1% at a mean age if 10 years, with revision for any cause as an endpoint. Most of the patients were happy with the outcome of their hip replacement as they were able to perform activities of daily living and work without compromise. Mean Oxford hip score was 43.Altogether, there were 12 revisions, 7 of these were for metallosis and associated symptoms. Average time to revision was 7 years. Other analysis revealed mean acetabular cup inclination angle to be 49 degrees but no significant correlation was found between this angle and serum metal ion levels. Serum Chromium and Cobalt levels were significantly higher in revision group. DISCUSSION: Metal on metal hip arthroplasty prime popularity time has gone. In younger population, although revision rates are higher, the surviving implants give a very good outcome in terms of patient satisfaction. Most of the patients report a desired outcome of 'forgotten hip'.

Spontaneous superior patellar dislocation in young age: case report and reduction technique.

Superior patellar dislocation is a very rare pathology, which happens in middle age. We report a case of spontaneous superior patellar dislocation, which occurred at 30 years of age. Differential diagnosis is patellar tendon rupture, which could be reliably excluded by clinical examination and radiographs. Reduction manoeuvres should be tried with diluted intra-articular local anaesthetic for hydrodilatation to gain mechanical advantage. Splinting the knee in gentle flexion is recommended if general anaesthetic is employed. Recurrent dislocation or osteochondral fractures warrants surgical treatment.