Risks in the Management of Polytrauma Patients: Clinical Insights.

Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.

The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients.

BACKGROUND: Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. AIMS: In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. METHODS: A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. RESULTS: A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). CONCLUSION: Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.

Industry 5.0 technology capabilities in Trauma and Orthopaedics.

Background: The fifth industrial revolution, which is also known as Industry 5.0, involves the interaction of human intelligence and cognitive computing to deliver personalised products. Industry 5.0 is an advancement on the inherent pillars of Industry 4.0 revolution with the 'Personalisation of Automation and Efficiency'. Aims: In this article, we explore the evolution of the Industry 5.0 revolution in the branch of trauma and orthopaedics. We highlight the interface of human intelligence, Robotic technology, and Smart machine systems in the development of personalised care for patients with orthopaedic conditions. Methods: A comprehensive search strategy was conducted using databases of Embase, PubMed, Google Scholar and ResearchGate to discover the suitable literature published till March 2022 on the subject. The keywords used for the search included "Industry 5.0" and "Orthopaedics" to identify the appropriate literature and prepare this narrative review. Results: Industry 5.0 revolution appears to have made significant expansion on Industry 4.0 enabled technologies. Innovations in computer technology, implant designs, orthopaedic research, increased collaboration between humans, Robots and smart systems have led to multiple inventions. Industry 5.0 has led to the development of patient-specific implants, instruments, and devices in the sub-specialty of trauma and orthopaedics. Conclusion: Evolution of Industry 5.0 has paved the way to introduce personalised products in the diagnosis, treatment, and management of a spectrum of orthopaedic pathologies. By enabling automation and enhancing labour efficiency, Industry 5.0 has made it possible to engineer patient-specific tools, instruments and implants to improve clinical, functional, and Patient Related Outcome Measures (PROMs).

Clinical Characteristics and Learning Outcomes of Managing Orthopaedic Trauma Patients during the First Wave of Covid- 19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Management of trauma and emergency orthopaedic conditions during the pandemic was reorganised across the United Kingdom including our hospital following the COVID-19 British Orthopaedic Association and National Health Service England guidelines. AIMS: This retrospective, observational cohort study analyses the impact of the first wave of COVID-19 pandemic on trauma and emergency patient care at a district general hospital. A comparative analysis to assess patient characteristics and clinical outcomes during the initial phase of COVID-19 outbreak with a cohort of patients treated during a similar period in 2019 was undertaken. METHODS: Patients who underwent trauma and emergency surgeries between 01 April to 31 May 2020 at a Northwest Mersey NHS Trust were studied and compared to a similar period in 2019. The outcome measures assessed were 30- and 60-day mortality, Time to Surgery, length of stay after surgery, systemic and orthopaedic complications including the subsequent need for surgery. RESULTS: Overall, there was a decrease in the number of patients who underwent trauma or emergency surgery from 184 in 2019 to 116 in 2020. 30- and 60-day mortality slightly increased by 2.05% and 2.68%, respectively. Time to surgery and hospital length of stay were comparable between both cohorts. CONCLUSION: Continuity of services to patients with obligatory injuries was managed using enhanced personal protective equipment and infection control strategies including segregation of patients based on COVID-19 status. Lessons learnt during this period such as COVID-19 testing regime and care pathways have prepared us for the near future. LEVEL OF STUDY: Retrospective Cohort study; Level III.

CONTEXTE: La gestion des traumatismes et des urgences orthopédiques pendant la pandémie a été réorganisée dans tout le Royaume-Uni, y compris dans notre hôpital, conformément aux directives COVID-19 de la British Orthopaedic Association et du National Health Service England. OBJECTIFS: Cette étude de cohorte rétrospective et observationnelle analyse l'impact de la première vague de la pandémie COVID-19 sur les soins aux patients en traumatologie et en urgence dans un hôpital général de district. Une analyse comparative visant à évaluer les caractéristiques des patients et les résultats cliniques pendant la phase initiale de l'épidémie de COVID-19 avec une cohorte de patients traités pendant une période similaire en 2019 a été entreprise. MÉTHODES: Les patients qui ont subi des traumatismes et des chirurgies d'urgence entre le 01 avril et le 31 mai 2020 dans un Northwest Mersey NHS Trust ont été étudiés et comparés à une période similaire en 2019. Les mesures de résultats évaluées étaient la mortalité à 30 et 60 jours, le délai d'intervention chirurgicale, la durée du séjour après la chirurgie, les complications systémiques et orthopédiques, y compris le besoin ultérieur de chirurgie. RÉSULTATS: Dans l'ensemble, le nombre de patients ayant subi une chirurgie traumatique ou d'urgence a diminué, passant de 184 en 2019 à 116 en 2020. La mortalité à 30 et 60 jours a légèrement augmenté de 2,05 % et 2,68 %, respectivement. Le délai d'intervention chirurgicale et la durée de séjour à l'hôpital étaient comparables entre les deux cohortes. CONCLUSION: La continuité des services aux patients présentant des blessures obligatoires a été gérée en utilisant des équipements de protection individuelle améliorés et des stratégies de contrôle des infections, y compris la ségrégation des patients en fonction de leur statut COVID-19. Les leçons apprises au cours de cette période, telles que le régime de test COVID-19 et les parcours de soins, nous ont préparés pour l'avenir proche. NIVEAU DE L'ÉTUDE: Étude rétrospective de cohorte ; Niveau III. MOTS-CLÉS: COVID-19; Coronavirus; pandémie; traumatisme; orthopédie ; mortalité; test COVID-19; évaluation des résultats; soins de santé.

Total hip arthroplasty in tubercular arthritis of the hip - Surgical challenges and choice of implants.

Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic consequences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various applications in different presenting scenarios with a guide to surgical tips and tricks for managing this challenging condition.

Planning and analysing 'Green' post-COVID-19 orthopaedic perioperative recovery pathway.

The effect of the severe acute respiratory syndrome coronavirus 2 pandemic on the National Health Service in the United Kingdom has been profound and unprecedented with suspension of most elective surgeries. As we are emerging from lockdown now, restarting elective surgical procedures in a safe and effective manner is an expected challenge. Many perioperative factors including patient prioritisation, risk assessment, health infrastructure and infection prevention strategies need to be considered for patient safety. The British Orthopaedic Association, along with the National Health Service, have provided recent guidelines for restarting non-urgent and orthopaedic care in the United Kingdom. In this article we review the current guidelines and literature to provide some clarity for clinical practice.

Update on functional imaging in the evaluation of diabetic foot infection.

Diabetic foot infection is a preventable complication of diabetes mellitus. It is an essential component of diabetic foot disease, which is characterised by a triad of neuropathy, ischaemia and infection. These factors may lead to foot ulceration, sepsis and amputation resulting in increased morbidity and poor quality of life. Confirming or excluding infection can be difficult especially when routine laboratory tests and plain radiographs are inconclusive. Early diagnosis and localization of diabetic foot infection is extremely important to institute timely, appropriate therapy. Structural imaging using computed tomography and magnetic resonance imaging all have individual applications towards the diagnostic workup of this condition but have their own limitations. Scintigraphic detection is based on physiochemical changes and hence provides a functional evaluation of bone pathology. We describe the evolution of functional nuclear medicine imaging including immunoscintigraphy in diabetic foot infection and highlight current applications of physiological 18-Fluoro-deoxyglucose positron emission tomography (18-FDG-PET) and computed tomography (18-FDG-PET/CT) in such patients. 18-FDG-PET/CT is a promising modality for imaging diabetic foot infection. Future studies will allow standardisation of technological details and options of 18-FDG-PET/CT interpretation in diabetic foot infection.

Total Hip Arthroplasty in Patients With Postpolio Residual Paralysis: A Systematic Review.

BACKGROUND: Patients with postpolio residual paralysis can develop disabling hip arthritis in paralytic as well as a nonparalytic limb, warranting total hip arthroplasty (THA). Limited literature is available on the results of THA among these patients in the form of small series or case reports. We have undertaken a systematic review to evaluate the clinical outcome of THA in patients with poliomyelitis with hip pathologies. METHODS: A systematic search of electronic databases of PubMed, Scopus, and Web of Science pertaining to English literature was undertaken from 1945 to August 2020 to assess the results of THA in patients with poliomyelitis. Information was gathered about demographics, indication, clinical course, complications, functional outcome, survival, and need for any revision surgery in these patients. RESULTS: The literature search revealed 81 articles. Finally, after deduplication and manual selection, 16 relevant articles (128 hips) were included for evaluation. There is a paucity of literature evaluating THA in patients with poliomyelitis over the last 2 decades. The principal reason for arthroplasty was osteoarthritis of the hip in the ipsilateral (paralyzed) limb. A combination of cemented, uncemented, and hybrid implant fixation system was found to be used by surgeons. Addressing instability and perioperative management of limb length discrepancy were found to be challenging propositions. CONCLUSION: THA remains an effective intervention to relieve pain and improve quality of life in patients of poliomyelitis afflicted with either primary or secondary arthritis of the hip. The use of uncemented nonconstrained hip implant designs appears to demonstrate better results than constrained implants.

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity.

PURPOSE: The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity. METHODS: Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3 months for 1 year and then every 6 months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER). RESULTS: Out of 51 patients, 49 completed all follow-ups. The median age was 27 years (17-45 years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12 months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24 months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity. CONCLUSION: The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength. LEVEL OF EVIDENCE: III.

Pitfalls in telemedicine consultations in the era of COVID 19 and how to avoid them.

BACKGROUND AND AIMS: With restrictions on face to face clinical consultations in the COVID-19 pandemic, Telemedicine has become an essential tool in providing continuity of care to patients. We explore the common pitfalls in remote consultations and strategies that can be adopted to avoid them. METHODS: We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020 including 'COVID-19', 'telemedicine' and 'remote consultations'. RESULTS: Telemedicine has become an integral part to support patient's clinical care in the current COVID-19 pandemic now and will be in the future for both primary and secondary care. Common pitfalls can be identified and steps can be taken to prevent them. CONCLUSION: Telemedicine it is going to play a key role in future of health medicine, however, telemedicine technology should be applied in appropriate settings and situations. Suitable training, enhanced documentations, communication and observing information governance guidelines will go a long way in avoiding pitfalls associated with remote consultations.

Challenges and strategies in management of osteoporosis and fragility fracture care during COVID-19 pandemic.

BACKGROUND: COVID-19 has resulted in restriction of face to face consultations and mechanisms to access health care. Osteoporosis and fragility fractures forms a significant proportion of adult trauma and orthopaedic workload even during the pandemic. AIMS: We assess the challenges and strategies used in the management of osteoporosis and fragility fracture care during the COVID-19 pandemic. METHODS: We have done a comprehensive review of the literature using suitable keywords on the search engines of PubMed, SCOPUS, Google Scholar and Research Gate in the first week of May 2020 on developments and guidance during the current COVID-19 pandemic. RESULTS: Osteoporosis and fragility fractures management has been hampered by lock down and infection transmission strategies used to contain the COVID-19 pandemic. Access to diagnostic tests, treatment facilities with the need to use clinical and prediction tools to guide management Telemedicine has an evolving role. CONCLUSION: Osteoporosis and fragility fractures in elderly individuals pose a real challenge for an appropriate diagnosis and management, during the COVID-19 pandemic. A clinical decision along with use of clinical prediction tools for osteoporosis should be used to direct treatment. Obligatory fractures such as hip fractures require operative intervention. Non-obligatory fractures such as distal radius fractures can be managed conservatively with use of telemedicine applications in monitoring both types of patients.

Post COVID-19: Planning strategies to resume orthopaedic surgery -challenges and considerations.

The Coronavirus SARS-CoV-2 (COVID-19) pandemic has had a substantial effect on the health care systems around the world. As the disease has spread, many developed and developing countries have been stretched on their resources such as personnel as well as adequate equipment. As a result of resource disparity, in a populous country like India, the elective orthopaedic surgeries stand cancelled whilst trauma and emergency services have been reorganised following Indian Orthopaedic Association and recent urgent British Orthopaedic association guidelines. Though these guidelines provide strategies to deal with trauma and orthopaedic surgery management in the present scenario, once the COVID-19 pandemic stabilizes, restarting elective orthopaedic surgery and managing delayed trauma conditions in evolving health care systems is going to be a profound task. We look at the future challenges and considerations of re-establishing trauma and orthopaedic flow during the post-COVID-19 phase and suggest an algorithm to follow (Fig. 1).

COVID-19 and orthopaedic surgeons: the Indian scenario.

The emergence of COVID-19 has impacted orthopaedic surgery worldwide. India, with its large population and limited health resources, will be overwrought over the coming days due to the number of cases of critically ill patients with COVID-19. It is important to understand the challenges for orthopaedic (and other) surgeons in India when dealing with patients during the COVID-19 pandemic. This article highlights the challenges in the triaging of patients, care in dealing with a patient with COVID-19 in orthopaedic surgery, and the effects on academics and research activities; it also suggests immediate measures and recommendations that also apply to other specialties.

Polymorphism of glutathione S-transferase M1 and T1 genes and susceptibility to psoriasis disease: A study from North India.

BACKGROUND: Increased oxidative stress and resulting inflammation has been emphasized as a factor in the pathogenesis of many diseases including psoriasis. Glutathione S-transferases (GSTs) protect against oxidative stress, inflammation, and genotoxicity. Polymorphisms in the GST genes may lead to an imbalance in pro- and antioxidant systems resulting in the increased production of reactive oxygen species that could influence the pathogenesis of psoriasis. AIM: The aim of this study was to investigate the association between GSTs (GSTM1 and GSTT1) gene polymorphism in patients with chronic plaque psoriasis as a factor in the susceptibility and development of psoriasis. MATERIALS AND METHODS: We assessed 128 patients with psoriasis and 250 age- and sex-matched healthy controls. Genomic DNA was extracted from peripheral blood by the phenol chloroform method. The null GSTT1 and GSTM1 genotypes were identified by multiplex polymerase chain reaction (PCR) method. RESULTS: The null genotype of GSTM1 and GSTT1 was seen in 45.3% and 40.6% in psoriasis patients whereas in the controls it was 34.4% and 20.0%, respectively. A significant association was seen between the null alleles of the GSTT1 (OR = 2.74) and GSTM1 (OR = 1.58) alone or in combination with tobacco use (P < 0.001) and psoriasis risk. The presence of both null genotypes of GSTM1 and GSTT1 further increased the risk of psoriasis (OR = 3.52) when compared with the positive genotypes of GSTM1 and GSTT1. LIMITATIONS: A major limitation of this study was the small sample size. A large epidemiological study is necessary to confirm these findings. CONCLUSIONS: The null genotype of GSTT1 is a strong predisposing factor for psoriasis in North India.

Comparative evaluation of efficacy and safety of calcipotriol versus tacalcitol ointment, both in combination with NBUVB phototherapy in the treatment of stable plaque psoriasis.

BACKGROUND: Vitamin D analogues and NBUVB phototherapy are both well-established modalities of treatment in psoriasis. The objective of this open label, intraindividual, left right study was to compare two different vitamin D analogues, calcipotriol and tacalcitol, in combination with NBUVB phototherapy in chronic stable plaque psoriasis. METHODS: Thirty patients with stable plaque psoriasis were enrolled for a 12-week clinical trial. The target lesion on left side was treated topically with tacalcitol ointment once daily, while that on the right side was treated with calcipotriol ointment twice daily. NBUVB phototherapy was given thrice weekly. Efficacy was assessed by target plaque scoring. RESULTS: Both therapies resulted in statistically significant reduction in erythema, scaling, thickness and target plaque score, seen as early as 2 weeks into therapy. However, calcipotriol combination led to an earlier clearance of plaques and a lesser relapse rate than tacalcitol combination. The number of treatment sessions and cumulative NBUVB doses were significantly lower in the calcipotriol-treated group. CONCLUSION: Both vitamin D analogues appear to be safe, effective and cosmetically acceptable, calcipotriol being more efficacious, well tolerated with a rapid onset of action and a better maintenance of response.