Where did all the trauma go? A rapid review of the demands on orthopaedic services at a UK Major Trauma Centre during the COVID-19 pandemic.

AIMS: This retrospective study aims to quantify the early impact of the COVID-19 pandemic on trauma and orthopaedic surgery at a Major Trauma Centre (MTC) in the United Kingdom. We hypothesise that the social restrictions placed on the public by the government will reduce the amount of trauma presentations and operations performed. METHODS: A database of all trauma patients at the MTC was retrospectively reviewed from start of social restrictions on 16 March 2020, to 22nd April 2020 inclusive. Referrals to the orthopaedic team were identified and included; these were sub-classified into major trauma patients, fragility hip fractures and paediatric trauma. All patients undergoing surgical intervention were identified. The outcome measures were the total number of referrals and trauma operations performed in the time period. This was compared with the corresponding dates of the 2019. RESULTS: There was an overall decrease in the number of referrals to the orthopaedic team from 537 in 2019 to 265 in 2020 (50.7% reduction). The number of trauma operations carried out at the trust decreased from 227 in 2019 to 129 in 2020 (43.2% reduction). The number of paediatric referrals decreased from 56 in 2019 to 26 in 2020 (53.6% reduction), and the number of major trauma patients reduced from 147 in 2019 to 95 in 2020 (35.4%). Fragility hip fracture referrals remained similar, with 52 in 2019 compared to 49 in 2020. CONCLUSION: The COVID-19 pandemic has had a profound effect of the provision of trauma and orthopaedic surgery. We report a significant decrease in all orthopaedic referrals during the pandemic, leading to a greatly reduced number of trauma operations performed. This has allowed for reallocation of staff and resources. We must plan for the lifting of social restrictions, which may lead to an increase in patients presenting with trauma requiring operative intervention.

Is patient satisfaction related to patient reported sounds from ceramic on ceramic total hip arthroplasty? A study of 265 hips.

INTRODUCTION: The ideal method and implant to perform total hip arthroplasty (THA) is still a debated topic. Ceramic on ceramic (CoC) bearings have favourable wear properties, but squeaking has been reported as an unwanted side effect. We aimed to determine the rate of noise generation from CoC hips and investigate whether there is a relationship with patient satisfaction. METHODS: A total of 246 consecutive CoC bearing uncemented THA were retrospectively identified in a single institution. Post-operatively patients were sent a postal questionnaire to evaluate their reported sounds and satisfaction with their THA. Uni- and multi-variate analyses were performed to identify potential predictor variables for reported post-operative sounds. RESULTS: Questionnaires were returned by 172 patients (70% return rate). 24% reported sounds from their hips with 11% reporting a squeak. Median satisfaction levels were minimally, but significantly less for "noisy" (9/10) than "quiet" hips (10/10) (median difference = - 1, 95% CI - 2 to 0, p < 0.001). Compared to those with "noisy" hips, patients with "quiet" hips were 1.7 times (95% CI 1.3-2.5, p = 0.0002) more likely to report a "forgotten" hip. Younger age (p < 0.043) and increased anteversion (p < 0.021) were predictors for reported sounds. CONCLUSION: We have identified a high rate of "noisy" hips in this series of CoC THA with a significant inverse relationship between "noisy" hips and patient satisfaction levels. In our unit, we are moving towards the use of ceramic on cross-linked polyethylene bearings as a result of these findings and the excellent survivorship of this bearing combination.

Does oversizing an uncemented cup increase post-operative pain in primary total hip arthroplasty?

INTRODUCTION: It has been suggested that one of the factors related to persistent post-operative pain following total hip arthroplasty (THA) is to over sizing of the acetabular component. In order to investigate this potential issue, we retrospectively analysed a series of consecutive uncemented THA. We assessed the incidence of persistent post-operative pain and the size difference between the implanted acetabular component and the native femoral head. METHODS: A total of 265 consecutive THAs were retrospectively identified. Standardised pre-operative radiographs were analysed using validated techniques to determine the native femoral head diameter. Post-operative standardised radiographs were reviewed and the acetabular orientation determined. Patients were sent postal questionnaires regarding their outcome and level of pain. RESULTS: Questionnaires were returned by 169 patients (189 hips, 71% response rate). A total of 17 were excluded due to inadequate radiographs., leaving 172 THA in the study group. The mean native femoral head (NFH) size was 47 mm. The most common implanted acetabular component size was 52 mm. The mean difference in cup to NFH diameter (delta) was 5.7 mm (range - 6.1 to 15.4 mm; 95% CI 5.3-6.2 mm). A delta of > 6 mm was found to be significant for predicting persistent post-operative pain (RR = 1.81; 95% CI 1.1-3.1; P = 0.027). CONCLUSION: Our study confirms that a delta of > 6 mm is associated with an increased risk of persistent post-operative pain following THA. We recommend pre-operative templating in all uncemented THA to ensure the planned acetabular component is no more than 6 mm larger than the NFH diameter.

Results of the learning curve for interventional hip arthroscopy: a prospective study.

This prospective study aims to explore hip arthroscopy, outcome and the effect of the learning curve. Using the non-arthritic hip score preoperatively and postoperatively in 120 patients with an average 23-month follow-up, a median improvement of 16 points was seen at 6 months (p < 0.0001, Wilcoxon's signed ranks) remaining at 2 years (15, p < 0.05). Dividing patients into consecutive chronological groups of 40, the learning curve was explored. At six-months scores improved by 12 (p < 0.05) in first 40, 15 (p < 0.0001) in second and 20 (p < 0.0001) in third. A reduction in THR (22.5%, 5%, 2.5%) and revision rates (10%, 7.5%, 0) was seen. An increase in cumulative percentage satisfaction (defined as minimum 10 points increase) was seen from 20th (45%) to 100th procedure (65%). Results significantly improve as experience increases, possibly due to improved surgical skill, preoperative workup or improved understanding of operative indications.

Magnetic resonance arthrography for labral tears and chondral wear in femoroacetabular impingement.

Magnetic resonance arthrography (MRA) is a useful pre-operative investigation for patients with clinical signs and symptoms of femoroacetabular impingement. Our aim was to assess the diagnostic accuracy of MRA in detecting labral tears and chondral wear in this context. Sixty nine hips were included in the study after exclusions. All patients underwent pre-operative MRA and then subsequent hip arthroscopy. The findings at MRA were compared to those found intraoperatively. For labral tears, sensitivity, specificity and accuracy were 81%, 51% and 58% respectively. For chondral wear these figures were 17%, 100%, and 55% respectively. In our institution, MRA was therefore not as accurate as previously published work suggests.

A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional.

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique with a move away from the traditional stretch and strap technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the paediatric orthopaedic surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). There were 114 feet (80 patients): 64 feet treated 'traditionally' and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 333 and 44.1 weeks for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to 25.5% (CI : 15.8 to 383%) in the Ponseti group. When idiopathic clubfoot alone was analysed, these rates reduce to 56.5% (CI: 423 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic clubfoot. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot.

The accuracy of computer-assisted percutaneous iliosacral screw placement.

The benchmark fluoroscopic technique of iliosacral screw insertion is disadvantaged by its reliance on ionizing radiation and presentation of dynamic information in only one plane. Multiplane targeting requires interpolation, which may be associated with inherent errors. Computer-assisted surgery enables surgeons to monitor their screw trajectory in 3-D space. The clinical application of computer-assisted surgery requires validation of its accuracy when tested against a benchmark technique. We simulated surgical implantation of cannulated screws in 10 embalmed human cadavers. Two specimens had sacral dysplasia. We inserted 20 screws into the S1 body, the left side by the benchmark fluoroscopic technique and the right side by a fluoroscopically registered computer-assisted surgery technique. All specimens were intact with no simulated injuries. A postoperative high-definition computed tomography scan showed the screw track. The actual track was compared with the intended screw track by a graphical technique. There was no deviation from the intended screw path in any of the simulated screw paths. With both techniques, two of the 10 tracks penetrated the sacral cortex in dysplastic pelvices. A fluoroscopic computer-assisted surgery technique appears as accurate as the standard fluoroscopic technique but no more so. Caution is recommended in dysplastic pelvices.

A possible link between multiple sclerosis and Creutzfeldt-Jakob disease based on clinical, genetic, pathological and immunological evidence involving Acinetobacter bacteria.

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the nervous system. There is an increasingly likelihood that MS could be triggered/perpetuated by environmental (microbial) agents. Sporadic Creutzfeldt-Jakob disease (sCJD) is a relatively rare but fatal disease, which shows various clinical, genetic, pathological and immunological features through which it resembles a severe form of MS. The disease in some patients with MS may show a rapidly downhill course with death occurring within one to two years and a similar situation occurs in sCJD. The occurrence of these comparative similarities between MS and sCJD could be explained on the basis that both of these conditions might be sharing a common aetiopathogenic factor such as infection by Acinetobacter microbes and this possibility could be investigated further by carrying out immunological studies on a relatively large numbers of patients with MS and CJD.