Orthopaedics and Trauma最新文献

Historically, orthopaedic implants required little clinical evidence before market introduction, either in the USA or the European Union (EU). There have been major incidents, with faulty designs or manufacturing techniques resulting in patient harm. The new EU Medical Device Regulations (MDR) have significantly changed the requirements around the introduction to the market of new medical devices in the EU. Initiatives like CORE-MD are founded to improve this process. EUDAMED will provide a mandatory European implant safety register. Real-world data, such as implant registries, have a major role to play in the continuous monitoring of implants, but this depends on them having high completeness (>95%) as well as coverage. Registries can also be used for post-market surveillance. Although implant registries use endpoints such as revision, as well as patient-reported outcomes, long-term follow-up is still needed to detect mediocre implants. For new designs, this often takes too long and potentially exposes patients to mediocre implants. This can be prevented by using more accurate, highly predictive methods at early follow-up (at 1 year), such as implant migration studies. Furthermore, registry-based or nested randomized controlled trials can be used to evaluate new implant designs and surgical techniques. Monitoring implants through registries remains vital in order to detect early or late unexpected failures related to the implant, surgical technique or indication, enhancing both implant development as well as patient safety.

A human factors (HF) approach can help optimize individual and team performance in healthcare and across related professions that work together. Trauma and orthopaedic surgeons carry out high-stakes tasks within a cognitively and physically demanding environment. This is compounded by the challenges of working in complex healthcare systems. Error is a ‘normal’ part of being human, and must be managed in order to prevent harm to patients and staff. HF is the science of how people work within their teams, and in the workplace. It examines interactions with equipment, and the processes used to achieve the desired outcome. It uses theory from fields as diverse as ergonomics, psychology and engineering in order to achieve these aims. This article outlines key topics relevant to surgeons striving to help improve patient safety and wellbeing within teams. These include theories of error in healthcare, systems-based approaches, performance-limiting factors, and non-technical skills.

Haematogenous pyogenic bone and joint infection is rarely seen in developed countries, but in the developing world it is still a major and common problem. New forms of acute fulminating osteomyelitis are likely to appear due to immunosuppression in the wake of the worldwide spread of HIV infection, AIDS, and the increased use of steroids, antibiotics, and immune activators. Osteomyelitis due to candida and cryptococcus infection in certain regions, are occasionally observed, whilst osteomyelitis that is resistant to treatment is associated with diabetes mellitus. Bone and joint infections are difficult to cure. This difficulty is related to the presence of bacteria adherent to dead bone and foreign material in many cases, and also to the drug resistance and limited penetration of antibiotics into infected bone. This presentation summarizes present knowledge of bone and joint infection and its management.

The core function of joint registries is to collect, collate, and present data about patients who undergo joint replacement surgery, and afford clinicians and administrators a range of analytic functions to monitor service performance. This article describes the development, evolution, and future of arthroplasty registries, drawing particularly from the experience of the Scottish Arthroplasty Project (SAP). The SAP was established in 1999 and is one of the oldest arthroplasty registries in the world. It collects information on patients undergoing hip, knee, ankle, shoulder, and elbow arthroplasty. The primary aim is to encourage continual improvement in the quality of care provided for arthroplasty patients in Scotland. It is distinct in terms of administration and methodology from the National Joint Registry (NJR) of England, Wales, and Northern Ireland as it monitors patients rather than implants. Since its inception, its work has contributed to a reduction in overall complication rates and a significant decrease in hospital length of stay for the growing number of patients undergoing arthroplasty. It continues to provide a robust database that is used to underpin national guidance through data-driven research. The research carried out by dedicated SAP fellows has enhanced the research portfolio of the SAP and raised its profile through high quality peer-reviewed publications. The SAP continues to evolve and by collaborating with other Scottish registries it will provide larger datasets containing greater diversity and granularity of information. These developments as well as ongoing analysis of existing areas ensure that the SAP continues to maintain and improve standards in arthroplasty across Scotland.

Skeletal muscle is an important structure responsible for producing movement, storing nutrients, maintaining posture and providing stability across joints. Unlike smooth and cardiac muscle, control can be voluntary. This review article will outline the macroscopic and microscopic appearance of skeletal muscle, the method by which it contracts, the types of skeletal muscle and pathology associated with it.

A review of the literature was undertaken to determine which amenable factors could be identified that would potentially improve the morbidity or mortality after hip fracture. Only four factors were identified that have been clearly reported to be associated with a reduction in mortality or morbidity, these were early surgery, cemented arthroplasty and experience of the surgeon and peri-operative antibiotics. Five interventions were identified that may reduce mortality or morbidity: nerve blocks, nutritional support, pharmacological thromboembolic prophylaxis, mechanical intermittent pneumatic compression and nail fixation of extracapsular fractures. Several other factors were identified for which it remains uncertain if they will reduce mortality or morbidity: preoperative assessment, β-blockers, blood transfusion, anti-embolism stockings, choice of surgical implant, cardiac output monitoring during surgery, choice of anaesthesia, prevention of intraoperative hypotension, anabolic steroids, multidisciplinary care, and rehabilitation. Continuing research is required to define which interventions are clearly effective and to further identify any adverse effects.

Sub-trochanteric femoral fractures represent around 10–34% of proximal femoral fragility fractures. They are notoriously difficult to treat, particularly achieving and maintaining reduction, which in turn can lead to longer operative time, more blood loss and higher rates of non-union. This review article provides an update on the potential reasons why fixation of sub-trochanteric fractures may fail, which implants are available, and what techniques can be used to try to avoid failure. Key papers from 2016 onwards were reviewed to deliver an overview of complications, implant choice, reduction techniques and consequences of open reduction.

With an increasingly ageing population it has never been more important to reduce the burden of fragility fractures. Fragility fractures, especially those of spine and hip, affect an individual's morbidity and mortality and carry a significant economic burden. There has been a recent shift towards a more stratified approach to the management of fracture risk, using fracture assessment tools, in combination with assessment of bone mineral density using dual X-ray absorptiometry scanning. Primary and secondary fracture prevention will be outlined including the important role of fracture liaison services. The use of medications which reduce fracture risks are discussed including the use of zoledronate in the immediate post-hip fracture setting.

The effective management of older patients with fragility fractures of the femur remains central to modern trauma care. Processes of assessment and communication alongside means of identifying poor performance are vital to improving care in this population. The National Hip Fracture Database (NHFD) now contains around 1 million cases and has evolved over time to reflect contemporary practices in the care of older injured patients. The NHFD is in a unique position to inform hip fracture care and the wider global management of injured older patients. This report provides an update and details the processes within the NHFD, the scope, lessons learned and highlights future direction.

Intertrochanteric fractures are a common type of proximal femoral fracture, and account for high morbidity and mortality. Early recognition and management of such fractures is important, with surgery preferably undertaken within 48 hours. The choice of surgical strategy remains variable between centres and individual surgeons; in part because evidence to support a specific strategy has been weak. Herein, we provide the latest evidence on the management of these fractures.