‘Hobson’s choice’: a qualitative study of consent in acute surgery

Objectives: The study aimed to understand through qualitative research what patients considered material in their decision to consent to an acute surgical intervention. Participants, setting and intervention: The patients selected aged between 18 and 90, having been admitted to a major trauma centre to undergo an acute surgical intervention within 14 days of injury, where English was their first language. Data saturation point was reached after 21 patients had been recruited. Data collection and analysis were conducted simultaneously, through interviews undertaken immediately prior to surgery. The data were coded using NVIVO V.12 software. Results: The key theme that originated from the data analysis was patients were unable to identify any individual risk that would modify their decision-making process around giving consent. The patient’s previous experience and the experience of others around them were a further theme. Patients sensed that there were no non-operative options for their injuries. Conclusion: This is the first study investigating what patient considered a material risk in the consent process. Patients in this study did attribute significance to past experiences of friends and family as material, prompting us to suggest that the surgeon asks about these experiences as part of the consent process. Concern about functional recovery was important to patients but insufficient to stop them from consenting to surgery, thus could not be classified as material risk

The Effect of an Abnormal BMI on Orthopaedic Trauma Patients: A Systematic Review and Meta-Analysis

Aims: The aim of this systemic review is to identify the complications that arise in operating on orthopaedic trauma patients with an abnormal body mass index (BMI). Materials and Methods: Systematic literature search using a combination of MESH subject headings and free text searching of Medline, Embase, SCOPUS and Cochrane databases in August 2019. Any orthopaedic injury requiring surgery was included. Papers were reviewed and quality assessed by two independent reviewers to select for inclusion. Where sufficiently homogenous, meta-analysis was performed. Results: A total of 26 articles (379,333 patients) were selected for inclusion. All complications were more common in those with a high BMI (>30). The odds ratio (OR) for high BMI patients sustaining post-operative complication of any type was 2.32 with a 23% overall complication rate in the BMI > 30 group, vs. 14% in the normal BMI group (p < 0.05). The OR for mortality was 3.5. The OR for infection was 2.28. The OR for non-union in tibial fractures was 2.57. Thrombotic events were also more likely in the obese group. Low BMI (<18.5) was associated with a higher risk of cardiac complications than either those with a normal or high BMI (OR 1.56). Conclusion: Almost all complications are more common in trauma patients with a raised BMI. This should be made clear during the consent process, and strategies developed to reduce these risks where possible. Unlike in elective surgery, BMI is a non-modifiable risk factor in the trauma context, but an awareness of the complications should inform clinicians and patients alike. Underweight patients have a higher risk of developing cardiac complications than either high or normal BMI patient groups, but as few studies exist, further research into this group is recommende

Fabrication of Multi-Layered Bone Scaffolds using Femtosecond Pulsed Lasers

An IR femtosecond pulsed laser was used for micropatterning of biomineral containing chitosan membranes, aiming to enhance bone mineralization and angiogenesis. Pre and post irradiation materials have been characterized with XRD, SEM and spectroscopic techniques

Periprosthetic acetabular fractures as a complication of total hip arthroplasty

Periprosthetic acetabular fractures are rare but potentially devastating complications of total hip arthroplasty. As the number of total hip arthroplasties performed annually increases, so has the incidence of periprosthetic fractures, with the topic being spotlighted more frequently in the orthopaedic community. There is a particular sparsity of literature regarding periprosthetic acetabular fractures, with periprosthetic femoral fractures after total hip arthroplasty being traditionally far more commonly reported. This article aims to provide an up-to-date review of the epidemiology, risk factors, diagnostic challenges, classifications, and management strategies for periprosthetic acetabular fractures after total hip arthroplasty

Unstable pelvic fractures in women: implications on obstetric outcome

Purpose Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery. Method A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16–45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared. Results Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate. Conclusion Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies

Synthesis of Chitosan and Ferric-Ion (Fe³⁺)-Doped Brushite Mineral Cancellous Bone Scaffolds

Biodegradable scaffolds are needed to repair bone defects. To promote the resorption of scaffolds, a large surface area is required to encourage neo-osteogenesis. Herein, we describe the synthesis and freeze-drying methodologies of ferric-ion (Fe³⁺) doped Dicalcium Phosphate Dihydrate mineral (DCPD), also known as brushite, which has been known to favour the in situ condition for osteogenesis. In this investigation, the role of chitosan during the synthesis of DCPD was explored to enhance the antimicrobial, scaffold pore distribution, and mechanical properties post freeze-drying. During the synthesis of DCPD, the calcium nitrate solution was hydrolysed with a predetermined stoichiometric concentration of ammonium phosphate. During the hydrolysis reaction, 10 (mol)% iron (Fe³⁺) nitrate (Fe(NO₃)₃) was incorporated, and the DCPD minerals were precipitated (Fe3+-DCPD). Chitosan stir-mixed with Fe³⁺-DCPD minerals was freeze-dried to create scaffolds. The structural, microstructural, and mechanical properties of freeze-dried materials were characterized

Regulation of Angiogenesis Discriminates Tissue Resident MSCs from Effective and Defective Osteogenic Environments

[Abstract] Background: The biological mechanisms that contribute to atrophic long bone non-union are poorly understood. Multipotential mesenchymal stromal cells (MSCs) are key contributors to bone formation and are recognised as important mediators of blood vessel formation. This study examines the role of MSCs in tissue formation at the site of atrophic non-union. Materials and Methods: Tissue and MSCs from non-union sites (n = 20) and induced periosteal (IP) membrane formed following the Masquelet bone reconstruction technique (n = 15) or bone marrow (n = 8) were compared. MSC content, differentiation, and influence on angiogenesis were measured in vitro. Cell content and vasculature measurements were performed by flow cytometry and histology, and gene expression was measured by quantitative polymerase chain reaction (qPCR). Results: MSCs from non-union sites had comparable differentiation potential to bone marrow MSCs. Compared with induced periosteum, non-union tissue contained similar proportion of colony-forming cells, but a greater proportion of pericytes (p = 0.036), and endothelial cells (p = 0.016) and blood vessels were more numerous (p = 0.001) with smaller luminal diameter (p = 0.046). MSCs showed marked differences in angiogenic transcripts depending on the source, and those from induced periosteum, but not non-union tissue, inhibited early stages of in vitro angiogenesis. Conclusions: In vitro, non-union site derived MSCs have no impairment of differentiation capacity, but they differ from IP-derived MSCs in mediating angiogenesis. Local MSCs may thus be strongly implicated in the formation of the immature vascular network at the non-union site. Attention should be given to their angiogenic support profile when selecting MSCs for regenerative therapy

Femoral artery thrombosis after internal fixation of a transverse acetabular fracture in a patient with osteogenesis imperfecta type I

Osteogenesis imperfecta is a genetic disorder characterized by increased susceptibility to fractures and vascular injuries due to connective tissue fragility. In this case report, we present a patient with osteogenesis imperfecta type I who sustained a transverse fracture of the right acetabulum while transferring from bed to chair. The fracture was repaired through an ilioinguinal approach. During the surgery, an iatrogenic injury to the femoral artery and vein occurred. This intraoperative complication was salvaged by immediate vascular repair. We discuss the possible causes of iatrogenic vascular injuries in patients with osteogenesis imperfecta. Orthopaedic surgeons should be aware of this potentially devastating complication in this particular patient cohort

Physiologically engineered porous titanium/brushite scaffolds for critical-size bone defects: A design and manufacturing study

Repairing critical-size bone defects still represents a critical clinical challenge in the field of trauma surgery. This study focuses on a physiological design and manufacturing of porous composite scaffold (titanium Ti with 10 % mole iron doped brushite DCPD-Fe3+) which can mimic the biomechanical properties of natural cortical bone, specifically for the purpose of repairing critical-size defects. To achieve this, the principle of design of experiments (DOE) was applied for investigating the impact of sintering temperature, mineral ratio, and volume fraction of porosity on the mechanical properties of the fabricated scaffolds. The fabricated scaffolds had open porosity up to 60 %, with pore size approximately between 100 μm and 850 μm. The stiffness of the porous composite scaffolds varied between 3.30 GPa and 20.50 GPa, while the compressive strength ranged from approximately 130 MPa–165 MPa at sintering temperatures equal to or exceeding 1000 °C. Scaffolds with higher porosity and mineral content demonstrated lower stiffness values, resembling natural bone. Numerical simulation was employed by Ansys Workbench to investigate the stress and strain distribution of a critical size defect in mid-shaft femur which was designed to be replaced with the fabricated scaffold. The fabricated scaffolds showed flexible biomechanical behaviour at the bone/scaffold interface, generating lower stress levels and indicating a better match with the femoral shaft stiffness. The experimental and numerical findings demonstrated promising applications for manufacturing a patient-specific bone scaffold for critical and potentially large defects for reducing stress shielding and minimizing non-union risk