Bite wounds are a common form of hand injury with the potential to lead to severe local and systemic sequelae and permanent functional impairment. Mammalian bite wounds may be caused by a variety of animal class and species; injuries resulting from dogs, cats and humans are the most widely discussed and reported in the literature. Bite wounds may be contaminated with aggressive pathogens and the anatomical vulnerability of structures within the hand means that without early recognition and treatment with irrigation and antibiotics, alongside a low index of suspicion for deep structural involvement requiring formal surgical exploration and washout, the consequences of such injuries can be disastrous. We review the literature and discuss the epidemiology, pathophysiology and microbiology relating to these injuries, as well as clinical aspects including signs, symptoms, and management.

We present three- to five- year results of 100 sequential patients undergoing total hip replacement (THR) through a multidisciplinary rapid recovery programme, with mean length of stay (LOS) 1.99 nights. Patients attend pre-admission 'bone school', with talks and assessments by the senior sister, physiotherapist and occupational therapist. All receive an uncemented Corail-Pinnacle THR via piriformis-sparing mini-posterior approach. 'Low dose' spinal plus light general anaesthesia provides sensory block whilst retaining motor function; painfree mobilisation is predictably achieved within four hours. Following radiograph and haemoglobin check next morning, patients are discharged on meeting specific nursing/physiotherapy criteria. Those within 20 miles receive outreach follow-up. Follow-up assessment is undertaken using SF36, Visual Analogue, Merle d'Aubigné-Postel and Oxford Hip Scores. Mean age was 65 years (25-91), mean BMI 28.7 (19-43). ASA ranged 1-3 (mode 2), Charlson comorbidity index from 0-9 (mode 3). Major complications were: one dislocation with deep infection; one myocardial infarction; one trochanteric bursitis requiring exploration; one ceramic fracture; and three metal debris reactions. Several more minor complications occurred. LOS was longer in older patients (p = 0.03) and those with higher Charlson index (p = 0.02).Eighty-two patients remain under follow-up, (mean 37.8 months, range 36-61). Six have died; five underwent revision; seven have moved away or been lost. Ninety-seven percent remain quite or very satisfied. Our LOS is amongst the shortest in the United Kingdom, with encouraging outcomes. The SSP succeeds by involving all team-members, and managing patient expectation. At a time of limited healthcare resources we propose that our SSP could readily be reproduced elsewhere with similar benefits.

Hutchinson-Gilford progeria syndrome (HGPS) is a rare genetic disorder. The estimated incidence is one in 4 million births. Orthopaedic manifestations include abnormality of the hips occurring early in the disease process. Severe coxa valga can be apparent by the age of 2 years. We report two cases of HGPS, one in a 7-year-old girl with avascular necrosis of the left hip and the second in a 13-year-old girl with recurrent traumatic hip dislocations. We demonstrate the pathoanatomical changes in the hip with HGPS using a combination of imaging modalities including radiographic, computed tomographic and MRI scans. These include coxa magna, coxa valga and acetabular dysplasia. We also comment on how these would affect the surgical management of this high-risk group of patients.

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Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries represent a significant disruption to the complex articulations of the midfoot. Many of these injuries are unstable with displacement and articular incongruity. This necessitates surgical intervention with the primary goals of anatomic reduction and midfoot stability. Evidence around surgical treatments for Lisfranc complex injuries is limited by heterogeneity in outcome measures and small patient numbers. Dorsal bridge plating is a well-recognized surgical technique with the benefits of rigid stability and joint preservation. The primary aim of this study is to assess the midterm functional outcomes for patients treated with this technique at our major trauma centre. Additionally, we assess the complication profile and review for risk factors that influence the functional outcome. Methods: Eighty-five adult patients were identified as undergoing open reduction and dorsal bridge plate fixation for displaced, unstable Lisfranc injuries at our major trauma centre between January 2014 and January 2018. Supplemental Kirschner wire stabilization was used for the lateral column if necessitated by the injury pattern. Importantly, metalwork was not routinely removed. A retrospective review of case notes and imaging was conducted in order to collate demographic data including co- morbidities and smoking status. Patient-reported outcome measures were collected at final follow-up, with a minimum follow-up of 24 months. The Manchester-Oxford Foot Questionnaire summary index (MOXFQ-Index) was the primary patient-reported outcome. The American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale, complications, and all-cause re-operation rates were secondary outcome measures. Univariate and multivariate analyses were used to identify risk factors associated with poorer functional outcomes. Results: The mean follow-up in this study was 40.8 months (24 - 72). 61/85 patients (72%) had high-energy or crush mechanisms of injury. The mean MOXFQ-Index was 27.0 (SD 7.1). The mean AOFAS score was 72.6 (SD 11.6). 48/85 patients (56%) had injury patterns that included an intra-articular fracture and this was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both p<0.001). There were trends towards poorer outcomes in diabetic patients (p=0.07), those patients needing supplementary Lisfranc or intercuneiform screws (p= 0.39 and 0.45 respectively), and as a greater number of tarsometatarsal joints were stabilized (p=0.12). Overall, eighteen patients (21%) underwent removal of metalwork for either prominence or stiffness. Female patients were more likely to require metalwork removal (OR 3.89, 95% CI 1.27 to 12.0, p=0.02). Eight patients (9%) required secondary arthrodesis for post-traumatic osteoarthritis. Conclusion: This is the largest series of Lisfranc injuries treated with dorsal bridge plate fixation reported to-date. Bridge plating is safe and effective in stabilizing this complex midfoot injury. The presence of an intraarticular fracture is a poor prognostic indicator. This is the first study to report on outcomes with routine retention of bridge plates. 21% of patients required removal of metalwork and this was more likely in female patients. Patient-reported outcomes and secondary arthrodesis rates were comparable to the existing literature in which bridge plates are routinely explanted. This suggests that routine removal may not be a necessity.