Aims. The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures. Methods. Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores. Results. In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47). Conclusion. Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery. Cite this article: Bone Jt Open 2021;2(8):646–654

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon.

We investigated whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration producing greater compression across the fracture. An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. There were two arms to this investigation. (1) Standard tension band wire configuration with stainless steel. (2) Modified tension band wire configuration with stainless steel. The simulated elbow was put through a range of movement and sensors measured the compression at the articular and non-articluar surfaces of the fracture. Measurements were taken for compression with different weights applied to challenge both the techniques of tension band wiring. Measurements from the non articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p<0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. The alternative tension band wiring technique proved superior in providing greater compression over the fracture site

Introduction. Despite costing up to 5X more than a one-third tubular plate (TTP) and no absolute indications, distal fibula locking plates (DFLP) are becoming increasingly popular in the fixation of ankle fractures, particularly in the elderly. We reviewed all our distal fibula fracture fixations, over the course of one year, in order to rationalise DFLP use. Methods. Patient demographics, Weber classification, use of DFLP or TTP and the mode of fixation were recorded. Open fractures and tibial plafond fractures were excluded. Results. 51/84 (61%) of patients had DFLP fixation of their distal fibula fracture, the majority (44/51) of which were for Weber B fractures. The DFLP was used in bridge mode for 12 Weber B fractures and in neutralisation mode for remaining 32. There was a significant difference in age between the DFLP and TTP groups for all fractures (p< 0.005) and for Weber B fractures treated in bridge mode (p=0.036), but not for Weber B fractures treated with a lag screw/ neutralisation plate (p=0.09). Discussion. In 32/44 of our cases, we used the DFLP to neutralise a lag screw. However DFLP are only of mechanical benefit when adequate fracture compression is not obtained either due to fracture comminution or due to osteoperotic bone, often seen in the elderly. All 32 of these Weber B fractures were amenable to a lag screw and were not comminuted. There was also no significant age difference between this group and the group of Weber B fractures that were treated with a lag screw/ neutralisation plate. In these cases therefore, the DFLP did not offer any mechanical advantage. Conclusion. We propose limiting the use of the DFLP to fibula fractures where intra-fragmentary compression cannot adequately be obtained, thus reducing our use by over 60% and significantly reducing our implant costs for such injuries

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented. Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed. 77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points. The XXS nails allow a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented. Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed. 77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points. The XXS nails allows a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low

The olecranon is exposed to high tension and bending forces. In 2/3 multifragment fractures occur. Tension belt and plate fixation in these not only transverse but also sagital and frontal plane fractures is often not possible. As a central weight bearing device the XS 4,5mm nail is exposed to a lower bending moment and a angle stable transverse fixation with 2,4mm threaded wires every 9mm is possible. Also a soft tissue independent fracture compression with a set screw (proximal longitudinal holes) is possible. Additional frontal and sagital plane fragments can be fixed to the system with fibre wire hemicerclages. From 5.1999 to 12.2002 80 consecutive cases with XS nail osteosynthesis of a olecranon fracture were treated and 73 (91%) could be re-examined clinically and radiological 15 months after surgery. 13,7% were open fractures 67% were 3 or more part fractures. For evaluation the Murphy score was used. The mean time for surgery was 37min for two part and 56 min. for more part fractures. The Murphy score showed in 64% very good and in 29% good results. Only in 4 patients with more part fractures with additional radius head fractures and previous surgery had fair or unsatisfactory results. The XS nail is a new concept for stabilisation of all but specially of complex and very comminuted olecranon fractures with a very low complication rate and good functional results

Introduction: The growth plate almost always is involved in periarticular fractures in children. Treatment and prognosis of these fractures depends on the extend of the injury. Reduction has to itle and anatomical while fixation has to be secure and minimal secondary to the small size of epiphysis. The K-wires do not cause so much tissue damage but there is the possibility of sliding suiting in loss of fixation. On the other hand they offer no fracture compression. The use of screws may result in bone collapse. It is also inappropriate for small fragments. Patients and Methods: From November 1999 untill December of 2001 17 patients with a diagnosis of a periarticular fracture were admitted to the pediatric orthopaedic department of KAT Hospital. There were 9 fractures of the elbow and 8 ankle fractures. Mean age was 12 years (6–14) (11 boys and 6 girls). Plain radiographs and CT were obtained before surgery to evaluate the kind and extend of the fracture. After limited arthrotomy percutaneous fixation was obtained with the use of at least wires 2 FFS wires and then a splint or cast was applied. Results: FFS screws were removed in 3–6 weeks without anesthesia. In all of the patients the fracture was healed and there was not any infection or loss of reduction. Screws breakage was seen in Datient with no any functional consequences. Conclusion: The use of FFS allows compressive fixation in periarticular fractures in children. It can be used percutaneously and it can be removed without need for another surgery

Percutaneous compression plates (PCCP) used in the treatment pertrochanteric fractures are made of stainless steel, available in one size only and have two threaded oblique proximal holes for the telescopic cephalic (femoral neck) screws and three distal holes for the shaft self-tapping screws. The plate is inserted at right angles to the femoral diaphysis through a small incision and rotated so that its axis is parallel to the diaphysis. By means of small movements it is advanced along the bone, positioned between the vastus lateralis muscle and the periosteum and then fixed with the proximal and distal screws. The neck screws are telescopic and they provide a double axis fixation in the femoral neck, which increases rotational stability by allowing fracture compression and preventing collapse of the neck and subsequent cut-out. Surgery takes about 30 min and consists of two small longitudinal incisions; thus the procedure is associated with only minimal blood loss. From March 2003 to May 2004 we treated 101 patients with PCCP: 73 women and 28 men with an average age of 82 years (range 26–101 years). The average blood loss was 92.4 ml. Of the patients, 31 (29.8%) did not receive blood transfusions and of the remaining 70 patients (70.2%), 26 received one unit of blood, 35 two units and nine two units operatively and two post-operatively. When possible, weight-bearing was allowed on the third postoperative day, thus achieving a functional recovery. The healing times are similar to those of other methods. No incidence of fracture collapse or screw cut-outs was seen in this series

Clinical Problem: fractures under tension are common injuries and occur when patients are falling on partial flexed limbs under maximal contraction of the extensor muscles. Typical injuries are patella and olecranon. For these fractures the tension belt osteosyntheses is the mainly used procedure. A high complication rate regarding dislocation, bone healing, pain and functional outcome are reported. This is due to the unstable fixation with the tension belt because of the tendon insertion around the bone fragment witch allow secondary loosening of the tension belt under alternating load. This was found allready 1987 by Brill and Hopf in an experimental study. Materials and Methods: To improve stabilisation a new device was developed: the XS (4,5mm diameter) and the XXS nail (3,5mm) witch is locked with threaded wires and a set screw allows fracture compression inside the nail independend from the soft tissues around. Fiber Wire cerclage transversal around the threaded wire ends allow the fixation of additional frontal plane fragments or marginal fragments. Experimental test were performed in a patella sow-bone models and showed superior to tension bel (patella) and Plate fixation/fibula). On the other side the locked nail system allows percutaaneous osteosynthesis of the whole ulna also in shaft, distal fractures and shortening osteotomies. All clinical cases treated with the XS/XXS nail where recorded prospectively and re-examined after 6–12 months. From may 2000 to march 2002 76 patients with olecranon fractures were evaluated. 85% of the olecranon fracture patients could be re-examined. Most patients where treated immediately or after wound healing without splint. Results: the experimental results shows in all XS nail group no gap after alternating load of 250 and 500N and a rigidity a little higher than that of the not osteotomised patellae. In the tension belt groups in all tested patellae visible gaps of 1 to 3 mm occurred. There was no difference between the single and double XS nail Osteosynthesis. 71.7% of all patients with olecranon fractures showed a very good result according to the Murphy score. In 2 part fractures the rate was even 94.7%. Only in the group of more part fractures in 5.9% fair results were found. No patient showed a poor result. The technical possibilities of XS nail osteosynthesis in ulna shaft, distal fractures and shortening osteotomies are presented. Conclusions: the XS nail is a new device witch allows good anatomical reconstruction and stable fixation with immediate functional therapy in all olecranon and ulna fractures

We have identified 69 patients with Vancouver B1 periprosthetic fractures around stable femoral implants. Open reduction internal fixation is the recommended treatment; however recent studies have revealed high rates of nonunion. We have reviewed the fixation techniques utilized to treat these patients, and identified outcomes in relation to rates of union, further surgery and mortality. Patients were identified from a prospective database of all trauma admissions at Nottingham University Hospitals from 1999 to 2010. Hospital notes were independently reviewed and data retrieved. 69 patients were identified. Mean age 77 years and 63% were female. 51 (74%) occurred around total hip replacements and 18 (26%) around hip hemiarthroplasty after a previous hip fracture. Periprosthetic fracture occurred around an Exeter stem (n=18), Charnley (n=10), Austin Moore (n=15), other (n=6). 20 patients had undergone previous revision surgery. The mean time from index surgery to fracture was 58 months (median 24) around primary stems, and 48 months (median 22) around revision stems. 6 patients (9%) were treated non-operatively. Five of these had undisplaced fractures (all healed but one required revision due to loosening) and one was too unwell. 63 patients (91%) were treated by open reduction internal fixation. Of these, single plate fixation was performed in 40 cases (64%). In the vast majority of cases, lag screw fixation of the fracture with a long (>12 hole) pre-contoured 4.5mm locking plate was utilised with cables. Both locking and cortical screws were used to achieve stable fixation (Figure 1). A double plate technique was used in 16 cases (25%), where plates were placed perpendicularly to each other (laterally and anteriorly). Strut grafts were used in 13 cases (21%). 7 patients (11%) were treated with cables alone. 23 patients have subsequently died (33%). Two have been lost to follow up and three are awaiting union. There is a mean follow-up of 35 months. Deep infection occurred in 4 cases (6%). Non-union occurred in four cases (6%). Two of these were infected and one was treated with cables alone. Malunion occurred in one case treated with cables. One patient had a dislocation and two superficial infections occurred. Further surgery took place in 8 patients (12%). Three of the infected cases were revised and one underwent wound washout. The two other non-unions were revised. Three further revisions were performed: one for malunion, one for aseptic loosening (treated non-operatively) and another for a second periprosthetic fracture. Superficial wound washout was performed in one case. Mortality was 10% at 3 months, 22% at 1 year and 47% at 3 years. We have identified that union can be achieved in the majority of cases after periprosthetic fracture fixation. Cable fixation was associated with a high complication rate (7 cases: two requiring revision surgery: one nonunion, one malunion). We recommend that Vancouver B1 periprosthetic fractures are treated with meticulous technique to achieve anatomical reduction and fracture compression using lag screw technique and plating. Further mechanical support can be provided through the use of a second plate, cables and/or strut grafts

Aims

Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods.

Objectives

CT-based three-column classification (TCC) has been widely used in the treatment of tibial plateau fractures (TPFs). In its updated version (updated three-column concept, uTCC), a fracture morphology-based injury mechanism was proposed for effective treatment guidance. In this study, the injury mechanism of TPFs is further explained, and its inter- and intraobserver reliability is evaluated to perfect the uTCC.

Introduction: The conventional treatment of humeral shaft nonunion is plating and cancellous bone grafting. This option is very efficient but not absolutly safe. In case of initial treatment by nailing, a secondary compression at the site of the fracture could be an alternative. Materials and Method: Between January 2000 and december 2003, in a prospective study, 56 patients have been operated for an acute humeral shaft fracture using retrograde locking nailing (UHN. ®. , Synthes™). 4 patients (7%) had an aseptic and tight nonunion. All of them were treated by secondary closed compression without bone graft. The mean age of the patients was 42 years-old at the procedure (range 17 to 73). All the patients were reviewed with clinical and radiological exams, using the DASH and Rommens scores and standard radiographs. Results: No per or post operative complication occurred. Bone healing was obtained in all cases within 4 months. At an average follow-up of 66 months (range 51 to 74), the average DASH score was 29.6/100 (range 8.3 to 60.8) and the Rommens score was excellent in 3 patients and moderate in one because of history of Complex Regional Pain Syndrome. Discussion and Conclusion: One of the characteristics of the retrograde nailing with UHN is to permit an initial or secondary axial compression at the site of the fracture. Secondary compression in the treatment of non union offers the advantages of a closed procedure which avoids any radial nerve injury, and preserves the bone vascular supply. In the present preliminary series, the isolated secondary compression appeared as a simple and safe procedure which allowed bone healing in all cases

Clinical Problem. Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems. We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail. Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,. Material and Methods. the XS nail is a 4.5mm or the XXS a 3.5mm straight nail witch is locked by threaded wires witch are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The Fibula is fixed percutaneusly and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. From july 2000 to july2006 54 pilon fractures where treated. The mean age was 54 years (range 25–92). In all cases except one referred after 4 weeks the fibula and joint dislocations where stabilised primarily. The tibia XS nail osteosynthesis or limited invasive plate fixation was performed after 5–8 days except two fixed primarily. Up to now 43 patients could be re-examined more than 12 months after surgery. The results were classified according to the Ovadia Score. In a second study: from 05/2000 to 03/2002 214 ankle fractures were stabilised with a XS or XXS nail. The mean age was 51 year, 59% were woman. 35% were Weber B and 25% type C fractures. The re-examination after 6 months could be performed in 91 Patients and was evaluated according to the Ovadia score (clinical and radiological). Results. All articular pilon fractures and fibula fractures healed without problems but in 3 metaphyseal fractures delayed union required bone grafting. According to the Ovadia Score after one year the results were very good or good in the subjective criteria in 69% of the patients and 61% in the objective criteria. In the ankle fractures study in 2 patients haematoma revisions and in 2 patients with the primary used oblique insertion of the nail a proximal fibula fracture occured. At re-examination 71% showed an excellent and 25% a good result. Conclusion. the minimal invasive stabilisation of pilon fractures with the XS nail and the absence of plates on the bone surface reduces significantly the healin. The Xs nail is also a new option for ankle stabilisation. It improves the stability and reduces the complication of ankle osteosynthesis due to the lack of implant under the skin on the bone surface and due to the higher biomechanical stability of intramedullary implants

Objective: To assess the correlation between the Denis classification and clinical outcomes. Subjects and Design: We performed a retrospective study of 87 patients with spinal injuries in the thoracolumbar region. All patients were admitted to the Oswestry Spinal injuries unit between Jan 1990 and December 1998. Following a review of their notes, CT scans and radiographs, we attempted to classify their injuries according to the Denis (3 column) Classification of spinal injuries. Outcome Measures: The patients were assessed both at the time of presentation and on subsequent follow up. Neurological function was assessed using the Frankel classification. Results: The results of the study show that the correlation between Denis classification and clinical outcome is poor. In addition, the relative proportions of the two most common Major Injury types described by Denis were reversed in our study with Burst fractures forming the majority of injuries. This difference in out come was attributed primarily to the increased use of CT scanning in our study. It appears that Denis misdiagnosed a significant number of burst (two column) fractures as compression (anterior column) fractures. Conclusions: Our findings showed no correlation between the degree of instability and the number of columns disrupted. We believe that only 3 column fracture dislocations are fundamentally unstable. In addition, our results support the practise of treating vertebral fractures by conservative means with no apparent correlation between treatment modality and neurological outcome at long term follow up

Introduction: Allen and Ferguson in 1982 described five stages of compression extension injury to the cervical spine; the first stage that was considered as a stable injury involves fracture of the articular process, pedicle or lamina which may be associated with a rotary spondylolisthesis. This fracture pattern, which is not uncommonly missed on the initial X-rays, can be diagnosed using CT scanning especially if patients present with root symptoms. This fracture will be usually treated conservatively as a stable injury. In practice we found out that this type of bony fracture might present later on with subluxation and/or persistence of symptoms even if treated in rigid immobilisation devices including halo jacket. The hypothesis around this fracture pattern will be a hyperextension mechanism combined with a degree of lateral tilt and rotation producing an anterior annular disruption under tension and a unilateral posterolateral mass or laminar fracture under compression with a resultant rotational instability around the intact lateral mass. Material and Methods: Ten patients with stage I compression extension injury who presented with subluxation were studied prospectively aiming for addressing the patho-anatomy and define a method for treatment. All the cases presented with neurological manifestations, nine cases with root symptoms and one case with incomplete cord injury. The treatment consisted of early closed reduction followed by anterior fusion and fixation. Results and Conclusion: All patients showed neurological improvement. Radiological union was achieved in all the patients with maintenance of the alignment. In conclusion, extension compression injury type I (fracture of the bony posterior elements) is usually a stable injury but if there is additional failure of the disc this segment will be rendered rotationally unstable. Despite the limited number of patients in this series the results of early anterior fusion with fixation were very satisfactory encouraging the recommendation for using this type of treatment

Introduction The aim of this study was to assess the effectiveness of percutaneous vertebroplasty as an invervention therapy in symptomatic vertebral compression fractures on pain relief and improvement of the quality of life of the patients. The increasing elderly population is assumed to be associated with an increased incidence of osteoporotic vertebral compression fractures. These fractures lead to a severe morbidity, decreasing quality of life, worsening co-morbidity and sometimes resulting in death. It is justifiable to treat stable vertebral compression fractures by non-operative therapy. Previous studies have shown that vertebroplasty as a non-operative treatment increases the vertebral body strength, restores vertebral body stiffness, reinforces fractured bone, prevents further deformity and alleviates the local pain. Complication rates are reputed to be low. Methods This is a prospective clinical study of percutaneous vertebroplasty in treating stable vertebral compression fractures. Since January 2001, 30 patients were treated by percutaneous vertebroplasty for 58 osteoporotic compression vertebral fractures, four non-osteoporotic stable compression fractures, two compression vertebral fractures due to metastatic carcinoma of the prostate and one due to metastatic carcimona of the cervix. Bone cement PMMA (Howmedica) mixed with Vancomycin antibiotic, and Tantalum Dust Powder (Cook Medical Co) was inserted to the facture site using Oseo-Site Bone Biopsy needle (Cook Medical Co). Pre and post treatment pain, morbidity, quality of life, hospital stay, complication and long term results were evaluated. Results The average hospital stay after vertebroplasty was 2.2 days. Signficant pain relief from 9.9 (pain scale) to 1.8. Improvement of the quality of life: siting, standing, walking without a lumbar brace was achieved one day after the treatment. In some cases the delay of improvement was influenced by the co-morbidity of the patients. No complications were found during the procedure of this treatment. Conclusions Vertebroplasy provided a promisingly good result in alleviating the local pain and improving the quality of life in osteoporotic thoraco-lumbar compression fractures. Prospective and long term results should be evaluated in greater sample size for non osteoporotic stable compression fractures. Although vertebroplasty does not change the nature of carcinoma, it improves the rest of the quality of life of someone suffering from metastatic fractures. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits