Aims

Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures.

Thrombelastography (TEG) is a point-of-care tool that can measure clot formation and breakdown using a whole blood sample. We have previously used serial TEG analysis to define hypercoagulability and increased venous thromboembolism (VTE) risk following a major fracture requiring surgical treatment. Additionally, we have used serial TEG analysis to quantify the prolonged hypercoagulable state and increased VTE risk that ensues following a hip fracture. Recently developed cartridge-based platelet mapping (PLM) using TEG analysis can be used to activate platelets at either the adenosine diphosphate (ADP) receptor or at the Thromboxane A2 (AA) receptor, in order to evaluate clot strength when platelets are activated only through those specific receptors. This study aim was to evaluate platelet contribution to hypercoagulability, in order to identify potential therapeutic targets for VTE prevention. We hypothesized that there would be a platelet-predominant contribution to hypercoagulability following a hip fracture.

Patients aged 50 years or older with a hip fracture treated surgically were enrolled in this prospective cohort study. Exclusion criteria were: prior history of VTE, active malignancy, or pre-injury therapeutic dose anticoagulation. Serial TEG and PLM analyses were performed at admission, post-operative day (POD) 1, 3, 5, 7 and at 2-, 4-, 6- and 12-weeks post-operatively. All patients received thromboprophylaxis with low molecular weight heparin (LMWH) for 28 days post-operatively. Hypercoagulability was defined as maximal amplitude (MA; a measure of clot strength) over 65mm based on TEG analysis. Independent samples t-tests were used to compare MA values with this previously established threshold and a mixed effects linear regression model was used to compare MA values over time. Independent samples t-tests and Chi-sqaured analyses were used to compare between the surgical fixation and arthroplasty groups.

Forty-six patients with an acute hip fracture were included, with a mean age of 77.1 (SD = 10.6) years, with 61% (N=11) being female. Twenty-six were treated with arthroplasty (56.5%), while the remainder underwent surgical fixation of their hip fractures. TEG analysis demonstrated post-operative hypercoagulability (mean MA over 65mm) at all follow-up timepoints until 12-weeks. PLM identified a platelet-mediated hypercoagulable state based on elevated ADP-MA and AA-MA, with more pronounced platelet contribution demonstrated by the AA pathway. Patients treated with arthroplasty had significantly increased AA-MA compared with ADP-MA at POD 3 and at the 12-week follow-up.

Thrombelastography can be used to identify hypercoagulability and increased risk for VTE following a hip fracture. Platelet mapping analysis from this pilot study suggests a platelet-mediated hypercoagulable state that may benefit from thromboprophylaxis using an anti-platelet agent that specifically targets the AA platelet activation pathway, such as acetylsalicylic acid (ASA). This research also supports differences in hypercoagulability between patients treated with arthroplasty compared to those who undergo fracture fixation.

Dual plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation, as these are common reasons for revision surgery. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating to traditional small-fragment clavicle plates for biomechanical non-inferiority and to determine if an optimal plate configuration could be identified, using a cadaveric model.

Twenty-four cadaveric clavicles were randomized to one of six groups (n=4 per group), stratified by CT-based bone mineral content (BMC). The six different plating configurations compared were: pre-contoured superior or anterior fixation using a single 3.5-mm LC-DC plate, and four different dual-plating constructs utilizing 2.4-mm and 2.7-mm reconstruction or LC-DC plates. The clavicles were plated and then osteotomized to create an inferior butterfly fracture, which was then fixed with a single interfragmentary screw (OTA 15.2B). Axial, torsional, and bending (anterior and superior surface loading) stiffness were determined for each construct through non-destructive cyclic testing, using an MTS 858 Bionix materials testing system. This was followed by a load-to-failure test in three-point superior-surface bending. Kruskal-Wallace H and Mann-Whitney U were used to test for statistical significance.

There were no significant differences in BMC (median 7.9 g, range 4.2-13.8 g) for the six groups (p=1.000). For axial stiffness, the two dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either reconstruction or LC-DC) were significantly stiffer than the other four constructs (p=0.021). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared to the 3.5-mm superior plate (p=0.043). In addition, a 3.5-mm plate placed anterior was a stiffer construct than a superior 3.5-mm plate (p=0.043). No significant differences were found in torsional stiffness or load-to-failure between the different constructs.

Dual plating using mini-fragment plates is biomechanically superior for fixation of midshaft clavicle fractures when compared to a single superior 3.5-mm plate and has similar biomechanical properties to a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual plating constructs were compared to each other. However, placing a 2.4-mm plate superiorly in combination with a 2.7-mm plate anteriorly might be the optimal construct, given the biomechanical superiority over the 3.5-mm plate placed superior.

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

Major orthopaedic fractures are an independent risk factor for the development of venous thromboembolism (VTE), which are significant causes of preventable morbidity and mortality in trauma patients. Despite thromboprophylaxis, patients who sustain a pelvic or acetabular fracture (PA) continue to have high rates of VTE (12% incidence). Thrombelastography (TEG) is a whole-blood, point-of-care test which provides an overview of the clotting process. Maximal amplitude (MA), from TEG analysis, is the measure of clot strength and values ≥65mm have been used to quantify hypercoagulability and increased VTE risk. Therefore, the primary aim was to use serial TEG analysis to quantify the duration of hypercoagulability, following surgically treated PA fractures.

This is a single centre, prospective cohort study of adult patients 18 years or older with surgically treated PA fractures. Consecutive patients were enrolled from a Level I trauma centre and blood draws were taken over a 3-month follow-up period for serial TEG analysis. Hypercoagulability was defined as MA ≥65mm. Exclusion criteria: bleeding disorders, active malignancy, current therapeutic anticoagulation, burns (>20% of body surface) and currently, or expecting to become pregnant within study timeframe.

Serial TEG analysis was performed using a TEG6s hemostasis analyzer (Haemonetics Corp.) upon admission, pre-operatively, on post-operative day (POD) 1, 3, 5, 7 (or until discharged from hospital, whichever comes sooner), then in follow-up at 2-, 4-, 6-weeks and 3-months post-operatively. Patients received standardized thromboprophylaxis with low molecular weight heparin for 28 days post-operatively. VTE was defined as symptomatic DVT or PE, or asymptomatic proximal DVT, and all participants underwent a screening post-operative lower extremity Doppler ultrasound on POD3. Descriptive statistics were used to determine the association between VTE events and MA values. For the primary outcome measure, the difference between the MA threshold value (≥65mm) and serial MA measures, were compared using one-sided t-tests (α=0.05).

Twenty-eight patients (eight females, 29%) with a mean age of 48±18 years were included. Acetabular fractures were sustained by 13 patients (46%), pelvic fractures by 14 patients (50%), and one patient sustained both. On POD1, seven patients (25%) were hypercoagulable, with 21 patients (78%) being hypercoagulable by POD3, and 17 patients (85%) by POD5. The highest average MA values (71.7±3.9mm) occurred on POD7, where eight patients (89%) were hypercoagulable. At 2-weeks post-operatively, 16 patients (94%) were hypercoagulable, and at four weeks, when thromboprophylaxis was discontinued, six patients (40%) remained hypercoagulable. Hypercoagulability persisted for five patients (25%) at 6-weeks and for two patients (10%) by three months.

There were six objectively diagnosed VTE events (21.4%), five were symptomatic, with a mean MA value of 69.3mm±4.3mm at the time of diagnosis. Of the VTE events, four occurred in participants with acetabular fractures (three male, 75%) and two in those with pelvic fractures (both males).

At 4-weeks post-operatively, when thromboprophylaxis is discontinued, 40% of patients remained hypercoagulable and likely at increased risk for VTE. At 3-months post-operatively, 10% of the cohort continued to be hypercoagulable. Serial TEG analysis warrants further study to help predict VTE risk and to inform clinical recommendations following PA fractures.

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT.

This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF.

Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position.

Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers.

Venous thromboembolism (VTE) is the second most common complication and pulmonary embolism (PE) is the fourth most common cause of death after a hip fracture. Despite thromboprophylaxis, deep vein thrombosis (DVT) is detected in up to 45% of hip fracture patients. Thrombelastography (TEG) is a whole-blood, point of care test capable of providing clinicians with a global assessment of the clotting process, from fibrin formation to clot lysis. Maximal amplitude (mA) from TEG analysis is a measure of clot strength. Elevated admission mA values of >65mm and >72mm have been determined to be independent predictors of in-hospital PE. The coagulation index (CI) is calculated based on TEG parameters and defines hypercoagulable state as CI >3. This study aimed to use serial TEG analysis to determine the duration of hypercoagulable state after hip fracture.

A prospective cohort of hip fracture patients >50 years of age amenable to surgical treatment (AO 31A1–A3 & 31B1–B3) were enrolled at a Level I trauma centre. Serial TEG analysis (TEG 6S) was performed every 24-hours from admission until 5-days post-operatively and at 2- and 6-week follow-up visits. All patients received a minimum of 28 days of thromboprophylaxis. Descriptive statistics and single sample t-tests were used for comparison of mA to the 65mm threshold.

Thirty-five patients (26 female) with a median age of 83 (range = 71–86) years were included. On admission, 31.4% and 82.9% of patients were hypercoagulable based on mA >65mm and CI, respectively. At 2 weeks, all patients remained hypercoagulable, however, mA >72mm showed that 16 patients (47.1%) were at even higher risk for VTE. At 6-weeks, 65.7% and 97.1% of patients were hypercoagulable based on mA >65mm and CI, respectively. When compared with the mA >65mm threshold, patients were hypocoagulable at the time of admission (mA = 62.2 (±6.3), p = 0.011), but became significantly more hypercoagulable at 2-weeks (mA = 71.6 (±2.6), p < 0 .001), followed by continued hypercoagulability at 6-weeks, however not significantly elevated above the 65mm threshold (mA = 66.2 (±3.8), p = 0.058). One patient developed a symptomatic DVT at 2-weeks and had a mA = 72.9 and a CI of 5.9.

This is the first study to demonstrate that >50% of hip fracture patients remain hypercoagulable 6 weeks post fracture despite thromboprophylaxis, and there are individual hypercoagulable responses. This is critical, as guidelines only recommend 28 to 35 days of thromboprophylaxis in this high-risk population. Previously determined mA thresholds may be a more sensitive test for risk-stratifying patients' VTE risk than the CI threshold. Additionally, assessing ΔmA using serial TEG may better predict VTE risk.

Distracted driving is now the number one cause of death among teenagers in the United States of America according to the National Highway Traffic Safety Administration. However, the risks and consequences of driving while distracted spans all ages, gender, and ethnicity. The Distractions on the Road: Injury eValuation in Surgery And FracturE Clinics (DRIVSAFE) Study aimed to examine the prevalence of distracted driving among patients attending hospital-based orthopaedic surgery fracture clinics. We further aimed to explore factors associated with distracted driving.

In a large, multi-center prospective observational study, we recruited 1378 adult patients with injuries treated across four clinics (Hamilton, Ontario, Toronto, Ontario, Calgary, Alberta, Halifax, Nova Scotia) across Canada. Eligible patients included those who held a valid driver's license and were able to communicate and understand written english. Patients were administered questions about distracted driving. Data were analyzed with descriptive statistics.

Patients average age was 45.8 years old (range 16 – 87), 54.3% male, and 44.6% female (1.1% not disclosed). Of 1361 patients, 1358 self-reported distracted driving (99.8%). Common sources of distractions included talking to passengers (98.7%), outer-vehicle distractions (95.5%), eating/drinking (90.4%), music listening/adjusting the radio (97.6%/93.8%), singing (83.2%), accepting phone calls (65.6%) and daydreaming (61.2%). Seventy-nine patients (6.3%), reported having been stopped by police for using a handheld device in the past. Among 113 drivers who disclosed the cause of their injury as a motor vehicle crash (MVC), 20 of them (17%) acknowledged being distracted at the time of the crash. Of the participants surveyed, 729 reported that during their lifetime they had been the driver in a MVC, with 226 (31.1%) acknowledging they were distracted at the time of the crash.

Approximately, 1 in 6 participants in this study had a MVC where they reported to be distracted. Despite the overwhelming knowledge that distracted driving is dangerous and the recognition by participants that it can be dangerous, a staggering amount of drivers engage in distracted driving on a fairly routine basis. This study demonstrates an ongoing need for research and driver education to reduce distracted driving and its devastating consequences.

The syndesmosis ligament complex stabilizes the distal tibiofibular joint, while allowing for the subtle fibular motion that is essential for ankle congruity. Flexible fixation with anatomic syndesmosis reduction results in substantial improvements in functional outcomes. New dynamic CT technology allows real-time imaging, as the ankle moves through a range of motion. The aim of this study was to determine if dynamic CT analysis is a feasible method for evaluating syndesmosis reduction and motion following static and flexible syndesmosis fixation.

This is a subgroup analysis of a larger multicenter randomized clinical trial, in which patients with AO 44-C injuries were randomized to either Tightrope (one knotless Tightrope, Group T) or screw fixation (two 3.5-mm cortical screws, Group S). Surgical techniques and rehabilitation were standardized. Bilateral ankle CT scans were performed at one year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). Three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: anterior, midpoint, and posterior tibiofibular distances. T-tests compared Group T and Group S, and injured and uninjured ankles in each group.

Fifteen patients (six Group T [three male], nine Group S [eight male]) were included. There was no difference for mean age (T = 42.8 ± 14.1 years, S = 37 ± 12.6, P = 0.4) or time between injury and CT scan (T = 13 ± 1.8 months, S = 13.2 ± 1.8, P = 0.8). Of note in Group S, seven of nine patients had at least one broken screw and one additional patient had screws removed by the time of their dynamic CT. There was no significant difference between treatment groups for tibiofibular distance measurements in maximal PF or DF. Group T showed no significant difference between the injured and uninjured side for tibiofibular measurements in maximal PF and DF, suggesting anatomic reduction. For Group S, however, there was a significantly larger distance for all three measurements at maximal PF compared to the uninjured ankle (all P < 0 .05).

In all but one Group S patient, screws were broken or removed prior to their dynamic CT, allowing possible increased syndesmotic motion, similar to Group T. Despite this, dynamic CT analysis detected increased tibiofibular distance in Group S as ankles moved into maximal PF when compared with the uninjured ankle. Given the importance of anatomic syndesmosis reduction, dynamic ankle CT technology may provide valuable physiologic information warranting further investigation.

Tibial plateau fractures are common injuries. Displaced fractures are treated with open reduction and internal fixation (ORIF). Goals of treatment include restoration of extremity axial alignment, joint stability and congruity, allowing for early motion and prevention of osteoarthritis. Short term results of surgical fixation of tibial plateau fractures are good, however, longer term outcomes have demonstrated a higher risk of end-stage arthritis and total knee arthroplasty. Despite the vast literature around tibial plateau fractures, to our knowledge there are no series examining post-operative reductions using axial imaging. It is our goal to define the incidence of articular malreductions following surgical fixation of tibial plateau fractures, to identify patient or surgeon factors associated with malreductions, and to define any regional patterns of malreduction location.

De-identified post operative computed tomography (CT) scans were reviewed to identify tibial plateau malreductions with a step or gap greater than 2 mm, or condylar width greater than 5 mm. Three independent assessors reviewed the scans meeting criteria using Osirix DICOM software. Steps and gaps were mapped onto the axial sequence at the level of the joint line. Images were then matched to side and overlaid as best fit in Photoshop software to create a map of malreductions. A grid was created to divide the medial and lateral plateaus into quadrants to identify the density of malreductions by location. A multi-variate regression model was used to assess risk factors for malreduction.

Sixty five post-operative CT scans were reviewed. Twenty one reductions had a step or gap more than 2 mm for a malreduction incidence of 32.3%. The incidence in patients undergoing submeniscal arthrotomy or fluoroscopic assisted reduction was 16.6% and 41.4%, respectively (p <0.001). Side of injury, age, BMI, AO fracture type, and use of locking plates were not predictive of malreduction. Malreductions were heavily weighted to the posterior lateral tibial plateau.

The incidence of articular malreductions was high at 32.3%. Fluoroscopic reduction alone was a predictor for articular malreduction with most malreductions located in the posterior lateral quadrants of the plateau.

Orthopaedic surgeons frequently assess fragility fractures (FF), however osteoporosis (OP) is often managed by primary care physicians (PCP). Up to 48% of FF patients have had a previous fracture (Kanis et al., 2004). Discontinuity between fracture care and OP management is a missed opportunity to reduce repeat fractures. This studied aimed to evaluate current OP management in FF patients presenting to cast clinic.

A single centre, prospective observational study where seven traumatologists screened for FF in cast clinic. FF was defined as a hip, distal radius (DR), proximal humerus (PH), or ankle fracture due to a ground level fall. Patients completed a self-administered questionnaire for demographics, fracture type and treatment, medical and fracture history, and previous OP care. The primary outcome was number of FF patients who received OP investigation and/or treatment. Secondary outcomes included Fracture Risk Assessment Tool (FRAX), repeat fracture rate, and anti-resorptive related fractures. Descriptive statistics were used for analysis.

Between November 17, 2014 and October 13, 2015, a total of 1,677 patients attended cast clinic for an initial assessment. FF were identified in 120 patients (7.2%). The FF cohort had a mean age of 65.3 (± 14.3) years, mean BMI of 26.1 (± 5.3), and was comprised of 83.3% females. Fracture distribution was 69 (57.5%) DR, 23 (19%) ankle, 20 (16.5%) PH, and seven (5.8%) hip fractures, with 24 of the FF (19.8%) treated operatively. Thirteen (10.8%) were current smokers and 40 (33.3%) formerly smoked. A history of steroid use was present in 13 patients (10.8%). Ninety (n = 117; 76.9%) of patients ambulated independently. Twenty-two patients (18.3%) reported prior diagnosis of OP, most often by a PCP (n = 19; 73.7%) over 5 years previously. Calcium (n = 59; 49.2%) and Vitamin D (n = 70; 58.3%) were common and 26 patients (21.5%) had a prior anti-resorptive therapy, with Alendronate (n = 9) being most common. One patient had an anti-resorptive-related fracture. Raloxifene was used in ten patients. Forty-seven patients (39.2%) had a prior fracture at a mean age of 61.3 (± 11.9) years, with DR and PH fractures being most common. Eleven patients had two or more prior fractures. A family history of OP was found in 34 patients (28.1%). Mean FRAX score was 20.8% (± 10.8%) 10-year major fracture risk and 5.9% (± 6.6%) 10-year hip fracture risk (n = 30 bone densiometry within one-year). Of the 26 patients with a Moderate (10–20%) or High (> 20%) 10-year major fracture risk, only eight (30.8%) reported a diagnosis of OP and only three (11.5%) had seen an OP specialist.

Cast clinics provide an opportunity for OP screening, initiation of treatment, and patient education. This cohort demonstrated a high rate of repeat fractures and poor patient reporting of prior OP diagnosis. This study likely underestimated FF and calls for resource allocation for quantifying true burden of disease and outpatient fracture liaison service.

Introduction

Historical studies have reported incidences of taper corrosion in retrieved MoP hips of 20–50%. These studies relied on visual assessments, rather than using modern analytical techniques.

Bone and joint infections of the lower limbs cause significant morbidity for patients. Infection is a devastating complication for prosthetic joint replacements. In this large case series from a single centre in the NE of England, we present our experience of using antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 for local elution of antibiotics at the site of infection.

At our centre, from August 2012 to Jan 2015, antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 was used for local elution of antibiotics in 45 patients with lower limb bone or joint infections. Tailored plans were made by Orthopedic surgeon and Microbiologist MDTs based on bacteria and sensitivities.

Cases included 20 THR, 13 TKR, 5 Hemiarthroplasties, 4 tibial nonunions, 1 infected femoral plate and 2 paediatric osteomyelitis.

Organisms isolated – Coagulase negative Staphs, Staph aureus, MRSA, E coli, Enterococcus, Enterobacter cloacae, Serratia and 1 Salmonella typhimurium!!

In our cases, a combination of Vancomycin and Gentamicin was added to Stimulan beads following manufacturer's mixing guide. In 2 cases, we added Ceftazidime to the beads and Daptomycin in 1 case.

In bone infections, surgical debridement and systemic antibiotics were also needed. All arthroplasty infections underwent explantation with addition of antibiotic impregnated beads either at single stage or both stages of 2 stage revisions and systemic antibiotics.

Follow up (ranging 9months to 2 years) indicates no failure so far. The beads caused no excessive wound drainage. There was no need to remove beads as they dissolve. In the cases where a staged revision was performed, the beads were inserted at first stage and there was microbiological clearance of infection at 2nd stage. Our series includes some experince in paediatric cases too.

As far as we are aware, this is the largest series in the UK from a single centre reporting experience with Stimulan in infected bone and joints of the lower limbs. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with carefully selected antibiotics, works as an effective adjunct to current treatments and offers flexibility with choice of antiobiotics that can be added locally.

Objective

To evaluate the volume of cases, causes of failure, complications in patients with a failed Thompson hemiarthroplasty.

Aims: There are concerns over the physiological effects of intramedullary femoral fracture stabilisation in patients with pulmonary injury. This large animal study used invasive monitoring to obtain sensitive cardiopulmonary measurements and compared the responses of ‘Early Total Care’ (intramedullary fracture fixation) and ‘Damage Control’ (external fixation), after the induction of lung injury.

Methods: Acute lung injury (PaO2/FiO2 < 200 mmHg) was induced in 12 invasively monitored and terminally anaesthetised sheep via oleic acid infusion into the right atrium. Each animal underwent surgical femoral osteotomy and fixation with either reamed intramedullary (n=6) or external fixation (n=6). Haemodynamic and arterial blood-gas measurements were recorded at baseline, 5, 30 and 60 minutes after fracture stabilisation.

Results: The mean (+/− S.E.) PaO2/FiO2 fell significantly (p< 0.05) from 401 (+/− 39) to 103 (+/− 35) and 425 (+/− 27) to 122 (+/− 21) in the externally fixated and intramedullary nailed groups respectively after acute lung injury. The further combined effect of surgical osteotomy and fracture fixation produced a mean (+/− S.E.) PaO2/FiO2 of 98 (+/− 21) and 114 (+/− 18), in the externally fixated and intramedullary nailed groups immediately after surgery. This was not significantly different within or between groups. Similarly the pulmonary vascular resistance (PVR) measured at 5.8 (+/− 0.8) and 4.8 (+/− 0.7) after lung injury in the externally fixated and intramedullary nailed groups changed to 5.7 (+/− 0.5) and 4.0 (+/− 0.7) after surgical osteotomy and fracture fixation (no significant difference within or between groups). The PaO2/FiO2 or PVR was not significantly different at the monitored 5, 30 and 60 minute intervals after fracture stabilisation.

Conclusion: Against a background of standardised acute lung injury, there was no further deterioration produced by the method of isolated femoral fracture fixation in sensitive physiological parameters commonly used during intensive care monitoring.

Purpose: The purpose of this study is to evaluate the hemodynamic and pulmonary effects of intramedullary nailing with a removable filter placed into the common iliac vein.

Methods: Under general anaesthesia, a collapsible filter was inserted into the left common iliac vein in eight dogs and compared to a control group from a previous study. The left femora and tibiae were then pressurized by injection of bone cement and the insertion of intramedullary rods. Echocardiographic images and hemodynamic measurements including arterial blood gas, cardiac output, left atrial, right atrial, pulmonary arterial, and aortic pressure were recorded as baseline measurements and at 1, 5 and 15 minutes after medullary-canal pressurization. After fifteen minutes of pressurization the filter debris was evacuated, the samples sent for analysis and the filter was collapsed and removed. The dog’s hemodynamics were then monitored for a further fifteen minutes. The animals were killed and the lungs were harvested for histomorphometric analysis.

Results: Full hemodynamic and histomorphometric results of the lung tissue and debris collected from the evacuated filters are still pending at the time of this submission however initial findings indicate that the filter prevented an immediate increase in mean pulmonary artery pressure after canal pressurization. No large embolic event was visualized in any of the filtered dogs. In contrast, all animals in the control group demonstrated moderate-to-severe echogenic response with intense showering of echogenic material, including large embolic masses. Removal of the filter was safe and repeatable.

Conclusions: This experiment has shown that proximal venous blockade by means of a removable filter was able to reduce the size and the quantity of the embolic load on the lungs and the filter could be safely collapsed and removed after suctioning of the debris. High rates of embolization causing increased morbidity and mortality after intramedullary stabilization of pathological fractures and of traumatic fractures with concomitant lung injury have been reported. Prophylactic insertion of a removable temporary filter in this high-risk group prior to reamed intramedullary nailing may be beneficial.

Funding : Other Education Grant

Funding Parties : Synthes Canada

Purpose: External fixation is a popular treatment method of unstable distal radius fractures. There has been much debate and confusion however regarding the use of bridging versus non-bridging fixation. The aim of this study is to define the indications for bridging and non-bridging external fixation in the treatment of unstable distal radius fractures. The study also endeavours to evaluate the complications and pitfalls associated with this treatment and to determine if non-expert surgeons can reproduce successful outcomes.

Methods: Between January 1995 and December 2000, 641 patients with fractures of the distal radius were treated at our institution with external fixation. The fractures were treated either by bridging or non-bridging external fixation. Demographic data was collected prospectively for these patients including their hospital number, date of birth, gender, age at injury, mode of injury, type of external fixator and whether the fracture was an open or closed injury. Further information was collected retrospectively from review of case notes and x-rays and included AO classification, status of the operating surgeon, duration of fixation, and complications.

Results: Patients treated with bridging external fixation had significantly more mal unions in terms of dorsal angulation and shortening. The non-bridging fixators were better able to maintain and in some cases improve on the immediate post external fixation measurements. Minor pin tract infections were more common in the non-bridging group.

Conclusions: Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius with sufficient space for the placement of pins in the distal fragment. A predictable outcome with low complication rate can be expected.

Purpose: The Less Invasive Stabilization System (LISS), Dynamic Condylar Screw (DCS) and Condylar Buttress Plate (CBP) are three common fixation methods for supracondylar femur fractures. The DCS and CBP are compression plates while the LISS uses locking screws to transfer load from bone to plate without compression. We developed a study to determine if the theoretical biomechanical advantages of the LISS would be evident in laboratory testing.

Methods: Identical AO type C fractures were created in eighteen composite femurs and fixed with either LISS, CBP, or DCS (6 each). Roentgen Stereophotogrammetric Analysis (RSA) was used for analysis. Reference markers were implanted into each bone segment. Biplanar x-rays were taken to give a three-dimensional representation of the fracture. The femurs were loaded axially in an Instron 1350 and subjected to cyclic loading (50kg ± 25 for 50000 cycles). After loading, the bones were x-rayed to determine relative motion between fracture segments. To examine inducible displacement under static loading, the femurs were x-rayed in an unloaded and loaded (50 kg) condition. Again, RSA was used for analysis.

Results: RSA-CMS software was used to analyze relative motion between the bone segments. After cyclic loading, the condylar buttress plate showed significantly more permanent deformation between the medial condyle and shaft of the femur than the DCS or LISS. Under static load, the LISS showed greater displacement than the other devices between the medial condyle and shaft, and between the lateral condyle and shaft.

Conclusions: The LISS demonstrated less permanent deformation but greater inducible deformation between the medial femoral condyle and femoral shaft, compared to the DCS and CBP. The results were statistically significant. These results may have clinical implications regarding the choice of fixation devices for this difficult fracture pattern.

Funding : Other Education Grant

Funding Parties : Capital Health Research Grant

One hundred and ninety patients requiring total knee arthroplasty were randomized to one of two treatments: retaining or sacrificing the posterior cruciate ligament during surgery. Both groups received a Genesis II implant (Smith and Nephew Richards) appropriate to the treatment. Patients were seen preoperatively, at three months, one year, and two years. The end-of-study date is at five years postoperatively. Outcome measures include range of motion, the KSCRS, SF-12, and WOMAC. At two years both groups have shown improvement in pain, function, and stiffness. There is no apparent difference between groups with regard to any outcome measures or complications.

The purpose of this study was to compare retaining vs. sacrificing the posterior cruciate ligament (PCL) in total knee arthroplasty in the patients who satisfy the criteria for a cruciate retaining knee.

Two years after total knee replacement, both groups have improved knee function, less pain, and less knee stiffness. There is no apparent difference between the groups with regards to range of motion, function, or other outcome measures.

Designs of total knee arthoplasty implants, as well as surgical techniques continue to evolve. The role of the PCL in primary total knee arthroplasty remains controversial. Current prosthetic designs have the flexibility to either substitute for a resected PCL or allow preservation of the ligament.

One hundred and ninety patients requiring total knee arthroplasty upon satisfying the criteria for a cruciate retaing arthroplasty were randomized to receive either a posterior cruciate retaining implant or a posterior cruciate sacrificing implant. Surgery was performed following standard procedure with the only difference between groups being the sacrificing or retaining of the PCL. Patients were followed at three months, one year, and two years postoperatively. Outcome measures included range of motion, the Knee Society Clinical Rating Score (KSCRS), SF-12, and Western Ontario and McMaster Osteoarthritis Index (WOMAC).

Early results indicate that both groups are doing equally well with no statistical difference in outcomes at two years. There is a trend toward increased range of motion at six and twelve months in the PCL sacrificing group. A six- degree gain was noted in the sacrificed group as compared to a two degree gain in the intact group.

Funding: Smith and Nephew