Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery. A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”. Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation

The October 2024 Trauma Roundup³⁶⁰ looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?

Aims

This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures.

Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended. Cite this article: Bone Joint J 2024;106-B(9):1008–1014

Aims. The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality. Methods. A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence. Results. A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments. Conclusion. MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment. Cite this article: Bone Jt Open 2024;5(8):652–661

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Aims. To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results. We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion. A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531

Background. In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods. Method. The study was supported by CORNET, the North East trainee research collaborative, and BOTA. Data was collected using REDCap from 22 centres in the UK retrospectively for a one-year period between 1. st. January 2019 and 31. st. December 2019 on injury mechanism, fracture characteristics, comorbidities, fixation and complications. Follow-up data was collected to at least two-years from the time surgery. Results. 1448 ankle fractures which involved fixation of the fibula were recorded; one-third tubular plate was used in 866 (59.8%) cases, a locking plate in 463 (32.0%) cases and other methods in 119 (8.2%) cases. There was significant difference between centres (p<0.001) in implant type used. Other factors associated with implant type were age, diabetes, osteoporosis, open fractures, fracture pattern and the presence of comminution. Incidence of lateral wound breakdown was higher in locking plates than one-third tubular plates (p<0.05). There was no significant difference in infection, non-union, fixation failure or removal of metalware. Conclusion. There is significant variation in practice in the UK in implant use for fixation of the fibula in ankle fractures. Potentially unnecessary use of locking plates, where a one-third tubular shows equivalent outcomes, incurs additional cost and may increase the risk of lateral wound breakdown. We would encourage surgeons with high locking plate usage to evaluate their own unit's practice against this data

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

The June 2024 Wrist & Hand Roundup³⁶⁰ looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review.

Aims

This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

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.

Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries. A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head. Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value < 0.001. The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures

Introduction. Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach. Materials & Methods. We compared clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, fracture classification, post-treatment alignment and presence of an open fracture. Results. The mean time in frame was 168 days for the 2-ring group and 200 days for the 3+ rings group (p=0.003). No significant difference was found in the rate of malunion (p=0.428) or the requirement for secondary surgical intervention to achieve union (p=0.363). No significant difference in time in frame was found between individual surgeons. Conclusions. This study finds that 2-ring frame constructs are a reliable option associated with significantly shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations. Although this study cannot identify the underlying cause of the difference in treatment time between frame designs, it is possible that differences in mechanical stability lead to a more favourable strain environment for fracture healing in the 2-ring group

Aims

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component.

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

The April 2024 Trauma Roundup³⁶⁰ looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?.