Introduction:. Displaced and shortened clavicle shaft fractures can be treated operatively by intra- or extramedullary fixation. The aim of the study was to compare the effectiveness of these two treatment modalities. Methods:. Forty seven patients with acute displaced and shortened clavicle shaft fractures were randomly assigned to either an
Aim: To report the clinical and radiological outcome of
Introduction: Mid-shaft clavicular fractures that are displaced and shortened are often treated surgically. The standard technique in the past has been to use plate fixation. However, in the last five years
We undertook a prospective randomised trial to determine the outcome of locked
The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by
Aims. Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary
Background: Long bone fractures and intramedullary stabilisation can result in the extravasation of fat and marrow emboli into the venous circulation. The effects of these emboli can become systemic causing neurological features. Aim: To establish the cerebral microembolic load following femoral and tibial diaphyseal fractures treated by
Purpose. Plating remains the most widely employed method for the fixation of displaced diaphyseal clavicle fractures. The purpose of this study was to assess the efficacy and outcomes of diaphyseal clavicle fractures treated with
Aims. The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001),
Introduction: The majority of forearm fractures in children can be managed with a plaster cast alone and manipulation under anaesthetic as required. A small number of cases however require surgical intervention. A variety of methods are available but the use of elastic intramedullary nails is becoming the technique of choice. Method: We present a two-centre study assessing the outcome of either Elastic StabJe Intramedullary Nails (ESIN) or Kirschner wires as the method of fracture stabilisation in diaphyseal forearm fractures of the radius and ulna. Results: ESIN group: 24 children underwent ESIN fixation. There were 22 boys and 2 girls, mean age 9.4 years (1.4–15.2 years, p=O.ll). Indications for stabilisation included 21 cases for fracture instability (immediate or delayed,) 2 irreducible fractures and 1 open fracture. 14 children underwent surgery on the day they sustained their fracture. The remainder were operated on an average 6.5 days following injury (1–14 days). In the K wire group: 36 children underwent K-wires fixation with 2.5mrn wires. There were 21 boys and 15 girls, mean age 10.6 years (2.2–15.5 years). Indication for stabilisation included 22 cases for fracture instability , 6 irreducible fractures and 8 open fractures. 32 children underwent surgery on the day they sustained their fracture. The remaining 4 patients were operated on the following day. Conclusions: All fractures united with no resultant subjective disability. The complication rate following K-wires was 16% and that following nail fixation 9%. Loss of forearm rotation was documented in 4 children in the K-wire group and 3 children stabilised with nails. These results confirm an excellent outcome following
Introduction:
Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture. A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D3 supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months.Aims
Methods
Aim: To compare two implants, the Gamma Nail and the ACE Trochanteric Nail in the treatment of pertrochanteric femoral fractures. Patients and methods: Sixty patients were randomized on admission to two treatment groups. Thirty patients were treated with the Gamma nail implants , and thirty had
Aims and methods. To compare the mechanical stability of an intramedullary (IM) screw with two crossed interfragmentary compression screws for fixation of the 1st MTPJ in ten pairs of cadaveric feet. One foot underwent fixation with two crossed 4.0-mm cannulated cancellous screws. The contralateral foot was fixed with an IM 1.6-mm Kirschner wire and an IM 6.5-mm partially threaded cancellous lag screw. A plantar-to-dorsal load was applied to the distal end of the proximal phalanx at a rate of 1 mm/sec. Failure was defined as gross actuator displacement of 5 mm. Stiffness was defined as the slope of the force versus deformation curve between 10 and 60 N. Strength was defined as the load at failure. The differences in stiffness and strength parameters between the two fixation techniques were checked for significance (P <
0.05) with a paired t-test. Results. The
Tip-apex distance (TAD) has long been discussed as a metric for determining risk of failure in fixation of peritrochanteric hip fractures. This study seeks to investigate risk factors including TAD for hospital readmission one year after hip fixation surgery. A retrospective review of proximal hip fractures treated with single screw intramedullary devices between 2016 and 2020 was performed at a 327 bed regional medical center. Patients included had a postoperative follow-up of at least twelve months or surgery-related complications developing within that time. 44 of the 67 patients in this study met the inclusion criteria with adequate follow-up post-surgery. The average TAD in our study population was 19.57mm and the average one year readmission rate was 15.9%. 3 out of 6 patients (50%) with a TAD > 25mm were readmitted within one year due to surgery-related complications. In contrast, 3 out of 38 patients (7.9%) with a TAD < 25mm were readmitted within one year due to surgery-related complications (p=0.0254). Individual TAD measurements, averaging 22.05mm in patients readmitted within one year of surgery and 19.18mm in patients not readmitted within one year of surgery were not significantly different between the two groups (p=0.2113). Our data indicate a significant improvement in hospital readmission rates up to one year after hip fixation surgery in patients with a TAD < 25mm with a decrease in readmissions of over 40% (50% vs 7.9%). This result builds upon past investigations by extending the follow-up time to one year after surgery and utilizing hospital readmissions as a metric for surgical success. With the well-documented physical and financial costs of hospital readmission after hip surgery, our study highlights a reduction of TAD < 25mm as an effective method of improving patient outcomes and reducing financial costs to patients and medical institutions.
The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome.Introduction
Materials & Methods
Purpose: Many surgical techniques have been described for the treatment of pathological fractures due to aggressive unicameral bone cysts in order to varying rates of success and incomplete healing or recurrence. Many Authors suggested curettage and bone grafting as effective treatment in case of active lesion in children 8 – 12 years old, adjacent to the physis with width of the lesion exceeds that of the adjacent physis and recurrence or persistence. Due to invasive nature of operation this method non is preferred by several Authors : we preferred minimally invasive treatment consisting closed reduction and flexible with titanium rod (Nancy)intramedullary fixation for low operative morbidity whether for the fracture or for the cyst; in case of recurrence of the cyst the closed curettage of the cyst with arthroscopic technique can be applied successful. Methods: Between 2002–2004 40 aggressive unicameral cysts were observed as pathologic fractures in patients between 5–15 years old in these cases there was a significant loss of bone stock. The site of involvement was in 33 patients the metadiaphysis of humerus, in 7 the femur; radiograms reveal expanding lesion in metaphyseal-diaphyseal site with cortex tinned from its inner surface and erosion with infraction with displacement. The parents were informed about contextual presence of two lesions: the fracture and cyst. The proposed internal fixation with Nancy titanium rods heals the first and might heal the second lesion ; in case of failure this method do not exclude another possibility of treatment as arthroscopic curettage. The Nancy flexible
400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer. The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails.
The Sliding Hip Screw (SHS) is currently the treatment of choice for all trochanteric hip fractures. An alternative treatment is the short femoral nail. Earlier designs of these nails were associated with an increased fracture healing complication rate in comparison to the sliding hip screw. The new designs of nails (third generation nails) may however be as good as or even superior to sliding hip screw fixation. We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the Sliding Hip Screw. Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgery was supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. The mean age was 82 years, range 27 to 104 years), 20% were male. Length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There was only one compilation in the nailed a case of cut-out which required secondary surgery. At follow-up no difference in pain scores but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails.
Regardless of the method used, open ankle arthrodesis is known to have a high rate of nonunion, reported to range from 4% to 25%. Salvage of failed ankle fusion is thus a relatively common procedure. Further, in cases of bone loss after distal tibial trauma, necrosis of the talus, Charcot joints and severe deformities of the ankle, there are known to be increased incidences of delayed union and nonunion. Since 1997, 25 salvage ankle arthrodesis procedures have been performed, using a retrograde interlocking intramedullary nail as fixation. In this paper we discuss the indications, surgical techniques and results. At a mean of nine weeks postoperatively, union was achieved in all cases. Complications included one case of late sepsis, which presented four years after surgery. During the operation one tibial fracture occurred. One distal screw backed out. The fixation was removed from three patients, one for late sepsis, one for septic nonunion, and the patient in whom the tibia fractured.
Lower limb fractures in children are common. These fractures can be managed in a variety of ways, and the method chosen depends on a number of factors including: Age of the child. Site of fracture. Whether the fracture is open or closed. Associated injuries. Surgeon’s expertise and experience. Parental wishes.
We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively. We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients.
From May 2002 to April 2003, a prospective, non-randomised, blinded study was undertaken in 30 patients with fractures of the femur and tibia, all treated with unreamed intramedullary (AO) nail fixation. There were 17 (57%) femoral shaft fractures and 13 (43%) tibial shaft fractures. Most of the patients (23) had been injured in road findings accidents, 17 of them pedestrian. No patient had any known co-morbidities. Fourteen patients (47%) were HIV positive, nine with femoral fractures and five with tibial fractures. Three patients with compound femoral fractures were HIV positive, two HIV negative. The mean age of HIV-positive patients with femoral shaft fractures, two men and seven women, was 33 years (18 to 48). The mean age of the eight HIV-negative men with femoral shaft fractures was 28 years. Five tibial fractures were compound, three in HIV-positive patients and two in HIV-negative patients. The mean age of HIV-positive patients with tibial fractures, three men and two women, was 31 years (18 to 56). The mean age of the HIV-negative patients, seven men and one woman, was 28 years. All the fractures were Gustillo-Anderson grade- II. At 12 weeks, 29 fractures had united. In one HIV-positive patient with a compound tibial fracture there were no radiological signs of union at 12 weeks, but after bone grafting the fracture united uneventfully. An HIV-positive patient, who had sustained a gunshot femur injury, developed deep wound infection four months after fixation. In all other patients, the wounds healed uneventfully. In asymptomatic HIV-positive patients, wound healing and fracture union rates are comparable with those of HIV-negative patients.
Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up. 244 patients with a subtrochanteric femur fracture were treated at one centre over a 21 year period were prospectively studied. 75 were treated with an extramedullary fixation implant and 168 with an intramedullary nail. Surviving patients were followed up till one year from injury.Introduction
Methods
A retrospective study was done on the outcome of supracondylar femoral fractures treated with retrograde or supracondylar intramedullary nails. Between January 1998 and December 2000, 69 patients were treated with Russell Taylor nails, 30 at Kalafong Hospital and 39 at Pretoria Academic Hospital. Injuries had resulted from motor vehicle accidents in 27 patients, from falls in 32 and from gunshots in 10. There were 13 open fractures and 14 patients had multiple injuries, including three head injuries and two vascular injuries. Using the AO classification, 40 fractures were graded type A and 29 type C. The mean age of the 18 female and 51 males was 45 years (17 to 90). Senior registrars performed the surgery. In all cases, the knee was opened for the procedure. Four patients died from their injuries. The mean time to union was 13 weeks. Four patients had poor range of motion. Complications included two cases of superficial sepsis and three of deep sepsis. There were two cases of delayed union and three of fixation failure. In one patient the fixation impinged on the patella. We find this a good way of treating supracondylar femoral fractures.
Revision knee prostheses are often augmented with intramedullary stems to provide stability following bone loss. However, there are concerns with the use of such stems, including loosening caused by strain-shielding, end-of-stem pain, and removal of healthy bone surrounding the medullary canal. Extracortical fixation plates may present an alternative. The aim of the study was to quantitatively evaluate and compare strain-shielding in the tibia following implantation of a knee replacement component augmented with either a conventional intramedullary stem (design1), or extracortical plates (design2) on the medial and lateral surfaces. Eight composite synthetic tibiae were implanted with one of the two designs, painted with a speckle pattern, loaded in axial compression (peak 2.5 kN) using a materials test machine, and imaged with a 5-megapixel digital image correlation (DIC) system throughout loading. Bone loss was simulated in all models by removing a volume of metaphyseal bone. For four tibiae, the tibial tray was augmented with a cemented stem (∼150 mm). The others were augmented by extracortical plates (maximum 90 mm long) along the medial and lateral surfaces (Fig. 1). Strains were computed using an ARAMIS 5M software system between loaded and unloaded states in the longitudinal direction, for the medial, posterior and lateral surfaces of the tibiae. Strains were checked locally by use of strain gauge rosettes at three levels on medial, lateral and posterior aspects. The bone strains measured on the posterior surfaces were reported in three regions; proximal (0–70 mm, where the medial extracortical plate lies), middle (70–130 mm, the stem is present but not the extracortical plates), and distal (130–200 mm, beyond the stem). Mean longitudinal strains for both implant types were comparable in the distal region, and were greater than in the other regions (Fig 2). The mean strains differed considerably in the middle region: 565–715 μstrain with stemmed components 1050–1155 μstrain with plated components. Strains followed a similar pattern in the proximal region, particularly very close (20 mm) to the tibial tray component, where the stemmed component bones (775 ± 160 μstrain) displayed less surface strain than the plated component bones (1210 ± 180 μstrain). Strain-shielding was observed for both designs. The side plates were shorter than the intramedullary rods, so the region of the bone distal to the plates was not strain-shielded, while the same region was strain-shielded when a stemmed component was implanted. It was also shown that in the region of bone just distal of the tibial tray component, design1 shielded the bone from strain 56% more on average than design2. From these results, it can be speculated that the use of extracortical plate rather than intramedullary stems may lead to improved long-term results of revision TKA, assuming the plates and screws provide adequate stability. The extramedullary fixation system preserves more bone than IM fixation, and has the advantage of allowing use of primary TKA components, cemented over the subframe. Similar components have been developed for the femur.
To assess and compare the functional, radiological and cosmetic results as well as patient satisfaction in patients treated with the IMN Device Vs Volar Locking Plate All patients who presented to our institution with extra articular distal radius fractures and met the inclusion criteria were invited to take part in the study. The patients were randomly allocated to two groups, those who underwent intramedullary (IMN) distal radius fixation using the Sanoma Wrx Distal radius nail and those who underwent fixation using a volar locking plate. The patients were then followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year. The radiological parameters, ie radial height, inclination and tilt were compared as well as the functional outcomes by means of DASH score. The range of motion of the wrist was compared as well as the scar size. Complications were reviewed.Aims of study
Method
All fractures healed at an average time of 9.2 weeks (5–26) and for the open fractures 19 (12–26) weeks. Hardware was removed in 8 cases with no complications. In two cases re-operation was needed. In one early case the nail was fractured and replaced. In the second case the bone was circlaged due to fragmentation around the fracture site and a bigger nail was inserted few days later (wrong smaller nail was inserted previously).
Methods of treatment of femoral fractures still remain controversial in adolescent age when the patients are too young for adult-type stabilization. This study examines the possibilities for improving the mechanical parameters of the bone-nail interface in flexible intramedullary nailing. Mathematical models, which simulate different fractures, have been created by using the finite elements method. The stabilizing construction with two 4,00 mm Ender nails was performed in two versions:
standard divergent “C” configuration (3 points of pressure); divergent “S” configuration (4 points of pressure). Each version has been tested towards the deforming forces – bending in frontal and sagital plane; torsion and axial loading. Strength coefficient of the nails has been calculated as well as the stiffness of the configuration. The comparative analysis of the results found out that under the angular and torsional forces the mechanical parameters of the two types of configurations are equivalent. However, under axial loading, the divergent “S” configuration shows definitely better mechanical characteristics. The strength coefficient is 30% higher and the stiffness of the configuration is twice as strong. The specific intramedullary cohesion enables more considerable resistance towards the transverse displacement in telescoping of the fragments. Proceeding from the presented data, it could be considered that the divergent “S” configuration creates much more sufficient length control. Its implementation in axial unstable femoral fractures could enable an earlier mobilization, respectively – an earlier weight-bearing loading.
The purpose of our study was to compare the mechanical nature of nails with different cross-sections in order to optimise the elasticity-stability ratio. There is no doubt that elastic intramedullary osteosynthesis is a successful choice for treating femoral shaft fractures in children. However, misalignment is a potential problem connected with stability of the fixation. The mechanics of two types of nails with the same type of surface, but with different kind of cross sections – a circle (Ender) and an ellipse – was examined using the “finite elements” method. The standard configuration of the two nails was put under four kinds of deforming forces: bending in the frontal plane and the sagital plane, torsion, and axial compression. Strength coefficient and stiffness were calculated in each particular situation. In respect to angular stability (frontal plane) and axial compression, the mechanical characteristics of the two types of nails are similar. The stability of the elliptical nail is higher in bending in the sagital plane and in torsion. The elliptical implant has better intramedullary cohesion because the large half-axis is perpendicular to the sagital plane. Nails with an elliptical cross section provide the opportunity for redistribution of stiffness. As a result, better mechanical properties are achieved. The elliptical cross section assures better intramedullary cohesion.
Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked
The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.Objectives
Methods
Conservative treatment of the ‘boxer’s fracture’ gives acceptable functional results but often leaves the patient with a residual deformity. Using a prograde intramedullary K-wire, we treated 23 consecutive patients with a fractured neck of the fifth metacarpal. Volar angulation exceeded 40°. A 1.6-mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were recorded. All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients, the reduction was anatomical with no residual angulation. In five the residual angulation ranged from 5° to 15°, with a mean of 8°. There was a transient sensory neuropraxia in two patients. This minimally invasive technique is a simple, cost-effective and reliable method of treating a ‘boxer’s fracture’ and ensures a rapid return to full function with little or no residual deformity.
To assess the effectiveness of a novel locked intra-medullary device in the treatment of acute clavicle shaft fractures. Patients admitted with midshaft clavicle fractures were assessed for inclusion in the study. Inclusion criteria were mid shaft clavicle fractures with 100% displacement; more than 1, 5 cm of shortening or containing a displaced butterfly segment. Fractures were assessed for suitability to intra-medullary fixation (fracture distance from the medial and lateral end of the clavicle, medullary diameter and fracture type). 35 patients were treated operatively using the device by the author. Post-op, patients were kept in a master sling for a period of 6 weeks and followed up for a period of at least 3 months. Fracture reduction, fracture progression to union, scar size, Dash score, Constant Shoulder score, patient satisfaction and complications were assessed at follow-up by the surgeon, a radiologist and an occupational therapist.Purpose of study:
Description of methods:
We investigated the effect of the location and the number of distal screws in the efficiency of an intramedullary nail implementing the finite element method (FEM). The left proximal femur of a 93-year old man was scanned and two series of full 3D models were developed. The first series, consisting of five models, concerned the use of a single distal screw inserted in five different distal locations. The second series, consisting of four models, concerned the use of four different pairs of distal screws. Each model was analyzed with the (FEM) twice, first considering that the femur is fractured and then considering that the femur is healed. For nails with a single distal screw, stresses around the nail hole were reduced with proximal placement of the distal screw but the area around the nail hole where the lag screw is inserted is stressed more. Furthermore, for nails with a pair of distal screws, placing the pair of distal screws at a specific location is most beneficial for the mechanical behavior of the femur/nail assembly. The distal area of the nail generally gets less stressed when a pair of distal screws is introduced, while the presence of two distal screws far away from each other results in lower proximal femoral head displacements. The stress field at the area of fracture is not influenced significantly by the presence of a single distal screw or a pair of distal screws.
Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent
Introduction. The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. Materials & Methods. A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following
The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an
Background. Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting
Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods. A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results. A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by
Background. Fractures of the femoral neck occurring outside the capsule of the hip joint are assumed to have an intact blood supply and hence their conventional management is by fixation rather than arthroplasty. The dynamic hip screw and its variants have been used over many years to fix such fractures but have inherent vulnerabilities; they require an intact lateral femoral cortex, confer a relatively long moment arm to the redistribution of body weight and may cause a stress riser due to the plate with which they are fixed to the femur. Intramedullary devices for fixation of proximal femoral fractures have a shorter moment arm, can be distally locked with reduced perforation of the femoral cortex and are believed to be inherently more stable. For these reasons, a number of surgeons believe them to be superior to the DHS for all extracapsular fractures and their use is now widespread. In this study, we present the usage trends of both devices in extracapsular fractures over the last five years and set these results in the context of patient demographics. Methods. Our departmental electronic patient management system was used to identify all patients undergoing surgery coded as either DHS or its variants or
Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to
Aims. Little is known about the effect of haemorrhagic shock and resuscitation
on fracture healing. This study used a rabbit model with a femoral
osteotomy and fixation to examine this relationship. Materials and Methods. A total of 18 male New Zealand white rabbits underwent femoral
osteotomy with
Aims. The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. Patients and Methods. This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications. Results. Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (. sd. 7.0) and 4.4 (. sd. 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (. sd. 8.7) and 7.0 (. sd. 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure. Conclusion. A single thick K-wire is sufficient for
Introduction and Objective. Hip fractures represent one of the most challenging injuries in orthopaedic practice due to the associated morbidity, mortality and the financial burden they impose on the health care systems. By many still considered as the gold standard in the management of intertrochanteric fractures, the Dynamic Hip Screw utilizes controlled collapse during weight bearing to stabilize the fracture. Despite being a highly successful device, mechanical failure rate is not uncommon. The most accepted intraoperative indicator for lag screw failure is the tip apex distance (TAD), yet lateral femoral wall thickness (LWT) is another evolving parameter for detecting the potential for lateral wall fracture with subsequent medialization and implant failure. The aim of this study is to determine the mean and cut off levels for LWT that warrant lateral wall fracture and the implications of that on implant failure, revision rates and implant choice. Materials and Methods. This prospective cohort study included 42 patients with a mean age of 70.43y with intertrochanteric hip fractures treated with DHS fixation by the same consultant surgeon from April 2019 to December 2019. The study sample was calculated based on a confidence level of 90% and margin of error of 5%. Fracture types included in the study are 31A1 and 31A2 based on the AO/OTA classification system. LWT was assessed in all patients preoperatively using Surgimap (Nemaris, NY, USA) software. Patients were divided into two groups according to the post-operative integrity of the lateral femoral wall, where group (A) sustained a lateral femoral wall fracture intraoperatively or within 12 months after the index procedure, while in group (B) the lateral femoral wall remained intact. All patients were regularly followed up radiologically and clinically per the Harris Hip Score (HHS) for a period of 12 months. Results. At 12 months five patients (12%) suffered a postoperative lateral wall fracture, while in 37 patients (88%) the lateral femoral wall remained intact. The mean preoperative LWT of patients with a postoperative lateral wall fracture was 18.04 mm (SD ± 1.58) compared to 26.22mm (SD ± 5.93) in the group without a lateral wall fracture. All patients with post-operative lateral femoral wall fracture belong to 31A2 group, while 78.4% of the patients that did not develop post-operative lateral femoral wall fracture belong to 31A1 group. Eighty percent of patients in group (A) experienced shortening, collapse, shaft medialization and varus deformity. The mean Harris hip score of group (A) was 39.60 at 3 months and 65.67 at 6 months postoperatively, while that of group (B) was 80.75 and 90.65 at 3 and 6 months respectively, denoting a statistically significant difference (P<0.001). Treatment failure meriting a revision surgery was 40 % in group (A) and 8% in group (B) denoting a statistically significant difference (p<0.001). The cut-off point of LWT below which there is a high chance of post-operative lateral wall fracture when fixed with DHS is 19.6mm. This was shown on the receiver operating curve (ROC) by plotting the sensitivity against the 100 % specificity with a set 95% confidence interval 0.721 – 0.954. When lateral wall thickness was at 19.6 mm, the sensitivity was 100% and specificity was 81.8%. The area under the curve (AUC) was 0.838, which was statistically significant (P = 0.015). Conclusions. Preoperative measurement of LWT in elderly patients with intertrochanteric hip fractures is decisive. The cut off point for postoperative lateral wall fracture according to our study is 19.6 mm; hence,
Purpose.
Introduction: Most of the bone metastases have origin in breast, lung, prostate, thyroid and kidney neoplasms. The commonest locations are the axial skeleton and the proximal region of the long bones, being the femur the most affected one. The main objectives of the surgical treatment are a quick functional recuperation and immediate pain relief. Objectives: The aim of this work was to define a strategy for the surgical treatment of the bone methastasis located in the femur. Material: The study includes 94 patients with femoral methastasis (100 metastasis) surgicaly treated in the last 10 years in our department. Methods: Retrospective descriptive study based on medical records evaluation. Results: The proximal third of the femur was involved in 80 % of the cases. Pathological fracture was identified in 72 cases and impending fracture in 28. Half of the primitive neoplasms was originated in the breast. It was identified as solitary metastatic lesion only in 33 % of the situations. The mean patient survival time was 9,2 months. They were treated with a cemented calcar-replacing prosthesis in 40 patients, 10 patients submited to conventional arthroplasty and 36 with
The “keel” is the relatively short part of the undersurface of the tibial component that extends into the medullary canal. Most knee replacement systems have the capacity to attach modular stem extensions for enhanced intra-medullary fixation for revision. Diaphyseal length, large diameter stems may also guide positioning of trial components and are ideal for accurate surgical technique, even if fully cemented stems are eventually implanted. Smaller diameter non-modular stem extensions may be used for fully cemented fixation. They do not however guide component position very accurately and do not make sense for uncemented fixation. Revision surgery is different from primary surgery and enhanced fixation with some type of
Introduction and Aims: A retrospective review of the medical records and radiographs of patients treated with operative fixation of two-part proximal humerus fractures was undertaken to compare the results of different modes of fixation. Comparison was made between ORIF with a blade plate, percutaneous Kirschner wire fixation, and intramedullary nail fixation utilising a Polarus nail. Method: Thirty-six patients were treated with
Purpose of Study. To see if the addition of a locking plate to FD rod fixation of osteogenesis imperfecta confers extra strength and allows earlier mobilisation. Introduction. Osteogenesis imperfecta is a heterogeneous group of disorders with congenital osseous fragility. The goal of surgery is to minimise the incidence of fracture and correct deformity. The concept of multilevel osteotomies and
Atypical femoral fractures (AFFs) are reported in patients taking bisphosphonates (BPs). This study aims to describe demographics, potential risk factors and outcome of fixation in AFFs. Forty-three patients with AFF were identified retrospectivity from all identified patients with subtrochanteric or diaphyseal fractures within NHS Grampian between 2008–2018. Patients were identified via hospital coding and electronic search of patients undergoing femoral fixation. AFFs were diagnosed by the 2014 American Society of Mineral and Bone Research diagnostic criteria by electronic patient record review by two investigators. Within this cohort, the incidence of AFF was 8.25% with male to female ratio of 10:1 and a mean of presentation age 73.3 years. 27.9% of AFFs occurred in the diaphysis. 22% of AFFs were bilateral. Mean follow-up was 11.5 months. 87.5% of patients had documented prodromal symptoms. 35% had proven radiological changes before fracture. All patients identified were on BPs. Duration of BPs before fracture was 5 months- 13.2 years (mean 6.3 years). Concurrent use of BPs with steroid and proton pump inhibitors was seen in 58.5%. All patients had
Objectives.
We are presenting a prospective study of 25 patients with clavicle fracture treated with Rockwood
High complication rates and technical difficulties of
Background. Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented
High complication rates and technical difficulties of
We present five case studies of a new technique for the treatment of distal femur fractures after total knee arthroplasty. This type of fracture is rare, but when it occurs can present a dilemma as to the correct treatment. If the prosthesis is loose, the logical treatment is revision surgery with the use of long stem stabilisation. If the prostheses are firmly fixed, the best method of treatment is difficult to determine.
Purpose: We present 10 cases of long bone fractures in children (femur, tibia, forearm) that were treated with internal
Many tumors metastasise to bone, therefore, pathologic
fracture and impending pathologic fractures are common reasons for
orthopedic consultation. Having effective treatment strategies is
important to avoid complications, and relieve pain and preserve
function. Thorough pre-operative evaluation is recommended for medical
optimization and to ensure that the lesion is in fact a metastasis
and not a primary bone malignancy. For impending fractures, various scoring
systems have been proposed to determine the risk of fracture, and
therefore the need for prophylactic stabilisation. Lower score lesions
can often be treated with radiation, while more problematic lesions
may require internal
Traditionally midshaft clavicle fractures have been treated conservatively. It is recognized that displaced and shortened fractures may be better treated operatively. In particular, patients with greater than 20 mm of shortening and 100 percent displacement have a symptomatic non union rate of 30 percent. The standard technique used previously has been via plate fixation with LC-DCP or DCP. However in the last 5 years
Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children. We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails. Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome. We conclude that flexible
Objectives. Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible. The aim of the present study was to biomechanically compare retrograde
Periprosthetic femoral fractures are increasing in incidence, and typically occur in frail elderly patients. They are similar to pathological fractures in many ways. The aims of treatment are the same, including 'getting it right first time' with a single operation, which allows immediate unrestricted weightbearing, with a low risk of complications, and one that avoids the creation of stress risers locally that may predispose to further peri-implant fracture. The surgical approach to these fractures, the associated soft-tissue handling, and exposure of the fracture are key elements in minimizing the high rate of complications. This annotation describes the approaches to the femur that can be used to facilitate the surgical management of peri- and interprosthetic fractures of the femur at all levels using either modern methods of fixation or revision arthroplasty. Cite this article:
Damage Control techniques involve primary external fracture fixation to reduce the ‘second hit’ of surgery. This study used a large animal (ovine) trauma model to compare pathophysiological responses of primary external femoral fixation and intramedullary stabilisation. Under terminal anaesthesia bilateral femoral fractures and hypovolaemia were produced using a pneumatic ram. 24 sheep were randomised into 4 groups and monitored for 24 hours. Group 1 – Control; Group 2 – Trauma only; Group 3 – Trauma and external fixation; Group 4 – Trauma and reamed intramedullary stabilisation. Outcome measures: pulmonary embolic load (transoesophageal echocardiography); plasma coagulation markers; bronchoalveolar lavage differential cell counts (neutrophils, lymphocytes and macrophages). Total embolic load was significantly higher (p<0.001) in the
The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults. This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative).Aims
Methods
Aims. The fundamental concept of open reduction and internal fixation
(ORIF) of ankle fractures has not changed appreciably since the
1960s and, whilst widely used, is associated with complications
including wound dehiscence and infection, prominent hardware and
failure. Closed reduction and
Malnutrition is a potentially modifiable risk factor that may contribute to complications following geriatric hip fracture surgery. The purpose of this study was to investigate the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the thirty days following surgery for geriatric hip fracture. The American College of Surgeons National Surgical Quality Improvement Program was used to conduct a retrospective cohort study of geriatric patients (>65 years) undergoing surgery for hip fracture. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration <3.5g/dL). All comparisons were adjusted for baseline differences between populations. 17,651 Patients were identified. Of these, 8,272 (46.9%) underwent hemiarthroplasty, 759 (4.3%) total joint arthroplasty, 324 (1.9%) percutaneous fixation, 2,445 (13.9%) plate/screw fixation, and 5,833 (33.1%)
The April 2023 Children’s orthopaedics Roundup360 looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up
Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined. This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up.Aims
Methods
Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered. Cite this article:
This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome.
Some DEFINITIONS are necessary: “STEMS” refers to “intramedullary stem extensions”, which may be of a variety of lengths and diameters, fixed with cement, porous coating or press fit alone and which may be modular or an inherent part of the prosthesis. The standard extension keel on the tibia does not qualify as a “stem (extension)”. COMPLEX implies multiple variables acting on the end result of the arthroplasty with the capability of inducing failure, as well as necessary variations to the standard surgical technique. A lesser degree of predictability is implied. More specifically, the elements usually found in an arthritic knee and used for the arthroplasty are missing, so that cases of COMPLEX primary TKA include: Soft tissue coverage-(not relevant here), Extensor mechanism deficiency-patellectomy, Severe deformity, Extra-articular deformity, Instability: Varus valgus, Instability: Plane of motion, Instability: Old PCL rupture, Dislocated patella, Stiffness, Medical conditions: Neuromuscular disorder, Ipsilateral arthroplasty, Prior incisions, Fixation hardware, Osteopenia, Ipsilateral hip arthrodesis, Ipsilateral below knee amputation, etc. Complexity includes MORE than large deformity, i.e., success with large deformity does NOT mean success with constrained implants regardless of indication. In addition, the degree of constraint must be specified to be meaningful. NECESSARY presumably this means: “necessary to ensure durable fixation in the face of poor bone quality or more mechanically constrained” and SUFFICIENT suggests that stems, by themselves or in some shape of form, by themselves “will ensure success (specifically here) of fixation”. If we can start with the second proposal, that STEMS are SUFFICIENT for success the answer is: “NO”, many more aspects of surgical technique and implant design are required. Even if all other aspects of the technique are exemplary, some types of stems or techniques are inadequate, e.g., completely uncemented, short stem extensions. The answer to the first proposal is: “YES, in many cases”. The problem will be to determine which cases. There are philosophical analogies to this question that we already know the answer to. ANALOGY: Is a life-raft necessary on a boat? Yes, you may not use it, but it is considered necessary. Is a life-raft “sufficient” on a boat? No, other problems may occur. Are seat belts necessary? Are child seats necessary? The AAOS already has a position on child restraints, an analogous situation, where a party who cannot control their situation (anesthetised patient/ child) functions in the care of a responsible party. The objection may be argued in terms of cost saving by NOT using increased fixation. A useful analogy, (that would of course require specific analysis), is that of patellar resurfacing: universal resurfacing is cost-effective when considering the expense of even a small number of secondary resurfacings. Of course a complex arthroplasty that requires a revision procedure is far more expensive than secondary patellar resurfacing and so universal use of the enhanced fixation in the face of increased constraint makes sense. The human cost of revision surgery tips the balance irrefutably. DANGER-We must avoid the glib conclusion, often based on poor quality data, that constrained implants do not need additional
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. 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.Aims
Methods
Intramedullary infection in long bones represents
a complex clinical challenge, with an increasing incidence due to the
increasing use of
Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models. Literature research was performed on PubMed and Embase databases. Keywords used for search criteria were “bone AND biofilm”. Information on the species of the animal model, bacterial strain, evaluation of biofilm and bone infection, complications, key findings on observations, prevention, and treatment of biofilm were extracted.Aims
Methods
We identified 25 children (10 girls and 15 boys) who had been treated with single bone
Limb deformity is common in patients presenting for knee arthroplasty, either related to asymmetrical wear patterns from the underlying arthritic process (intra-articular malalignment) or less often major extra-articular deformity due to prior fracture malunion, childhood physical injury, old osteotomy, or developmental or metabolic disorders such as Blount's disease or hypophosphatemic rickets. Angular deformity that is above the epicondyles or below the fibular neck may not be easily correctable by adjusted bone cuts as the amount of bone resection may make soft tissue balancing impossible or may disrupt completely the collateral ligament attachments. Development of a treatment plan begins with careful assessment of the malalignment which may be mainly coronal, sagittal, rotational or some combination. Translation can also complicate the reconstruction as this has effects directly on location of the mechanical axis. Most intra-articular deformities are due to the arthritic process alone, but may occasionally be the result of intra-articular fracture, periarticular osteotomy or from prior revision surgery effects. While intra-articular deformity can almost always be managed with adjusted bone cuts it is important to have available revision type implants to enhance fixation (stems) or increase constraint when ligament balancing or ligament laxity is a problem. Extra-articular deformities may be correctable with adjusted bone cuts and altered implant positioning when the deformity is smaller, or located a longer distance from the joint. The effect of a deformity is proportional to its distance from the joint. The closer the deformity is to the joint, the greater the impact the same degree angular deformity will have. In general deformities in the plane of knee are better tolerated than sagittal plane (varus/valgus) deformity. Careful pre-operative planning is required for cases with significant extra-articular deformity with a focus on location and plane of the apex of the deformity, identification of the mechanical axis location relative to the deformed limb, distance of the deformity from the joint, and determination of the intra-articular effect on bone cuts and implant position absent osteotomy. In the course of pre-operative planning, osteotomy is suggested when there is inability to correct the mechanical axis to neutral without excessive bone cuts which compromise ligament or patellar tendon attachment sites, or alternatively when adequate adjustment of cuts will likely lead to excessive joint line obliquity which can compromise ability to balance the soft tissues. When chosen, adjunctive osteotomy can be done in one-stage at the time of TKA or the procedures can be done separately in two stages. When simultaneous with TKA, osteotomy fixation options include long stems added to the femoral (or tibial) component for
We describe ten patients with Turner’s syndrome (karyotype 45, XO) who had leg lengthening for short stature. A high incidence of postoperative complications was encountered and many patients required
Presenters Position:. Purpose of Study:. To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. Description of Methods:. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination. Summary of Results:. Eleven patients presented with pseudarthrosis or bowing of the tibia (six females, five males, age range 4 months–7 years). Three were being treated conservatively and two patients had undergone primary below-knee amputation for severe deformity and functional deficit. Six patients had undergone resection of the pseudarthrosis with
Purpose of the study:. To determine the outcomes of cases converted from an external fixator to an internal fixation device in the management of limb reconstructions and deformity corrections. Method:. A retrospective review of 18 patients, that underwent a conversion procedure to internal fixation following long term external fixation use, was done. This comprised 24 limbs. Inclusion criteria: All cases of long term external fixator use converted to internal fixation over a 5 year period. Average external fixation time, pin site care, conversion timing, surgical device used as well as outcome were documented. Results:. The mean treatment time in an external fixator was 185 days (61–370). The reasons for conversion included patient dissatisfaction, pin tract sepsis and a refracture. The conversion procedures included 8 intramedullary nail fixations and 16 plate and screw fixations. An acute conversion was identified as an internal fixation that was done in the same sitting as external fixator removal. A delayed conversion was any internal stabilisation that was done thereafter. In total, the complication rate associated with conversion to internal fixation following long term external fixation was 25%, mainly due to persistent non-union or sepsis. In the 8 conversions to intramedullary nails, 7 were acute: 4 had good outcomes with sepsis free union being achieved. 3 had poorer outcomes with a non-union and 2 amputations being documented. The single delayed nailing achieved union. In the 16 conversions to plate fixation, 13 achieved union. 10 were acute conversions and 3 were delayed. The remaining 3 that developed complications included 2 acute conversions with septic non-unions and a single delayed conversion which resulted in sepsis. Conclusion:. Conversion of an external fixator to an internal fixator in a non-acute reconstructive setting has a 75% success rate. In the acute conversion group (19 cases), plate and screw fixation had a superior outcome. In the delayed conversion group (5 cases),
A treatment regime using electrical stimulation in association with a variety of surgical procedures has improved the prognosis in congenital pseudarthrosis of the tibia--one of the most challenging of all orthopaedic disorders. The technique consists of correction of the tibial deformity,
A comparative study of methods for treating fractures of the distal half of the femur was carried out prospectively in the five-year period January 1973 to December 1977. The three methods compared were conservative treatment on a Thomas' splint, application of a knee-hinged cast-brace at five to seven weeks, and intramedullary nailing. The time in bed, in hospital and to union were compared as was the rate of functional recovery of the knee. It is concluded that the cast-brace provides a safe reliable method of treatment, combining the advantages of non-operative management with the early mobilisation possible with
Rates of operative fixation for clavicle fractures have been increasing over recent years, but non-operative treatment remains the most common treatment. However, the reported results of case series of non-operatively and operatively treated clavicle fractures show considerable variation, making comparison difficult. Non-operative treatment leads to unsatisfactory results in approximately 3 – 10% of cases, sometimes requiring delayed surgical intervention. Recent studies exploring predictors of poor results after non-operative treatment have shown that fracture displacement is a significant predictor of poor outcome. However, fracture comminution, angulation, shortening, smoking, age, and fracture type and location are not consistently associated with worse outcomes. This has lead to increased interest in surgical fixation for displaced fractures. Prior to the large randomised trial by the Canadian Orthopaedic Trauma Society (COTS), controlled trials comparing surgery to non-operative treatment provided no significant support for surgical fixation. The COTS study provides some evidence for plating displaced mid-shaft fractures, however, partly due to methodological issues, recent reviews of the topic have concluded that additional, more rigorous studies are required to confirm the findings of the COTS trial.
Stemless humeral implants have been developed to overcome stem-related complications in total shoulder arthroplasty (TSA). However, stemless implant designs may hypothetically result in less stable initial fixation, potentially affecting long-term survival. The aim of this study is to investigate early fixation and migration patterns of the stemless humeral component of the Simpliciti Shoulder System and to evaluate clinical outcomes. In this prospective cohort study, radiostereometric analysis (RSA) radiographs were obtained in 24 patients at one day, six weeks, six months, one year, and two years postoperatively. Migration was calculated using model-based RSA. Clinical outcomes were evaluated using the visual analogue scale (VAS), the Oxford Shoulder Score (OSS), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand (DASH) score.Aims
Methods
The aim of this study was to evaluate whether duration of surgery correlates with the survival and final outcome of the patient with metastatic bone disease. Between 1999 and 2002, 23 consecutive patients with impending or complete pathological fractures of the femur due to metastatic bone disease caused by variety of malignancies or an unknown primary were reviewed. These fractures were treated with
Biodegradable implants made from polyglycolic and polylactic acid co-polymers undergo degradation by hydrolysis which results in loss of their mechanical strength. The degradation of 1.5 mm polyglycolide rods (Biofix) was studied after intramedullary and subcutaneous implantation in rabbits. Two weeks after implantation there was a 73% reduction in strength of the intramedullary implants and a 64% reduction in the subcutaneous implants. Polyglycolide implants were compared with Kirschner wires for
Recently, secondary life-threatening inflammatory reactions have been identified with molecular biological techniques in patients with multi-system injuries who were submitted to immediate or early
Intraoperative pulmonary fat and bone-marrow embolism is a serious complication of bone and joint surgery. We have investigated the occurrence and incidence of intraoperative embolism in patients undergoing elective lumbar spinal surgery with or without instrumentation. Sixty adult patients with lumbar degenerative disease were examined by intraoperative transoesophageal echocardiography while undergoing posterior lumbar surgery. Of these, 40 underwent surgery with instrumentation and 20 without. Moderate to severe (grade 2 or 3 according to the grading scale of Pitto et al) embolic events were seen in 80% of the instrumented patients but in none of the non-instrumented patients (p <
0.001). The insertion of pedicle screws was particularly associated with large numbers of pulmonary emboli, while the surgical approach, laminectomy, disc removal and bone harvesting were associated with small numbers of emboli. We consider that, as in arthroplasty and
1. It appears that fracture of the humeral shaft occurs more often in persons over fifty. This incidence corresponds with that found in a study carried out by the Pennsylvania Orthopaedic Society in 1959. 2. The middle third of the bone is the most vulnerable portion of the shaft, where transverse fracture and radial nerve palsy most commonly occur. 3. Most fractures of the shaft of the humerus are best treated by simple splintage. The degree of radiological deformity that can be accepted is far greater than in other long bones. In this group anterior bowing of 20 degrees or varus of 30 degrees was present before it became clinically obvious and even then the function of the limb was good. 4. Internal fixation is only occasionally indicated but operation on the middle third of the bone increased the chances of delayed union. 5. In the treatment of delayed union
Immobilisation causes denervation-like changes in the motor endplates, decreases the content of IGF-I, and increases the number of IGF-I receptors in the spinal cord. In the rat we investigated whether similar changes occur after a fracture of the midshaft of the femur which had been treated by
Purpose. We retrospectively evaluated the outcome of fibula grafts in upper limb post infectious diaphyseal gap nonunions and assessed the following modifiers: age, site, vascularised/ nonvascularised, and length of the graft on time to union, graft incorporation, complication rate and reoperation rate. Methods. Thirty seven paediatric upper limb segmental defects treated over a period of 10 years were identified. Twenty two post septic defects in 21 children were treated with
Purpose: This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. Materials and Method: From 1990 to 2007, 142 tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Twenty-one tibial fractures were open and were treated primarily with external fixation and then with intramedullary nailing. Seventy patients (49%) were under 20 years old, 85 (59%) were men and traffic accident was the main cause of fracture in 58 (41%) patients. 108 patients were treated with GK nail, 14 patients with modified GK nail and 20 patients with S2 nail. All patients were allowed postoperatively full weight bearing with crutches till the fracture healing. Patients were evaluated clinically and radiographs were reviewed every three weeks till fracture healing. Last follow-up was at two years postoperatively. The functional results were evaluated with the Iowa Ankle-Evaluating System. Results: Acceptable radiographic alignment, defined as <
5° of angulation in any plane, was obtained in 135 patients (95%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. We had no non-unions or failures of the implant. Complications included one superficial infection at the entry point of the nail and one iatrogenic fracture at the time of the intramedullary nailing. The fractures united at an average of 12.5 weeks. The functional outcome was determined at one and two years postoperatively. There was improvement in the Iowa Ankle-Evaluating System scores with time. Conclusion: Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to
Following successful total knee arthroplasty, tibial periprosthetic fractures are rare and patellar fractures are sufficiently dependent upon vascular issues that they constitute a somewhat separate topic. Femoral periprosthetic fractures are extremely difficult to manage, usually producing flexion, internal rotation, and varus deformities. Malunion from insufficient stabilisation and stiffness from excessive immobilisation are the polar perils to be avoided. A variety of conservative treatment options will be discussed, ranging from casting and traction to open reduction and internal fixation. Within the latter category, recent enthusiasm has swayed the pendulum of therapeutic options towards
Introduction. Unstable intertrochanteric hip fractures (AO 31A2) continue to be a challenge, as non-locking implants have shown a considerable rate of loss of reduction.
High complication rates and technical difficulties of intra-medullary fixation in children with osteogenesis imperfecta has prompted the modification of existing rod systems. The Sheffield telescoping intramedullary rod has T-piece which is permanently fixed and is expanded to reduce metaphyseal migration. This study analyses the outcome of this rod system over an 11-year period. 32 rods were inserted in the lower limbs of 11 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion.24 rods were inserted into femur, of which 3 were exchange procedures for complications. 8 rods were inserted into tibia. 4 children had intramedullary rodding of all the 4 lower limb bones. The outcome was measured in terms of mobility status, incidence of refractures and rod related complications. Complications encountered include 2-rod migrations, one instance each of broken rod, bent rod and valgus drift in the tibia.There was no instance of epiphyseal damage or growth arrest. Our series demonstrates that there is significant reduction in refractures and improvement in the mobility status in children with osteogenesis imperfecta following
Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall. Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and
Non-operative treatment is usually employed in the treatment of femoral fractures in young individuals. Malunion, delayed union, joint stiffness, limb length discrepancy, psychological problems and delay in functional recovery are well known complications of conservative treatment. The length of hospital stay that will be a part of non-operative treatment will add to the cost of the treatment. We report our experience with intramedullary nailing of closed femoral shaft fractures with a new femoral nail in adolescent patients with an open physis. We treated 13 patients between 1995 and 2004 aged between 8–16 years (8 males and 5 females) with a new femoral nail for closed femoral shaft fractures using the tip of the greater trochanter as the entry point. 11 of the 13 patients had removal of the femoral nail. The mechanism of injury, length of hospital stay, patient mental well-being, surgical technique, requirement of secondary surgical procedures, associated complications, post-operative mobility, return to pre-injury status, range of movement at the hip and knee are discussed. At follow up ranging from few months to 7 years, we found no leg length discrepancy, rotational deformity, limp, problems with physis and all patients had a full range of movement at the hip and knee. External fixation, elastic intramedullary nails, plate and screw fixation are other surgical options available to treat femoral shaft fractures. Children poorly tolerate external fixators and plate fixation can be associated with a high incidence of complications. Flexible