Aims. The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. Methods. An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. In the base case analysis, surgical fixation with K-wire was more expensive (£29.65 (95% confidence interval (CI) -94.85 to 154.15)) and generated lower QALYs (0.007 (95% CI -0.03 to 0.016)) than moulded casting, but this difference was not statistically significant. The probability of K-wire being cost-effective at a £20,000 per QALY cost-effectiveness threshold was 24%. The cost-effectiveness results remained robust in the sensitivity analyses. Conclusion. The findings suggest that surgical fixation with K-wire is unlikely to be a cost-effective alternative to a moulded cast in adults, following manipulation of a fracture of the distal radius in a theatre setting. Cite this article: Bone Joint J 2022;104-B(11):1225–1233

Aims. The primary aim of this study was to report the radiological outcomes of patients with a dorsally displaced distal radius fracture who were randomized to a moulded cast or surgical fixation with wires following manipulation and closed reduction of their fracture. The secondary aim was to correlate radiological outcomes with patient-reported outcome measures (PROMs) in the year following injury. Methods. Participants were recruited as part of DRAFFT2, a UK multicentre clinical trial. Participants were aged 16 years or over with a dorsally displaced distal radius fracture, and were eligible for the trial if they needed a manipulation of their fracture, as recommended by their treating surgeon. Participants were randomly allocated on a 1:1 ratio to moulded cast or Kirschner wires after manipulation of the fracture in the operating theatre. Standard posteroanterior and lateral radiographs were performed in the radiology department of participating centres at the time of the patient’s initial assessment in the emergency department and six weeks postoperatively. Intraoperative fluoroscopic images taken at the time of fracture reduction were also assessed. Results. Patients treated with surgical fixation with wires had less dorsal angulation of the radius versus those treated in a moulded cast at six weeks after manipulation of the fracture; the mean difference of -4.13° was statistically significant (95% confidence interval 5.82 to -2.45). There was no evidence of a difference in radial shortening. However, there was no correlation between these radiological measurements and PROMs at any timepoint in the 12 months post-injury. Conclusion. For patients with a dorsally displaced distal radius fracture treated with a closed manipulation, surgical fixation with wires leads to less dorsal angulation on radiographs at six weeks compared with patients treated in a moulded plaster cast alone. However, the difference in dorsal angulation was small and did not correlate with patient-reported pain and function. Cite this article: Bone Jt Open 2024;5(2):132–138

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

Aims. The timing of surgical fixation in spinal fractures is a contentious topic. Existing literature suggests that early stabilization leads to reduced morbidity, improved neurological outcomes, and shorter hospital stay. However, the quality of evidence is low and equivocal with regard to the safety of early fixation in the severely injured patient. This paper compares complication profiles between spinal fractures treated with early fixation and those treated with late fixation. Methods. All patients transferred to a national tertiary spinal referral centre for primary surgical fixation of unstable spinal injuries without preoperative neurological deficit between 1 July 2016 and 20 October 2017 were eligible for inclusion. Data were collected retrospectively. Patients were divided into early and late cohorts based on timing from initial trauma to first spinal operation. Early fixation was defined as within 72 hours, and late fixation beyond 72 hours. Results. In total, 86 patients underwent spinal surgery in this period. Age ranged from 16 to 88 years. Mean Injury Severity Score (ISS) was higher in the early stabilization cohort (p = 0.020). Age was the sole significant independent variable in predicting morbidity on multiple regression analysis (p < 0.003). There was no significant difference in complication rates based on timing of surgical stabilization (p = 0.398) or ISS (p = 0.482). Conclusion. Our results suggest that these patients are suitable for early appropriate care with spinal precautions and delayed definitive surgical stabilization. Earlier surgery conferred no morbidity benefit and had no impact on length of stay. Cite this article: Bone Joint J 2020;102-B(5):627–631

Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing. £250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics. 11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort. Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort

Flail chest and multiple rib fractures are common injuries in trauma patients. Several small randomized studies have suggested significant improvements in patient outcomes with surgical fixation, compared to nonoperative management, yet emerging population-level data report some conflicting results. The objectives of this study were to compare the results of surgical fixation and nonoperative management of multiple rib fractures and flail chest injuries and to assess whether effects varied by study design limitations, including risk of confounding by indication. A comprehensive search of electronic databases (Medline, Embase, Web of Science) was performed to identify randomized controlled trials and observational studies. Random effects models were used to evaluate weighted risk ratios (RR) and mean differences (MD). Risk of confounding by indication was assessed for each study (low, medium, and high risk), and this categorization was used to stratify results for clinical outcomes. Publication bias was assessed. Thirty-nine studies, with a total of 19,357 patients met inclusion criteria. Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures was associated with decreased risk of death (overall RR 0.40, 95% confidence interval (CI) 0.28–0.56), pneumonia (overall RR 0.70, 95% CI 0.52–0.93), tracheostomy (overall RR 0.62, 95% CI 0.41–0.93), and chest wall deformity (overall RR 0.16, 95% CI 0.06–0.42). However, many of the observational studies were at risk of confounding by indication, and results varied according to risk of confounding by indication. Differences in ventilator time, intensive care unit length of stay (LOS), hospital LOS, and return to work will be assessed (results pending). Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures is associated with improved clinical outcomes. Discrepancies between some study results may be due to confounding by indication. Additional prospective randomized trials and high-quality observational studies are required to overcome potential threats to validity and to expand on existing evidence around optimal treatment of these injuries

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. Methods. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results. Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion. This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. Cite this article: Bone Joint J 2024;106-B(4):401–411

There has been a substantial increase in the surgical treatment of unstable chest wall injuries recently. While a variety of fixation methods exist, most surgeons have used plate and screw fixation. Rib-specific locking plate systems are available, however evidence supporting their use over less-expensive, conventional plate systems (such as pelvic reconstruction plates) is lacking. We sought to address this by comparing outcomes between locking plates and non-locking plates in a cohort of patients from a prior randomized trial who received surgical stabilization of their unstable chest wall injury. We used data from the surgical group of a previous multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries to non-operative management. In this substudy, our primary outcome was hardware-related complications and re-operation. Secondary outcomes included ventilator free days (VFDs) in the first 28 days following injury, length of ICU and hospital stay, and general health outcomes (SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores). Categorical variables are reported as frequency counts and percentages and the two groups were compared using Fisher's Exact test. Continuous data are reported as median and interquartile range and the two groups were compared using the Wilcoxon rank-sum test. From the original cohort of 207 patients, 108 had been treated surgically and had data available on the type of plate construct used. Fifty-nine patients (55%) had received fixation with non-locking plates (primarily 3.5 or 2.7 mm pelvic reconstruction plates) and 49 (45%) had received fixation with locking plates (primarily rib-specific locking plates). The two groups were similar in regard to baseline and injury characteristics. In the non-locking group, 15% of patients (9/59) had evidence of hardware loosening versus 4% (2/49 patients) in the locking group (p = 0.1). The rate of re-operation for hardware complications was 3% in the non-locking group versus 0% in the locking group (p = 0.5). No patients in either group required revision fixation for loss of reduction or nonunion. There were no differences between the groups with regard to VFDs (26.3 [19.6 – 28] vs. 27.3 [18.3 – 28], p = 0.83), length of ICU stay (6.5 [2.0 – 13.1] vs 4.1 [0 – 11], p = 0.12), length of hospital stay (17 [10 – 32] vs. 17 [10 – 24], p = 0.94) or SF-36 PCS (40.9 [33.6 – 51.0] vs 43.4 [34.1 – 49.6], p = 0.93) or MCS scores (47.8 [36.9 – 57.9] vs 46.9 [40.5 – 57.4], p = 0.95). We found no statistically significant differences in outcomes between patients who received surgical stabilization of their unstable chest wall injury when comparing non-locking plates versus locking plates. However, the rate of hardware loosening was nearly 4 times higher in the non-locking plate group and trended towards statistical significance, although re-operation related to this was less frequent. This finding is not surprising, given the inherent challenges of rib fixation including thin bones, comminution, potential osteopenia and a post-operative environment of constant motion. We believe that the increased cost of locking plate fixation in this setting is likely justifiable given these findings

Aims. Describe a statistical and economic analysis plan for the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) randomized controlled trial. Methods. DRAFFT2 is a multicentre, parallel, two-arm randomized controlled trial. It compares surgical fixation with K-wires versus plaster cast in adult patients who have sustained a dorsally displaced fracture of the distal radius. The primary outcome measure is the Patient-Rated Wrist Evaluation (PRWE, a validated assessment of wrist function and pain) at 12 months post-randomization. Secondary outcomes are measured at three, six, and 12 months after randomization and include the PWRE, EuroQoL EQ-5D-5L index and EQ-VAS (visual analogue scale), complication rate, and cost-effectiveness of the treatment. Results. This paper describes the full details of the planned methods of analysis and descriptive statistics. The DRAFFT2 study protocol has been published previously. Conclusion. The planned analysis strategy described records our intent to conduct statistical and within-trial cost-utility analyses. Cite this article: Bone Joint Open 2020;1-6:245–252

Background:. There are multiple risk factors regarding the outcome of open tibia fractures treated with surgical fixation. In this study we have looked at delay to debridement and HIV infection as risk factors in the outcome of open tibia fractures. Methods:. We present a prospective study of 89 patients with open tibia fractures treated with surgical fixation with a significant delay to first debridement and a high prevalence of HIV infection. Primary outcome of this study was time to union and wound infection in the first 3 months. All patients admitted in our hospital between February 2011 and October 2012 with open fractures of the tibia requiring surgical fixation were included in the study. Patients were tested for HIV infection and multiple clinical parameters were documented, including; Gustilo-Anderson classification, ASEPSIS wound score, New Injury Severity Score(NISS), comorbidities, time to 1st debridement, time to 1st dose of antibiotics, pin site score, level of contamination, level training of the surgeon, high energy injuries, time to union and socio-economic parameters. Patients were followed to union. Results:. Twenty-five (28%) of the 89 patients were HIV positive. Forty-six (52%) patients had a delay to debridement of more than 24 hours. Eight (9%) patients developed wound infection in the first 3 months. Seventeen (19%) patients had a delayed union of more than 6 months. This study was underpowered to show a relation between wound infection and the clinical parameters of our patients. A logistic regression analysis showed that grade 3 Gustilo-Anderson injuries were associated with delayed union. We did not find an association between delayed union and; – HIV status, NISS, time to 1st debridement, high energy injuries, level of contamination and time to 1st dose of antibiotics. Conclusion:. This study suggests that delay to 1st debridement and HIV status are not significant risk factors for wound infection and delayed union in patients with open tibia fractures. There was a significant association between Gustilo-Anderson grade 3 open fractures of the tibia and delayed union. We stress the importance of good clinical judgment in the surgical treatment of open tibia fractures in a setting with high rates of HIV infection and limited resources

Aims. Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. Methods. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England – Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024. Cite this article: Bone Jt Open 2024;5(4):343–349

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Aims. Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. Methods. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Results. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). Conclusion. The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were treated nonoperatively, locked anterior-plate fixation remains the predominant method of fixation for fractures of the distal radius; this is despite questions and continued debate about the best method of surgical fixation for these injuries. Cite this article: Bone Jt Open 2022;3(8):623–627

Aims. Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture. Methods. This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery. Results. The 30-day mortality was 6.9% for cemented and 4.9% for uncemented groups (p = 0.003). Cement use was significantly associated with 30-day mortality in the Kaplan-Meier survival curve (p = 0.003). After adjusting for covariates, no significant association between cement use and 30-day mortality was shown in the adjusted multilevel logistic regression (odd rati0 (OR) 1.1, 95% confidence interval (CI) 0.9 to 1.5; p = 0.366), or in the instrumental variable analysis (OR 1.0, 95% CI 0.9 to 1.0, p=0.524). There was no significant between-group difference in mortality within 30days (hazard ratio (HR) 0.9, 95% CI 0.7to 1.1; p = 0.355) or one year (HR 0.9 95% CI 0.8 to 1.1; p = 0.328) in the Cox modelling. Conclusion. No statistically significant difference in patient mortality with cement use in arthroplasty was demonstrated in this population, once adjusted for covariates. This study concludes that cementing in arthroplasty for hip fracture is a safe means of surgical fixation. Cite this article: Bone Jt Open 2023;4(3):198–204

Aims. This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. Methods. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Results. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. Conclusion. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe. Cite this article: Bone Joint J 2024;106-B(9):949–956

Purpose: Surgical trainees develop psychomotor skills using various techniques, with simulators providing safe practicing environments. There has been no development of virtual simulators with haptics (force feedback) that allow residents to practice the open surgical fixation of common orthopedic fractures. The main purpose of this study was to assess if residents performed similarly on a newly developed virtual simulator as on a Sawbones simulator using a modified checklist and global rating scale. Secondary purposes were to assess the reliability and validity of these procedural measurement tools. Method: A stratified randomized within-subjects study was performed with 22 surgical trainee volunteers. They were randomized to first perform surgical fixation of the ulna using either the virtual or Sawbones simulator, and then performed the same procedure on the other simulator. Evaluators completed a task-specific checklist, global rating scale (GRS), total error score and time to completion for each participant on both simulators. Results: The participants achieved significantly better scores on the virtual simulator compared to the Sawbones simulator (p0.8), except in time to completion. When combined, the checklist and GRS maintained high levels of internal consistency (Cronbach’s a > 0.80) and inter-rater reliability (intraclass coefficient > 0.90) for both simulators. A Pearson’s product moment correlation was used to demonstrate criterion validity of the measurement tools. They were all significantly correlated to each other within simulators (p0.9), while the virtual simulator achieved construct validity for the GRS and total error score (p1.1). Conclusion: The modified procedural measurement tools demonstrate reliability and validity and the virtual simulator shows evidence of construct validity. These tools were used to evaluate participants, demonstrating the achievement of better scores on the virtual simulator compared to the Sawbones simulator. The only concern at this time is that the procedural measurement tool scores do not correlate between simulators. The newly developed virtual ulna surgical fixation simulator with haptics shows promise for helping surgical trainees learn and practice basic skills, but requires further modifications before it can attain the same standards as the current gold standard simulators

Abstract

Aims

The aim of this study was to assess the effect of time to surgical intervention from admission on mortality and morbidity for patients with hip fractures.

To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery).

The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study.

Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization.

Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications.

Background

Trochanteric fractures account for up to 20% of all periprosthetic fractures occurring during or after total hip arthroplasties (THAs). They are frequently managed conservatively except in cases with significant displacement. There is a paucity of literature describing the indications and results of operative or non-operative management of these fractures.

Abstract

Introduction and Objective

The most common paediatric orthopaedic injury requiring hospital admission is a femoral fracture. There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12.

Aims

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique).

Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Introduction

We have evaluated the circulation of the femoral head after multiple pinning for femoral neck fractures by bone SPECT.

Introduction: Avulsion fractures of the anterior tibial spine are not so common. The best form of treatment for displaced fractures is still debatable.

Aims: We aimed to analyze the results of different forms of internal fixation for avulsion fractures of the anterior tibial spine.

Material and Methods: Twenty-five patients with avulsion fractures of the anterior tibial spine had open reduction and internal fixation with different implants (AO screw, Herbert screw, stainless steel wire loop and absorbable stitch) and techniques. The mean follow up period was 3.66 years. They were evaluated clinically and radiologically, using KT 1000 arthrometer for ACL laxity and goniometer for range of movements. The outcome was measured using Lysholm Knee Score.

Results: Significant residual anterior laxity despite adequate fracture union was a common finding. Maximum ACL laxity was seen in adults in whom absorbable stitches had been used and they had a corresponding lower Lysholm score. Significant migration of the Herbert screws was noted in two of five patients in which it was used. Five of the eight patients with higher Lysholm score had AO screw fixation. Three patients with steel wire loop for stabilization of the fracture also had better results comparatively. Three individuals who had their knee immobilised in 25°–50° of flexion developed fixed flexion deformities, which took 12–18 months to recover.

Conclusions: The use of absorbable stitches as the primary method of fixation for avulsion fractures of the tibial spine should be avoided in adults. Herbert screw in this situation has a tendency to migrate. AO screws and non-absorbable loop yields better functional outcome. Immobilization of the knee in excessive flexion leads to prolonged fixed flexion deformity. Early range of movements can be achieved by replacing cast with a brace allowing flexion up to 90 degrees.

Purpose

A recent multicentre randomized control trial (RCT) failed to demonstrate superior quality of life at one year following open reduction and internal fixation (ORIF) compared to nonoperative treatment for unstable isolated fibular fractures. We sought to determine the cost-effectiveness of ORIF compared to non-operative management of unstable fibular fractures.

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 intramedullary fixation of their fractured femora. This phenomenon was called “The second hit”, and it caused ARDS, PE, and Renal Failure.

In a consecutive series of 135 trauma patients with high energy long bone fractures, 40 had sustained multiple-injuries. All fractures were reduced and stabilized on admission by AO-Tubular External Fixation systems. After 72–96 hours, this system was converted to an hybrid-ring-tubular system, which had three dimensional stability. They commenced partial weight bearing 24 hours later, and were followed by bony union.

One patient developed DVT, none developed ARDS, PE, Renal Failure.

Superficial pin-tract infection was common, but no-deep infection and’or osteomyelitis were encountered.

With this minimal-invasive surgical technique, life threatening complications were avoided while preserving the integrity of the soft tissue envelope, the critical contributing biological factor for fracture healing.

Purpose: To assess the effect of regional versus general anesthesia on transcranial cerebral oxygen saturation (rSO₂) in elderly patients undergoing fractured proximal femur repair.

Materials and Methods: Prospective, randomized, open-label study. 60 geriatric patients were randomized to receive either general (Group GA) or spinal (Group S) anesthesia. In all cases frontal rSO₂ (INVOS^® 5100, SOMANETICS, Troy, Michigan, USA) was measured for a 10 minute pre-operative control period, throughout the surgical procedure and for 10 minutes postoperatively. If a drop in rSO₂ below baseline occurred, the following were instituted in order to improve cerebral oxygenation: normotension was ensured, the neck vessels were checked and cleared of extrinsic obstruction and the F_IO₂ was increased.

Results: The incidence of a decrease in rSO₂ below base-line preoperative levels was significantly (p < 0.0001) higher in Group S. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups. By contrast, general anesthesia was associated with a significantly higher rSO₂ when compared to spinal anesthesia. This is attributed to the volatile anesthetic agent induced reduction in the cerebral metabolic rate. Logistic regression revealed no correlation between changes in blood pressure, heart rate or peripheral oxygen saturation and the incidence of rSO₂ dips below baseline.

Conclusion: rSO₂ is likely patient specific and independent of the anesthetic technique administered. Therefore we support the utility of cerebral oximetry in this population in order to detect cerebral desaturation and correct reversible causes such as relative hypotension and neck vessel obstruction. Choice of anesthetic technique should still be tailored to individual patient needs.

Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients. This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures. Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8. This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking. We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80. A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax. This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax

Aims. The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. Methods. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. Results. Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. Conclusion. Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277–1283

The Unified Classification System (UCS), or Vancouver system, is a validated and widely used classification system to guide the management of periprosthetic femoral fractures. It suggests that well-fixed stems (type B1) can be treated with fixation but that loose stems (types B2 and B3) should be revised. Determining whether a stem is loose can be difficult and some authors have questioned how to apply this classification system to polished taper slip stems which are, by definition, loose within their cement mantle. Recent evidence has challenged the common perception that revision surgery is preferable to fixation surgery for UCS-B periprosthetic fractures around cemented polished taper slip stems. Indications for fixation include an anatomically reducible fracture and cement mantle, a well-fixed femoral bone-cement interface, and a well-functioning acetabular component. However, not all type B fractures can or should be managed with fixation due to the risk of early failure. This annotation details specific fracture patterns that should not be managed with fixation alone. Cite this article: Bone Joint J 2023;105-B(5):481–486

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period. Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year. 388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p<0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p<0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276). Of the surgical management group, those that underwent fixation <72 hours post injury were significantly less likely to develop pneumonia than those who were delayed >72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856). Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection. Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio. Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection. In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings

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

Aims. Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon. Methods. SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments. Discussion. There is currently no high-quality evidence comparing the clinical and cost effectiveness of the tension suture repair to the traditional tension band wiring currently offered for the internal fixation of displaced fractures of the olecranon. The Simple Olecranon Fracture Fixation Trial (SOFFT) is a randomized controlled trial with sufficient power and design rigour to provide this evidence for the subtype of Mayo grade IIA fractures. Cite this article: Bone Jt Open 2023;4(1):27–37

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

Aims. There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results. A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients. Cite this article: Bone Joint J 2024;106-B(4):387–393

The August 2023 Trauma Roundup. 360. looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Thrombelastography (TEG) is a point-of-care tool that can measure clot formation and breakdown using a whole blood sample. We have previously used serial TEG analysis to define hypercoagulability and increased venous thromboembolism (VTE) risk following a major fracture requiring surgical treatment. Additionally, we have used serial TEG analysis to quantify the prolonged hypercoagulable state and increased VTE risk that ensues following a hip fracture. Recently developed cartridge-based platelet mapping (PLM) using TEG analysis can be used to activate platelets at either the adenosine diphosphate (ADP) receptor or at the Thromboxane A2 (AA) receptor, in order to evaluate clot strength when platelets are activated only through those specific receptors. This study aim was to evaluate platelet contribution to hypercoagulability, in order to identify potential therapeutic targets for VTE prevention. We hypothesized that there would be a platelet-predominant contribution to hypercoagulability following a hip fracture. Patients aged 50 years or older with a hip fracture treated surgically were enrolled in this prospective cohort study. Exclusion criteria were: prior history of VTE, active malignancy, or pre-injury therapeutic dose anticoagulation. Serial TEG and PLM analyses were performed at admission, post-operative day (POD) 1, 3, 5, 7 and at 2-, 4-, 6- and 12-weeks post-operatively. All patients received thromboprophylaxis with low molecular weight heparin (LMWH) for 28 days post-operatively. Hypercoagulability was defined as maximal amplitude (MA; a measure of clot strength) over 65mm based on TEG analysis. Independent samples t-tests were used to compare MA values with this previously established threshold and a mixed effects linear regression model was used to compare MA values over time. Independent samples t-tests and Chi-sqaured analyses were used to compare between the surgical fixation and arthroplasty groups. Forty-six patients with an acute hip fracture were included, with a mean age of 77.1 (SD = 10.6) years, with 61% (N=11) being female. Twenty-six were treated with arthroplasty (56.5%), while the remainder underwent surgical fixation of their hip fractures. TEG analysis demonstrated post-operative hypercoagulability (mean MA over 65mm) at all follow-up timepoints until 12-weeks. PLM identified a platelet-mediated hypercoagulable state based on elevated ADP-MA and AA-MA, with more pronounced platelet contribution demonstrated by the AA pathway. Patients treated with arthroplasty had significantly increased AA-MA compared with ADP-MA at POD 3 and at the 12-week follow-up. Thrombelastography can be used to identify hypercoagulability and increased risk for VTE following a hip fracture. Platelet mapping analysis from this pilot study suggests a platelet-mediated hypercoagulable state that may benefit from thromboprophylaxis using an anti-platelet agent that specifically targets the AA platelet activation pathway, such as acetylsalicylic acid (ASA). This research also supports differences in hypercoagulability between patients treated with arthroplasty compared to those who undergo fracture fixation

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

This study aimed to determine if multiple failed closed reductions (CRs) prior to fixation of distal radius fracture is associated with the odds of complication-related reoperation up to two years post fracture. We identified all distal radius fracture patients aged 18 or older between the years of 2003-2016 in Ontario, Canada from linked administrative databases. We used procedural and fee codes to identify patients who underwent primary outpatient surgical fixation between 8 and 14 days post fracture, and grouped patients by the number of CRs they underwent prior to definitive fixation. We excluded patients who underwent fixation within 7 days of their fracture to exclude more complex fracture types and/or patients who required more immediate surgery. We grouped patients according to the number of CRs they underwent prior to definitive fixation. We used intervention and diagnostic codes to identify reoperations within two years of fixation. We used multi-level multivariable logistic regression to compare the association between the number of CRs and reoperation while accounting for clustering at the surgeon level and adjusting for other relevant covariables. We performed an age-stratified analysis to determine if the association between the number of CRs and reoperation differed by patient age. We identified 5,464 patients with distal radius fractures managed with outpatient fixation between 8 and 14 days of their fracture. A total of 1,422 patients (26.0%) underwent primary surgical fixation (mean time to fixation 10.6±2.0 days), while 3,573 (65.4%) underwent secondary fixation following one failed CR (mean time to fixation 10.1±2.2 days, time to CR 0.3±1.2 days), and 469 (8.6%) underwent fixation following two failed CRs (mean time to fixation 10.8±2.2 days, time to first CR 0.0±0.1 days, time to second CR 4.7±3.0 days). The CR groups had higher proportions of female patients compared to the primary group, and patients who underwent two failed CRs were more likely to be fixed with a plate (vs. wires or pins). The unadjusted proportion of reoperations was significantly higher in the group who underwent two failed CRs (7.5%) compared to those who underwent primary fixation (4.4%), and fixation following one failed CR (4.9%). Following covariable adjustment, patients who underwent two failed CRs had a significantly higher odds of reoperation (odds ratio [OR] 1.72 [1.12-2.65]) compared to those who underwent primary fixation. This association appeared to worsen for patients over the age of 60 (OR 3.93 [1.76-8.77]). We found no significant difference between the odds of reoperation between patients who underwent primary fixation vs. secondary fixation following one failed CR. We found that patients with distal radius fractures who undergo multiple CRs prior to definitive fixation have a significantly higher odds of reoperation compared to those who undergo primary fixation, or fixation following a single CR. This suggests that surgeons should offer fixation if indicated following a single failed CR rather than attempt multiple closed reductions. Prospective studies are required to confirm these findings

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK

Introduction and Objective. Ankle fractures are common and affect young adults as well as the elderly. An unstable ankle fracture treatment typically involves surgical fixation, immobilisation, and modified weight-bearing for six weeks. Non-weight bearing (NWB) cast immobilisation periods were used to protect the soft tissue envelope and osteosynthesis. This can have implications on patient function and may reduce independence, mobility and return to work. Newer trends in earlier mobilisation compete with traditional NWB doctrine, and weak consensus exists as to the best postoperative strategy. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Materials and Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus non-weight-bearing (NWB) and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury). The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the immediate weight-bearing group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a pulmonary embolism; both were randomised to NWB. Length of hospital stay (LOS) was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusions. There is a paucity of quality evidence supporting the postoperative management regimes used most commonly in clinical practice. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. In this large multicentre, randomised controlled trial, we investigated immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome. Once anatomical reduction and stable internal fixation is achieved, we recommend IWB in all types of ankle fractures in a compliant patient

The majority of 5th metatarsal fractures are successfully treated conservatively, with few patients requiring surgical fixation for symptomatic non-union. Tuberosity avulsion fractures are generally considered benign injuries with more distal fractures showing a propensity to develop delayed/non-union. We studied a cohort of patients who underwent surgery as treatment for non-union. We reported on outcome, rate of complications and requirement for additional surgery. All patients who required surgery to their 5th metatarsal from June 2008 to May 2018 were included. Demographic, clinical outcome data and radiographic classification of fracture types were collected, reviewed and analysed. 35 patients had undergone surgery for 5th metatarsal fractures during this time period and 31 of these had been operated on for a painful non-union. 12 were tuberosity avulsion fractures (Lawrence and Botte Type1) and 23 were Type 2/3. 5 patients (14.3%) experienced a further symptomatic non-union after initial surgery; Type 1 fractures were 11 times more likely to result in non-union (p=0.0375). 22.9% of the group required some form of further surgery, with a significant association between Type 1 fractures and the need for further surgery (p=0.0107). This study is the first of its kind, reporting specifically on the outcome after surgical fixation of a non-union of 5th metatarsal fractures. Overall, surgery had a good outcome with a low complication rate, though it is interesting to note that Type 1 fractures, which traditionally have a low non-union rate after conservative treatment, are associated with a significantly increased incidence of non-union if operated for symptomatic non-union

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. Methods. We describe the survival, radiological, and functional outcomes of 33 patients (38 THAs) at a mean follow-up of 27 years (25 to 32) between 1988 and 2018. Results. Of the surviving 30 patients (34 THAs), there were four periprosthetic fractures: one underwent femoral revision after 21 years, two had surgical fixation as the stem was deemed stable, and one was treated nonoperatively due to the patient’s comorbidities. The periprosthetic fracture patients showed radiological evidence of change in bone stock around the femoral stem, which may have contributed to the fractures; this was reflected in change of the canal flare index at the proximal femur. Two patients (two hips) were lost to follow-up. Using aseptic loosening as the endpoint, 16 patients (18 hips; 48%) needed acetabular revision. None of the femoral components were revised for aseptic loosening, demonstrating 100% survival. The estimate of the cumulative proportion surviving for revisions due to any cause was 0.97 (standard error 0.03). Conclusion. In young patients with high demands, the Furlong HAC-coated femoral component gives excellent long-term results. Cite this article: Bone Jt Open 2024;5(4):286–293

This study compares outcomes of fixation of subtrochanteric femoral fractures using a single lag screw (Gamma3 nail, GN) with a dual lag screw device (InterTAN nail, IN). The primary outcome was mechanical failure, defined as lag screw cut-out, back-out, nail breakage or peri-implant fracture. Technical factors associated with mechanical failure were also identified. All adult patients (>18yrs) with a subtrochanteric femoral fracture treated in a single centre were retrospectively identified using electronic records. Included patients underwent surgical fixation using either a long GN (2010–2017) or IN (2017–2022). Cox regression analysis was used to determine the risk of mechanical failure and technical predictors of failure. The study included 587 patients, 336 in the GN group (median age 82yrs, 73% female) and 251 in the IN group (median age 82yrs, 71% female). The IN group exhibited a higher prevalence of osteoporosis (p=0.002) and CKD□3 (p=0.007). There were no other baseline differences between groups. The risk of any mechanical failure was increased two-fold in the GN group (HR 2.51, p=0.020). Mechanical failure comprising screw cut-out (p=0.040), back-out (p=0.040) and nail breakage (p=0.51) was only observed in the GN group. The risk of peri-implant fracture was similar between the groups (HR 1.10, p=0.84). Technical predictors of mechanical included varus >5° for cut-out (HR 15.61, p=0.016), TAD>25mm for back-out (HR 9.41, p=0.020) and shortening >1cm for peri-implant fracture (HR 6.50, p=<0.001). Dual lag screw designs may reduce the risk of mechanical complications for patients with subtrochanteric femoral fractures

Background. Many approaches to management of medial malleolar fractures are described in the literature however, their morphology is under investigated. The aim of this study was to analyse the morphology of medial malleolar fractures to identify any association with medial malleolar fracture non-union or malunion. Methods. Patients who had undergone surgical fixation of their MMF were identified from 2012 to 2022, using electronic patient records in a single centre. Analysis of their preoperative, intraoperative, and postoperative radiographs was performed to determine their morphology and prevalence of non-union and malunion. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results. A total of 650 patients were identified across a 10-year period which could be included in the study. The overall non-union rate for our cohort was 18.77% (122/650). The overall malunion rate was 6.92% (45/650). There was no significant difference in union rates across the Herscovici classification groups. Herscovici type A fractures were significantly more frequently malreduced at time of surgery as compared to other fracture types (p=.003). Medial wall blowout combined with Hercovici type B fractures showed a significant increase in malunion rate. There is a higher rate of bone union in patients who have been anatomically reduced. Conclusion. The morphology of medial malleolar fractures does have an impact of the radiological outcome following surgical management. Medial wall blowout fractures were most prevalent in adduction-type injuries; however, it should not be ruled out in rotational injuries with medial wall blowouts combined with and Herscovici type B fractures showing a significant increase in malunions. Herscovici type A fractures had significantly higher malreductions however the clinical implications of mal reducing small avulsions is unknown

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics. Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used. 3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001). The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved. Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems

Majority of osteoporosis related fractures are treated surgically using metallic fixation devices. Anchorage of fixation devices is sometimes challenging due to poor osteoporotic bone quality that can lead to failure of the fracture fixation. Using a rat osteoporosis model, we employed neutron tomography and histology to study the biological effects of implant augmentation using an isothermally setting calcium sulphate/hydroxyapatite (CaS/HA) biomaterial with synthetic HA particles as recruiting moiety for systemically administered bisphosphonates. Using an osteoporotic sawbones model, we then provide a standardized method for the delivery of the CaS/HA biomaterial at the bone-implant interface for improved mechanical anchorage of a lag-screw commonly used for hip fracture fixation. As a proof-of-concept, the method was then verified in donated femoral heads and in patients with osteoporosis undergoing hip fracture fixation. We show that placing HA particles around a stainless-steel screw in-vivo, systemically administered bisphosphonates could be targeted towards the implant, yielding significantly higher peri-implant bone formation compared to un-augmented controls. In the sawbones model, CaS/HA based lag-screw augmentation led to significant increase (up to 4 times) in peak extraction force with CaS/HA performing at par with PMMA. Micro-CT imaging of the CaS/HA augmented lag-screws in cadaver femoral heads verified that the entire length of the lag-screw threads and the surrounding bone was covered with the CaS/HA material. X-ray images from fracture fixation surgery indicated that the CaS/HA material could be applied at the lag-screw-bone interface without exerting any additional pressure or risk of venous vascular leakage.: We present a new method for augmentation of lag-screws in fragile bone. It is envisaged that this methodcould potentially reduce the risk of fracture fixation failure especially when HA seeking “bone active” drugs are used systemically

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

Complex regional pain syndrome type 1 (CRPS-I) is a devastating complication that can occur after limb extremity injuries. The effectiveness of vitamin C in preventing CRPS-I incidence is debatable. Therefore, we conducted a systematic review and meta-analysis to assess the role of vitamin C in CRPS-I prevention and its effect on pain score, functional outcomes and complications rate after wrist, ankle, and foot fractures. We searched Medline, Embase, the Cochrane Library, . Clinicaltrial.gov. , and Google Scholar from infinity to May 2021 for relevant studies comparing the incidence of CRPS-I with administration of perioperative vitamin C versus placebo after wrist, ankle, and foot fractures. Continuous data such as functional outcomes and pain scores were pooled as mean differences (MD), whist dichotomous variables such as the incidence of CRPS-I and complications were pooled as odds ratios (OR), with 95% confidence interval (CI). Data analyses was done using R software (meta package, version 4.9-0) for Windows. Eight studies, including two quasi-experimental studies, were included. The timeframe for vitamin C administration ranged from 42 to 50 days post-injury and/or surgical fixation and the dosage was either 500 mg or 1000 mg. The results showed that vitamin C was associated with a lower rate of CRPS-I relative to a placebo (OR 0.33, 95% CI [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (OR 1.90, 95% CI [0.99, 3.65]), functional outcomes (MD 6.37, 95% CI [-1.40, 14.15]), and pain scores (MD -0.14, 95% CI [-1.07, 0.79]). The findings demonstrate that when compared to placebo, at least 42 days of vitamin C prophylaxis is associated with prevention of CRPS-I following wrist, ankle, and foot fractures, irrespective of vitamin C dosage or fracture type. No significant differences were found with secondary outcomes

There is very limited literature describing the outcomes of management for proximal humerus fractures with more than 100% displacement of the head and shaft fragments as a separate entity. This study aimed to compare operative and non-operative management of the translated proximal humerus fracture. A prospective cohort study was performed including patients managed at a Level 1 trauma centre between January 2010 to December 2018. Patients with 2, 3 and 4-part fractures were included based on the degree of translation of the shaft fragment (≥100%), resulting in no cortical contact between the head and shaft fragments. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Linear and logistic regression models were used to compare management options. There were 108 patients with a proximal humerus fracture with ≥100% translation; 76 underwent operative management and 32 were managed non-operatively with sling immobilisation. The mean (SD) age in the operative group was 54.3 (±20.2) and in the non-operative group was 73.3 (±15.3) (p<0.001). There was no association between OSS and management options (mean 38.5(±9.5) operative vs mean 41.3 (±8.5) non-operative, p=0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference 0.16 (95%CI 0.04-0.27, p=0.008); EQ-5D VAS adjusted mean difference 19.2 (95%CI 5.2-33.2, p=0.008). Operative management was further associated with a lower odds of non-union (adjusted OR 0.30, 95%CI 0.09-0.97, p=0.04), malunion (adjusted OR 0.14, 95%CI 0.04-0.51, p=0.003) and complications (adjusted OR 0.07, 95%CI 0.02-0.32, p=0.001). Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes following surgical fixation. Patients with this injury should be considered for operative intervention

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Subtrochanteric femoral fractures are a subset of hip fractures generally treated with cephalomedullary nail fixation\[1\]. Single lag screw devices are most commonly-used, but integrated dual screw constructs have become increasingly popular\[2,3\]. The aim of this study was to compare outcomes of fixation of subtrochanteric femoral fractures using a single lag screw (Gamma3 nail, GN) with a dual screw device (InterTAN nail, IN). The primary outcome was mechanical failure, defined as lag screw cut-out, back-out, nail breakage or peri-implant fracture. Consecutive adult patients (18yrs) with subtrochanteric femoral fracture treated in a single centre were retrospectively identified using electronic records. Patients that underwent surgical fixation using either a long GN (2010–2017) or IN (2017–2022) were included. Medical records and radiographs were reviewed to identify complications of fixation. Cox regression analysis was used to determine the risk of mechanical failure and secondary outcomes by implant design. Multivariable regression models were used to identify predictors of mechanical failure. The study included 622 patients, 354 in the GN group (median age 82yrs, 72% female) and 268 in the IN group (median age 82yrs, 69% female). The risk of any mechanical failure was increased two-fold in the GN group (HR 2.44 \[95%CI 1.13 to 5.26\]; _p=0.024_). Mechanical failure comprising screw cut-out (_p=0.032_), back-out (_p=0.032_) and nail breakage (_p=0.26_) was only observed in the GN group. Technical predictors of failure included varus >5° for cut-out (OR 19.98 \[2.06 to 193.88\]; _p=0.01_), TAD;25mm for back-out (8.96 \[1.36 to 58.86\]; p=0.022) and shortening 1cm for peri-implant fracture (7.81 \[2.92 to 20.91\]; _p=<0.001_). Our results demonstrate that an intercalated screw construct is associated with a lower risk of mechanical failure compared with the a single lag screw device. Intercalated screw designs may reduce the risk of mechanical complications for patients with subtrochanteric femoral fractures

The Poole Traction Splint (PTS) is a non-invasive technique that applies dynamic traction to the affected digit using materials readily available in the outpatient department. The primary aim of this study was to document the outcome of the PTS for hand phalangeal fractures. Over a four-year period (2017–2021), suitable patients were reviewed and referred for PTS to the hand physiotherapists. Functional outcome measures included range of motion (ROM), return to work, and a DASH score. In addition, a healthcare cost analysis was carried out. A total of 63 patients were treated with a PTS from 2017 to 2021. Data was analysed for 54 patients with 55 digits. The mean age was 43 years (17–72) and 53.7% (n=29) were female. There were 43 fractures involving the proximal phalanx and 12 involving the middle phalanx. The mean final composite range of movement averaged 209˚ (110–270°), classified as ‘good/excellent’ by ASSH criteria. The mean DASH score was 13.6 (0-43.2; n=45). All patients were able to return to work. Only two (3.7%) digits required conversion to surgical fixation. The PTS resulted in approximate savings of £2,452 per patient. The PTS is a cost-effective non-invasive low risk outpatient treatment method which provides a functional ROM and good functional outcomes in the treatment of complex phalangeal hand fractures, with minimal risk of surgical intervention being required

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

In 2007, the National Hip Fracture Database (NHFD) was conceived in the United Kingdom (UK) as a national audit aiming to improve hip fracture care across the country. It now represents the world's largest hip fracture registry. The purpose of the NHFD is to evaluate aspects of best practice for hip fracture care, at an institutional level, that reflect the evidence-based clinical guidelines and quality standards developed by the National Institute for Health and Care Excellence. No national program currently exists, equivalent to the NHFD, in Canada despite evidence suggesting that national audit programs can significantly improve patient outcomes. The purpose of this study was to evaluate aspects of best practice for hip fractures at our Canadian academic tertiary referral center using the Key Performance Indicators (KPI) and benchmarks used by the NHFD. In doing so, we aimed to compare our performance to other hospitals contributing to the NHFD database. A retrospective cohort study was conducted on consecutive patients who presented to our Canadian center for surgical management of a hip fracture between August 2019 to September 2020. Fracture types included intertrochanteric, subtrochanteric, and femoral neck fractures treated with either surgical fixation or arthroplasty. Cases were identified from the affiliate institute's Operatively Repaired Fractures Database (ORFD). The ORFD prospectively collects patient-level data extracted from electronic medical records, operating room information systems, and from patients’ discharge summaries. All applicable data from our database were compared to the established KPI and benchmarks published by the NHFD that apply to the Canadian healthcare system. Six hundred and seven patients’ data (64.5% female) were extracted from the ORFD, mean age 80.4 ± 13.3 years. The NHFD contains data from 63,284 patients across the entire UK. The affiliate institute performed inferiorly compared to the NHFD for two KPIs: prompt surgery (surgery by the day following presentation with hip fracture, 52.8% vs. 69%) and prompt mobilization after surgery (mobilized out of bed by the day after operation, 43.0% vs. 81.0%). However, more patients at the affiliate institute were not delirious when tested postoperatively (89.6% vs. 68.4%). There was no significant difference in the average length of stay (12.23 days versus 13.5 days) or in 30-day mortality rate (8.4% versus 8.3%). More than half of all KPI's and benchmarks for patients receiving a hip fracture surgery at our tertiary referral center in Canada ranked significantly lower than patients receiving a hip fracture surgery in the UK. These findings indicate that perhaps a national audit program should be implemented in Canada to improve aspects of hip fracture care, at an institutional level. Following evidence-based clinical guidelines and using standardized benchmarks would encourage change and foster improvement across Canadian centres when necessary

Mechanical failure of spine posterior fixation in the lumbar region Is suspected to occur more frequently when the sagittal balance is not properly restored. While failures at the proximal extremity have been studied in the literature, the lumbar distal junctional pathology has received less attention. The aim of this work was to investigate if the spinopelvic parameters, which characterize the sagittal balance, could predict the mechanical failure of the posterior fixation in the distal lumbar region. All the spine surgeries performed in 2017-2019 at Rizzoli Institute were retrospectively analysed to extract all cases of lumbar distal junctional pathology. All the revision surgeries performed due to the pedicle screws pull-out, or the breakage of rods or screws, or the vertebral fracture, or the degenerative disc disease, in the distal extremity, were included in the junctional (JUNCT) group. A total of 83 cases were identified as JUNCT group. All the 241 fixation surgeries which to date have not failed were included in the control (CONTROL) group. Clinical data were extracted from both groups, and the main spinopelvic parameters were assessed from sagittal standing preoperative (pre-op) and postoperative (post-op) radiographs with the software Surgimap (Nemaris). In particular, pelvic incidence (PI), sagittal vertical axis (SVA), pelvic tilt (PT), T1 pelvic angle (TPA), sacral slope (SS) and lumbar lordosis (LL) have been measured. In JUNCT, the main failure cause was the screws pull-out (45%). Spine fixation with 7 or more levels were the most common in JUNCT (52%) in contrast to CONTROL (14%). In CONTROL, PT, TPA, SS and PI-LL were inside the recommended ranges of good sagittal balance. For these parameters, statistically significant differences were observed between pre-op and post-op (p<0.0001, p=0.01, p<0.0001, p=0.004, respectively, Wilcoxon test). In JUNCT, the spinopelvic parameters were out of the ranges of the good sagittal balance and the worsening of the balance was confirmed by the increase in PT, TPA, SVA, PI-LL and by the decrease of LL (p=0.002, p=0.003, p<0.0001, p=0.001, p=0.001, respectively, paired t-test) before the revision surgery. TPA (p=0.003, Kolmogorov-Smirnov test) and SS (p=0.03, unpaired t-test) differed significantly in pre-op between JUNCT and CONTROL. In post-op, PI-LL was significantly different between JUNCT and CONTROL (p=0.04, unpaired t-test). The regression model of PT vs PI was significantly different between JUNCT and CONTROL in pre-op (p=0.01, Z-test). These results showed that failure is most common in long fused segments, likely due to long lever arms leading to implant failure. If the sagittal balance is not properly restored, after the surgery the balance is expected to worsen, eventually leading to failure: this effect was confirmed by the worsening of all the spinopelvic parameters before the revision surgery in JUNCT. Conversely, a good sagittal balance seems to avoid a revision surgery, as it is visible is CONTROL. The mismatch PI-LL after the fixation seems to confirm a good sagittal balance and predict a good correction. The linear regression of PT vs PI suggests that the spine deformity and pelvic conformation could be a predictor for the failure after a fixation

Metastatic bone disease (MBD) is a significant contributor to diminished quality of life in cancer patients, often leading to pathologic fractures, hypercalcaemia, intractable bone pain, and reduced functional independence. Standard of care management for MBD patients undergoing orthopaedic surgery is multi-disciplinary, includes regular surgical follow-up, case by case assessment for use of bone protective medications, and post-operative radiation therapy to the operative site. The number of patients in southern Alberta receiving standard of care post-operative management is currently unclear. Our aim is to develop a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD and to assess for deficiencies and opportunities to ensure standard of care for this complex patient population. Patients were identified for database inclusion by a search query of the Alberta Cancer Registry of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or pathologic fracture in the Calgary, South and Central Alberta Zones. Demographic information, primary cancer history, previous local and systemic treatments, anatomical location of MBD event(s), surgical fixation techniques, and post-operative care details were collected. The rate of standard of care post-operative treatment was evaluated. A comparison of outcomes between tertiary urban centres and rural centres was also completed. Survival was calculated from time of first operation to date of death. Univariate and multivariate analyses were performed to identify the impact of post-operative care variables on survival amongst patients surviving longer than one month. We identified 402 patients who have undergone surgical treatment for MBD in southern Alberta from 2006-2018. Median age at time of surgery was 66.3 years and 52.7% of patients were female. Breast, lung, prostate, renal cell and multiple myeloma were the most common primary malignancies (n=328, 81.6%). Median post-operative survival was 6.8 months (95%CI: 5.7-8.3). 203 patients (52.5%) were treated with post-operative radiotherapy and 159 patients (50.8%) had post-operative surgical follow-up. Only 39 patients (11.3%) received bone protective agents in the peri-operative period. On multivariate survival analysis, post-operative surgical follow-up was associated with improved survival (p<0.001). Patients were treated at nine hospitals across southern Alberta with most patients treated in an urban center (65.9%). Post-operative survival was significantly longer amongst patients treated in an urban center (9.0 months, 95%CI: 6.9-12.3 versus 4.3 months, 95%CI: 3.4-5.6, p<0.001). The burden of MBD is significant and increasing. With treatment occurring at multiple provincial sites, there is a need for standardized, primary disease-specific peri- and post-operative protocols to ensure quality and efficacious patient care. To provide evidence informed treatment recommendations, we have developed a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD. Our results demonstrate that many patients were not treated according to post-operative standard of care recommendations. Notably, half of the included patients did not have documented surgical follow-up, post-operative radiation treatment was low and only 11% were actively treated with bone protective agents. This data justifies the need for established surgical MBD care pathways and provides reference data to benchmark prospective QA and QI outcomes in this patient population

Orthopedic device-related bone infection is one of the most distressing complications of the surgical fixation of fractures. Despite best practice in medical and surgical interventions, the rate of infection remains stubbornly persistent, and current estimates indicate that treatment failure rates are also significant. As we approach the limit of the effectiveness of current anti-infective preventative and therapeutic strategies, novel approaches to infection management assume great importance. This presentation will describe our efforts to develop and test various hydrogels to serve as customized antibiotic delivery vehicles for infection prevention and treatment. Hydrogels offer solutions for many of the challenges faced by complex trauma wounds as they are not restricted spatially within a poorly defined surgical field, they often degrade rapidly with no compatibility issues, and releases 100% of the loaded antibiotic. The preliminary data set proving efficacy in preventing and treating infection in both rabbit and sheep studies will be described, including local antibiotic concentrations in the intramedullary canal over time, compared to that of the more conventional antibiotic loaded bone cement. These two technologies show potential for the prevention and treatment of infection in trauma patients, with a clear focus on optimized antibiotic delivery tailored for complex wounds

Abstract. Objectives. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus NWB and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures. The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection, displacement of osteosynthesis, the full arc of ankle motion, RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the IWB group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021 with a similar result at three months. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a PE, both were randomised to NWB. Length of hospital stay was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusion. In this large multicentre RCT, we investigated WB following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome

Aims. The aim of this study was to compare the clinical effectiveness of Kirschner wire (K-wire) fixation with locking-plate fixation for patients with a dorsally displaced fracture of the distal radius in the five years after injury. Patients and Methods. We report the five-year follow-up of a multicentre, two-arm, parallel-group randomized controlled trial. A total of 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation were recruited from 18 trauma centres in the United Kingdom. Patients were excluded if the surface of the wrist joint was so badly displaced it required open reduction. In all, 448 patients were randomized to receive either K-wire fixation or locking-plate fixation. In the K-wire group, there were 179 female and 38 male patients with a mean age of 59.1 years (19 to 89). In the locking-plate group, there were 194 female and 37 male patients with a mean age of 58.3 years (20 to 89). The primary outcome measure was the patient-rated wrist evaluation (PRWE). Secondary outcomes were health-related quality of life using the EuroQol five-dimension three-level (EQ-5D-3L) assessment, and further surgery related to the index fracture. Results. At 12 months, 402/448 participants (90%) recruited into the main study provided PRWE scores. At year two, 294 participants (66%) provided scores; at year five, 198 participants (44%) provided scores. There was no clinically relevant difference in the PRWE at any point during the five-year follow-up; at five years, the PRWE score was 8.3 (12.5) in the wire group and 11.3 (15.6) in the plate group (95% confidence interval -6.99 to 0.99; p = 0.139). Nor was there a clinically relevant difference in health-related quality of life. Only three participants had further surgery in the five years after their injury (one in the wire group and two in the plate group). Conclusion. This follow-up study continues to show no evidence of a difference in wrist pain, wrist function, or quality of life for patients treated with wires versus locking plates in the five years following a dorsally displaced fracture of the distal radius. Cite this article: Bone Joint J 2019;101-B:978–983

Decreased ankle dorsiflexion is common after injury and may result in patient complaints of stiffness and subsequent injury. The weight-bearing lunge test (WBLT) is a simple clinical measure of dorsiflexion. Previous study has defined a 2.0cm side-to-side discrepancy in WBLT as likely significant. With review of current literature, ankle stiffness is a concept largely undefined; we aim to relate patient complaints of stiffness to WBLT. This was a population-based inception cohort with longitudinal follow-up. Patients between ages 18–65 receiving surgical fixation for ankle fracture were screened. Pilon/plafond fractures, bilateral injuries, or polytrauma were excluded. At 6-weeks, 6-months, and 1-year WBLT was measured along with non-weight-bearing goniometry; and an Olerud-Molander ankle score completed. 155 patients were recruited (90 female, 65 male; mean age 42, range 20–67). 47% of injuries were unimalleolar, 17% bimalleolar, and 36% trimalleolar; 35% received syndesmotic fixation. 89% of patients reported feeling stiff at 6-weeks, 82% at 6-months, and 74% at 1-year. 98% of patients had ≥2.0cm discrepancy of WBLT at 6-weeks, 78% at 6-months, and 72% at 1-year. Different thresholds of WBLT (larger discrepancy or absolute negative measurement) had worse correlation with patient reported stiffness. Our population had high incidence of stiffness at 1-year. The proportion of patients complaining of stiffness after ankle fracture was similar to that measured with ≥2.0cm discrepancy of WBLT. This is the first study that we are aware of that relates the WBLT and the previously reported threshold of 2.0cm to stiffness. This measurement may give clinicians a better objective idea regarding patient perception of a “stiff” ankle. Reducing side to side discrepancy in range of motion should be considered in rehabilitation rather than total range of motion

To determine the biomechanical effect of increasing scaphoid malunion and scaphoid non-union on carpal kinematics during dynamic wrist motion using an active wrist motion simulator. Seven cadaveric upper extremities underwent active wrist flexion and extension in a custom motion wrist simulator with scaphoid kinematics being captured with respect to the distal radius. A three-stage protocol of progressive simulated malunion severity was performed (intact, 10° malunion, 20° malunion) with data analyzed from 45° wrist flexion to 45° wrist extension. Scaphoid malunions were modelled by creating successive volar wedge osteotomies and fixating the resultant scaphoid fragments with 0.062 Kirshner wires. At the completion of malunion motion trials, a scaphoid non-union trial was carried out by removing surgical fixation to observe motion differences from the malunion trials. Motion of the scaphoid, lunate, capitate, and trapezium-trapezoid was recorded and analyzed using active optical trackers. Increasing scaphoid malunion severity did not significantly affect scaphoid or trapezium-trapezoid motion (p>0.05); however, it did significantly alter lunate motion (p<0.001). Increasing malunion severity resulted in progressive lunate extension across wrist motion (Intact – Mal 10: mean dif. = 7.1° ± 1.6, p<0.05; Intact – Mal 20: mean dif. = 10.2° ± 2.0, p<0.05;) although this change was not as great as the difference seen during non-union trials (native – non-union: mean dif. = 13.8° ± 3.7, p<0.05). In this in-vitro model, increasing scaphoid malunion severity was associated with progressive extension of the lunate in all wrist positions. The clinical significance of this motion change is yet to be elucidated, but this model serves as a basis for understanding the kinematic consequences of scaphoid malunion deformities

Background: The aim of this study was to analyse mid-shaft clavicle fractures in children and adults to find out the factors that would influence the healing time and the necessity of surgical intervention. Methods: We identified all the midshaft clavicle fractures treated at Chesterfield Hospital between January 2003 and January 2006. We studied the case notes and radiographs of these patients. We grouped the midshaft fractures into those in children and those in adults. Each group was further subdivided into two part and three part fractures. It was also noted whether a vertical butterfly fragment was present in the three or more part fractures. The fractures were analysed for their incidence, presence of comminution, degree of displacement, type of treatment and the follow-up time before discharge. Results: – Over the 3 year period, 242 middle 1/3 clavicle shaft fractures were treated. Among the mid shaft fractures there were one hundred and eight (44.6%) children and one hundred and thirty four (55.3%) adults. There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures. There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%). The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment. Conclusion: The incidence of clavicle fractures in children is nearly as high as in adults. In children the number of days for discharge is nearly double for three part fractures when compared to two part fractures. The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment

The posterior malleolus of the ankle is the object of increasing attention, with considerable enthusiasm for CT scanning and surgical fixation, as expressed in a recent annotation in The Bone & Joint Journal. Undoubtedly, fractures with a large posterior malleolar fragment that allow posterior talar subluxation from the mortise are served better by fixation. However, in all other situations, the existing literature does not support this widespread change in practice. The available biomechanical evidence shows that the posterior malleolus has little part to play in the stability or contact stresses of the ankle joint. Radiographic studies have not shown that CT scanning offers helpful information on pathoanatomical classification, case selection, or prognosis, or that scanning improves the likelihood of an adequate surgical reduction. Clinical studies have not shown any improvement in patient outcome after surgical fixation, and have confirmed that the inevitable consequence of increased intervention is an increased rate of complications. A careful and thoughtful evaluation of indications, risks, and benefits of this fashionable concept is required to ensure that we are deploying valuable resources with efficacy, and that we do no harm. Cite this article: Bone Joint J 2018;100-B:566–9

Aim. Antibiotic prophylaxis is critical for the prevention of fracture related infection (FRI) in trauma patients, particularly those with open wounds. Administration of prophylactic antibiotics prior to arrival at the hospital (e.g. by paramedics) may reduce intraoperative bacterial load and has been recommended; however scientific evidence for pre-hospital administration is scarce. Methods. The contaminated rabbit humeral osteotomy model of Arens was modified to resemble the sequence of events in open fractures. In an initial surgery representing the “accident”, a 2mm mid-diaphyseal hole was created in the humerus and the wound was contaminated with a clinical Staphylococcus aureus strain (mean 1.6×106 Colony Forming Units, CFU). The animals were allowed recover for 4 hours mimicking the period from trauma to debridement. At this time, a second procedure was performed in order to debride and irrigate the wound, and to fix a complete osteotomy that was made through the initial defect. Three test groups were included (n=8 rabbits per group): 1) no antibiotic therapy; 2) standard “in-hospital” antibiotic prophylaxis (24 hours therapy starting 30 minutes before surgery); 3) “pre-hospital” antibiotics (single dose 15 minutes after the “accident”). The antibiotic used was cefuroxime and was administered in a weight-adjusted dosage. Results. In the absence of any antibiotic administration (group 1), high bacterial counts were identified at fixation (1.89×106 CFU) and at euthanasia (day 7, 7.70×107 CFU) in all rabbits. When 24 hours of antibiotics were administered commencing “in hospital” (group 2), the bacterial load during fixation surgery was slightly reduced (CFU 9.88×105) and 50% of animals were infected at euthanasia. When one single shot of antibiotics was administered in the “pre-hospital” setting (group 3), the bacterial load during fixation surgery was significantly lower than for both groups 1 and 2(CFU 2.34×103) yet all animals were infected at euthanasia. Conclusions. Early pre-hospital administration of antibiotics significantly reduced the bacterial load in the operative field at the time of debridement compared to regular prophylaxis. However, continuation of systemic antibiotics is necessary in order to prevent infection in this model

Introduction. Hoffa fractures are rare, intra-articular fractures of the femoral condyle in the coronal plane and involving the weight-bearing surface of the distal femur. Surgical fixation is warranted to achieve stability, early mobilisation and satisfactory knee function. We describe a unique type of Hoffa fracture in the coronal plane with sagittal split and intra-articular comminution. There is scant evidence in current literature with regards to surgical approaches, techniques and implants. We report of our case with a review of the literature. Case report. A 40 year old male motorcyclist was involved in a high speed road traffic collision. X-rays confirmed displaced unicondylar fracture of the lateral femoral condyle. CT showed sagittal split of the Hoffa fragment and intra-articular comminution. MRI showed partial rupture of the anterior cruciate ligament. The patient underwent definitive surgical treatment via a midline skin incision and lateral parapatellar approach using cannulated screws, headless compression screws and anti-glide plate. Weightbearing was commenced at 8 weeks. Arthroscopy and adhesiolysis was performed at 12 weeks to improve range of motion. The patient was discharged at one year with a pain-free, functional knee. Discussion. Hoffa fractures are high-energy fractures, often seen in young male motorcyclists with flexed and slightly abducted knee. Most papers recommend surgical fixation, however there is no widely accepted surgical method or rehabilitation regime. Varying surgical approaches, screw direction, choice of implants, and post-operative care have been described. Surgical approach depends on the configuration of the fracture. The medial/lateral parapatellar approach is commonly used as it does not compromise future arthroplasty, but it does not allow access to fix posterior comminution. Arthroscopic-assistance may be used with good outcomes and less tissue dissection. AP screws are widely reported in the literature, most likely due to easier access to the fracture site. PA screws may provide better stability, but access is more difficult. Fixation often involves passing screws through the articular surface, therefore the area damaged should be kept to a minimum by using the smallest possible screw; headless compression screws leave a smaller footprint in the articular cartilage. Locking plate augmentation generally gives good outcomes. Conclusion. Hoffa fractures are rare and difficult to treat. Surgical treatment is the best choice for optimum post-operative knee function. There is no consensus on choice of surgical approaches, techniques and implants, as these are dependent on fracture configuration. In this particular case we emphasise the importance of using an anti-glide plate to address the sagittal component. Despite the need for a secondary procedure, the treatment has had positive outcomes and may be used as a guide for treatment of future Hoffa fractures of a similar sub-type

Distal radius fractures are very common and they often require surgical intervention to prevent long-term complications. We noticed that several patients were being managed non-operatively for prolonged periods of time, when ultimately surgical fixation was inevitable. Delayed fixation of these injuries results in prolonged immobilisation, repeat fracture clinic attendances, callous formation, poor soft tissues, stiffness and union. Our aim was to analyse the time to fixation of distal radius fractures at our hospital using a standard volar locking plate. Between December 2010 and September 2011, our study population included all patients who underwent surgical fixation for a distal radius fracture at Royal Derby Hospital. All fractures were fixed using a volar locking plate. Data collected included date of injury, fracture clinic attendances, date listed for surgery and date of surgery. There were 100 patients who underwent surgical fixation, with a mean age of 63.6 years (17 to 91). The mean date from injury to fixation was 7.7 days (range 0 to 23). 82% of fractures were operated on within 14 days, and 98% were fixed within 21 days. We accept that our study does have some limitations; this includes patients who are unwilling to accept surgery at their initial consultation. Distal radius fractures have a strong tendency to revert back to their original configuration; hence we suggest that a decision to operate should ideally be made at the one-week fracture clinic appointment. This avoids the difficulties and complications associated with delayed surgical intervention. Stability, displacement, reduction and patient factors should all be taken into account

For the management of displaced patellar fractures, surgical fixation using cannulated screws along with anterior tension band wiring is getting popular. Clinical and biomechanical studies have reported that using cannulated screws and a wire instead of the modified tension band with Kirschner wires improves the stability of fractured patellae. However, the biomechanical effect of screw proximity on the fixed construction remains unclear. The aim of this study was to evaluate the mechanical behaviors of the fractured patella fixed with two cannulated screws and tension band at different depths of the patella using finite element method. A patella model with simple transverse fracture [AO 34-C1] was developed; the surgical fixation consisted of two 4.0-mm parallel partial-threaded cannulated screws with a figure-of-eight anterior tension band wiring using a 1.25-mm stainless steel cable. Two different locations, including the screws 5-mm and 10-mm away from the leading edge of the patella, were used. A tension force of 850 N was applied on the patellar apexes at two loading angles (45° and 0° [parallel] to the long axis) to simulate different loading conditions while knee ambulation. The proximal side (base) of the patella was fixed, and the inferior articular surface was defined as a compression-only support in ANSYS to simulate the support from distal femur condyles. Compression-only support enables the articular surfaces of the present patella to only bear compression and no tension forces. Under different loading conditions, the fixed fractured patella yielded higher stability during 0° loading of tension force than during 45° loading. When the screws were parallel placed at the depth of 5 mm away from the patellar surface, the deformation of patellar fragment and maximum gap opening at the fracture site were smaller than those obtained by screws placed at the depth of 10 mm away from the patellar surface. Compared to the superficial screw placement, the deeper placement (10 mm) increased the maximum gap opening at the fracture site by 1.56 times under 45° loading, and 1.58 times under 0° loading. The load on the tension band wire of the 10-mm screw placement was 3.12 times (from 230 to 717 N) higher than that of the 5-mm placement. Under the wire, the contact pressure on the patellar surface was higher with the 10-mm screw placement than the 5-mm screw placement. The peak bone contact pressures with the 10-mm placement were 7.7 times (99.5 to 764 MPa) higher. This is the first numerical study to examine the biomechanical effects of different screw locations on the fixation of a fractured patella using screws and tension band. Based on a higher stability and lower cable tension obtained by the superficial screws placement, the authors recommended the superficial screw placement (5 mm below the leading edge of the patella) rather than the deep screws while fixing the transverse patellar fracture with cannulated screws and cable

The primary objectives of this study were to: 1) identify risk factors for subsequent surgery following initial treatment of proximal humerus fractures, stratified by initial treatment type; 2) generate risk prediction tools to predict subsequent shoulder surgery following initial treatment; and 3) internally validate the discriminative ability of each tool. We identified patients ≥ 50 years with a diagnosis of proximal humerus fracture from 2004 to 2015 using linkable health datasets in Ontario, Canada. We used procedural and fee codes within 30 days of the index fracture to classify patients into treatment groups: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used intervention and diagnosis codes to identify all instances of complication-related subsequent shoulder surgery following initial treatment within two years post fracture. We developed logistic regression models for randomly selected two thirds of each treatment group to evaluate the association of patient, fracture, surgical, and hospital variables on the odds of subsequent shoulder surgery following initial treatment. We used regression coefficients to compute points associated with each of the variables within each category, and calculated the risk associated with each point total using the regression equation. We used the final third of each cohort to evaluate the discriminative ability of the developed risk tools (via the continuous point total and a dichotomous point cut-off value for “higher” vs. “lower” risk determined by Receiver Operating Curves) using c-statistics. We identified 20,897 patients with proximal humerus fractures that fit our inclusion criteria for analysis, 2,414 treated with fixation, 1,065 treated with replacement, and 17,418 treated conservatively. The proportions of patients who underwent subsequent shoulder surgery within two years were 13.8%, 5.1%, and 1.3%, for fixation, replacement, and conservative groups, respectively. Predictors of reoperation following fixation included the use of a bone graft, and fixation with a nail or wire vs. a plate. The only significant predictor of reoperation following replacement was poor bone quality. The only predictor of subsequent shoulder surgery following conservative treatment was more comorbidities while patients aged 70+, and those discharged home following initial presentation (vs. admitted or transferred to another facility) had lower odds of subsequent shoulder surgery. The risk tools developed were able to discriminate between patients who did or did not undergo subsequent shoulder surgery in the derivation cohorts with c-statistics of 0.75–0.88 (continuous point total), and 0.82–0.88 (dichotomous cut-off), and 0.53–0.78 (continuous point total) and 0.51–0.79 (dichotomous cut-off) in the validation cohorts. Our results present potential factors associated with subsequent shoulder surgery following initial treatment of proximal humerus fractures, stratified by treatment type. Our developed risk tools showed good to strong discriminative ability in both the derivation and validation cohorts for patients treated with fixation, and conservatively. This indicates that the tools may be useful for clinicians and researchers. Future research is required to develop risk tools that incorporate clinical variables such as functional demands

This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations. A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction and return to activity. Range of motion and several standardized outcome measurement tools were also included in the final analysis. Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improved postoperative objective scores (i.e., patient-reported outcome scores and active range of motion). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%. This study reports on the largest sample of patients who have undergone surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good patient satisfaction. Such patients should be aware that they are at increased risk of requiring a second procedure due to symptomatic hardware following ORIF

Fibular head avulsion fractures represent a significant injury to the posterolateral corner of the knee. There is a high rate of concomitant injuries including rupture of the cruciate ligaments. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments and possibly decrease the likelihood of degenerative change. The current presentation describes a novel technique which provides secure fixation to the fibular head, restoring integrity of the posterolateral ligament complex and facilitating early motion. We also present a case series of our experience by a single surgeon at our tertiary referral center. Twenty patients underwent open reduction and internal fixation between 2006 and 2016 using a large fragment cannulated screw and soft tissue washer inserted obliquely from the proximal fibula to tibia. Fixation was augmented with suture repair of the lateral collateral ligament and biceps tendon. The orientation of the fracture was assessed based on preoperative imaging. Repair / reconstruction of concomitant injuries was performed during the same procedure. Early range of motion was initiated at 2 weeks postoperatively under physical therapy guidance. All patients returned for clinical and radiographic assessment (average 3.5 years). All fractures went on to bony union. There were no reoperations for recurrent instability. All patients regained functional range of motion with mean extension of 0.94 degrees and mean flexion of 121.4 degrees. Two patients underwent hardware removal. One patient developed a late local infection, which occurred greater than 5 years after surgery. Eleven patients underwent postoperative varus stress radiographs which demonstrated less than 1 mm difference between the operated and contralateral side. Fracture morphology typically demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane. This study represents a novel surgical technique for the repair of fibular head avulsion fractures with a large fragment cannulated screw placed obliquely from the fibula to tibia. Fixation is augmented with a soft tissue washer and suture repair. Our results suggest that this technique allows for early range of motion with maintenance of reduction, high rates of union, and excellent postoperative stability

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

Surgical fixation of tibial plateau fractures in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared to younger patients. Primary total knee arthroplasty (TKA) may be of benefit in patients with pre-existing arthritis, marked osteopenia, or severe fracture comminution. Rationale for primary TKA includes allowing early mobility in hopes of reducing associated complications such as deconditioning, postoperative pneumonia, or venous thromboembolism, and reducing post-traumatic arthritis which occurs in 25% to 45% of patients and requires revision TKA in up to 15%. Subsequent revision TKA has been shown to have significantly worse outcomes than TKA for primary osteoarthritis. This systematic review sought to elicit the clinical outcomes and peri-operative complication rates following primary TKA for tibial plateau fractures. A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and clinical outcomes following primary TKA for tibial plateau fractures. Studies were included for final data analysis if they met the following criteria: (1) studies investigating TKA as the initial treatment for tibial plateau fractures, (2) patients must be ≥ 18 years old, (3) have a minimum ≥ 24-month follow-up, and (4) must be published in the English language. Case series, cohort, case-control, and randomized-control trials were included. Weighted means and standard deviations are presented for each outcome. Seven articles (105 patients) were eligible for inclusion. The mean age was 73 years and average follow-up was 39 months. All-cause mortality was 4.75% ± 4.85. The total complication rate was 15.2% ± 17.3% and a total of eight patients required revision surgery. Regarding functional outcomes, the Knee Society score was most commonly reported. The average score on the knee subsection was 85.6 ± 5.5 while the average function subscore was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5° ± 10°. Total knee arthroplasty for the treatment of acute tibial plateau fractures is enticing to allow early mobility and weightbearing. However, complication rates remain high. Functional outcomes are similar to patients treated with ORIF or delayed arthroplasty. Given these findings, surgeons should be highly selective in performing TKA for the immediate treatment of tibial plateau fractures

Tibial plateau fractures are common injuries. Displaced fractures are treated with open reduction and internal fixation (ORIF). Goals of treatment include restoration of extremity axial alignment, joint stability and congruity, allowing for early motion and prevention of osteoarthritis. Short term results of surgical fixation of tibial plateau fractures are good, however, longer term outcomes have demonstrated a higher risk of end-stage arthritis and total knee arthroplasty. Despite the vast literature around tibial plateau fractures, to our knowledge there are no series examining post-operative reductions using axial imaging. It is our goal to define the incidence of articular malreductions following surgical fixation of tibial plateau fractures, to identify patient or surgeon factors associated with malreductions, and to define any regional patterns of malreduction location. De-identified post operative computed tomography (CT) scans were reviewed to identify tibial plateau malreductions with a step or gap greater than 2 mm, or condylar width greater than 5 mm. Three independent assessors reviewed the scans meeting criteria using Osirix DICOM software. Steps and gaps were mapped onto the axial sequence at the level of the joint line. Images were then matched to side and overlaid as best fit in Photoshop software to create a map of malreductions. A grid was created to divide the medial and lateral plateaus into quadrants to identify the density of malreductions by location. A multi-variate regression model was used to assess risk factors for malreduction. Sixty five post-operative CT scans were reviewed. Twenty one reductions had a step or gap more than 2 mm for a malreduction incidence of 32.3%. The incidence in patients undergoing submeniscal arthrotomy or fluoroscopic assisted reduction was 16.6% and 41.4%, respectively (p <0.001). Side of injury, age, BMI, AO fracture type, and use of locking plates were not predictive of malreduction. Malreductions were heavily weighted to the posterior lateral tibial plateau. The incidence of articular malreductions was high at 32.3%. Fluoroscopic reduction alone was a predictor for articular malreduction with most malreductions located in the posterior lateral quadrants of the plateau

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

Paediatric femoral fractures are a common result of significant trauma, and always require intervention. Hip spica casting, traction, and surgical fixation can all be used to treat these fractures. This variety in treatment options leads to a vast potential for variability in management decisions among surgeons and has prevented effective comparative studies to show which treatment methods provide optimal outcomes for patients. The purpose of this study was to identify practice variability in management and follow-up and assess patient outcomes to aid in the development of a comprehensive, prospective, evidence-based pathway for the management of paediatric femoral fractures. A retrospective chart review was performed of all patients treated surgically for isolated femoral fractures during a six year period at a single tertiary care paediatric centre. Patients were identified from a surgical database and were included if there was no pre-existing pathology and no history of previous femoral fracture. Demographic data, operative details, post-operative management, and clinical outcomes were collected. Radiographic images and reports were analyzed to determine fracture classification and imaging parameters. Variability in treatment among eight surgeons was assessed, including number of follow-up appointments and length of follow-up. Patient demographics and follow up measures were summarised for each surgeon and between surgeon variability was assessed with linear models. In total, 138 femoral fractures in 134 patients (101 male, 33 female) were included in analysis. Of these patients, 55 had right femoral fractures, 76 left, and three bilateral (one bilateral patient had three distinct femoral fractures). Of 138 total fractures, 131 were of the diaphysis of the femur. 14 patients sought initial surgical treatment at our institution but received follow-up management elsewhere. Across all patients, median follow-up time was 32.8 weeks (0–201.4) with a median of three follow-up visits (0–26) in that period. Mean number of follow-up clinic visits ranged from 3 to 4.8 among surgeons, and mean length of follow-up ranged from 31.8 to 62.3 weeks. No significant differences in follow-up between surgeons were found, but small sample sizes are a likely contributing factor. Summary statistics show large ranges in most variables and differences in patient demographics between surgeon groups. The large ranges in follow-up time and visit number suggest a lack of consensus on optimal management for paediatric femoral fractures. Further prospective study examining long-term functional and quality of life outcomes will be required to identify and develop optimized management guidelines

Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea, chronic obstructive pulmonary disease, chronic steroid use, hypertension, cancer, bleeding disorders, and renal failure), time to surgery beyond 48h resulted in greater odds of both mortality (1.45, 95%CI 1.10–1.91) and major complications (1.45, 95%CI 1.12–1.84). Time to surgery is one of the few variables that can be influenced by timely medical assessment and access to the operation room. Expediting surgery within 48h of hip fracture is of paramount importance as it may significantly reduce the risk of mortality as well as major complications

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

We performed a randomized feasibility trial to examine the impact of preoperative femoral nerve block (FNB) on elderly patients with hip fractures, including those with mild to moderate cognitive impairment. We evaluated the impact of preoperative FNB on the following outcomes within 5 days of surgical fixation: 1. Pain levels, 2. Total narcotic consumption, 3. Postoperative mobilization. Randomized allocation of 73 patients in a 2:1 intervention:control ratio. To allow comparison between the 2 groups as well as sub- analysis of the intervention group to examine treatment fidelity (i.e. the ability to deliver the intervention as planned). Inclusion criteria: Patient age≥ 65 years admitted with a low energy hip fracture, ambulatory preinjury, Mini Mental State Exam MMSE score≥13 (moderate dementia), Able to provide direct or proxy consent. Exclusion criteria: Admission ≥ 30 hours after injury, prior regular use of opiates. Potential participants were identified and either participants or proxy respondents provided signed informed consent. Participants allocated to the intervention group received a FNB administered by the UAH acute pain service (APS) within 20 hours of admission to hospital in addition to the usual care. Participants in the control group received usual care. Participants were followed for 5 days postoperatively with daily assessment of pain, narcotic consumption, delirium and mobility. Main outcome measure: (1) Pain at rest and activity (2) Preoperative and postoperative opioid consumption, (3) Mobilization in POD#1. Overall, 73 participants were enrolled (23 Control: 50 FNB). The FNB group was slightly older (mean [SD] 80.1 [8.7] vs. 76.2 [9.2], p=0.09) and had more males (21 [42%] vs. 5 [22%], p=0.09) than the Control group. The mean MMSE score for both groups was >24 (p=0.35 for group comparison), suggesting minimal cognitive impairment of participants. The FNB group reported significantly less pain at rest and activity than the control group over time (p < 0 .001 for both). Opioid consumption were non-significantly higher and more variable in the control group preoperatively (Median [25, 75 quartile] 10.6 [0, 398] vs 7.5 [0, 125], p=0.26) and postoperatively (13.1 [0, 950] vs 10 [0, 260], p=0.31). 41 (85%) of FNB participants mobilized on day 1 vs. 16 (73%) of control participants (p=0.21). Preoperative FNB significantly reduced pain. Opioid consumption was not significantly different, but more variable in the control group. Although not significant, more FNB patients successfully mobilized on day 1 postoperatively. Participants with cognitive impairment were not enrolled due to difficulty in obtaining proxy consent. A definitive randomized trial would be feasible and add valuable information about pain management following hip fracture

The December 2023 Trauma Roundup³⁶⁰ looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery.

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

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.

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. Intramedullary fixation is also popular, but it does not have the weight of evidence of plate fixation

Supracondylar fractures of the humerus (SCFH) are the most common type of paediatric elbow fractures. Due to beliefs that non-operatively managed SCFH may displace further from the original position, they are monitored with repeated radiographs and a large number are unnecessarily surgically pinned. Very limited evidence currently exists to support these beliefs. This study aimed to determine the incidence of late “significant” displacement (requiring surgical management) of non-operatively managed paediatric SCFH, and whether they necessitate close radiographic follow-up. Patients aged ≤16, with a SCFH, were included in this retrospective cohort study. All were initially managed non-operatively with at least one follow-up radiograph within six weeks of injury. Data from four consecutive years (2013–2016) was collected using the hospital's radiology database. Two observers independently analysed patient radiographs and classified fractures by the Gartland and AO systems. The incidence of late displacement was determined using follow-up radiographs and clinic notes. Of the 164 patients included in the study, one patient (Gartland Type II, AO Type III) suffered late displacement at two weeks, requiring surgical fixation. One further patient (AO Type II) had a persistent cubitus varus deformity (Baumann's angle 90°), with no long-term functional deficit. Incidence of late displacement was 0.6% (n=1). Our findings suggest that stable Gartland Type I/AO Type I and II fractures do not require repeated radiographic follow-up. However, some Gartland Type II/AO Type III fractures require monitoring. This could considerably reduce the financial costs for the healthcare system, and inconvenience to families, associated with repeated follow-ups

Aims. This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. . Methods . We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. . Results . The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. Discussion. Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. Take home message: Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion. Cite this article: Bone Joint J 2016;98-B:125–30

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.

Aims

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.

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review. A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information. 30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1. Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve

Ankle fractures are common injuries affecting all age groups and constitute a large proportion of the orthopaedic trauma caseload. Frequently a large number of bed days are utilized waiting for swelling to subside and a theatre slot to become available. We audited current practice and then implemented a home therapy program (HTP). If HTP criteria were met then patients with reduced, unstable ankle fractures were taught how to use crutches and allowed home from the emergency department in order to ice and elevate at home. They were then admitted from clinic for surgery the same day and then discharged when safe and comfortable. The purpose of this study was to prospectively compare the local management of surgically stabilised ankle fractures before and after instigating a home therapy program. 43 consecutive patients met our inclusion criteria and underwent surgical fixation of unstable ankle fractures over a three month period (February to April 2008.) The average length of hospital stay was 8 days (1–18), 4.5 days pre-operatively and 3.5 days post operatively. Forty-eight patients underwent surgical fixation of unstable ankle fractures over a four month period (November 2008 to February 2009.) Twenty-one met the home therapy criteria. The average length of hospital stay was reduced to three days, 1.6 days pre-operatively and 1.3 days post operatively. Additionally a patient survey revealed high levels of satisfaction with the HTP. The home therapy program has effectively reduced hospital stay both pre and post-operatively. Patients mobilising at home pre-operatively mobilise earlier post-operatively and are discharged home earlier. Over the three-month period of HTP, 131 bed days were saved which equates to a saving of £30,000

All skeletally immature patients who presented with a supracondylar fracture between 01/09/2013 and 24/11/2015 (n = 50) were used to compare the current management of supra-condylar fractures of the humerus in children to the standards set by the BOAST 11 guidelines. 8.1% did not have full documentation of their neurovascular assessment. 93.9% underwent surgery within 24 hours of presentation. Average time to theatre for neurovascularly compromised patients was 4 hours 46 minutes. 81.8% were managed with 2 K-wires as recommended. Only 39.4% of the patients had their wires removed within 3 – 4 weeks. Only 6.1% had the recommended 2 mm wires. AO recommends the use of 2mm wires if 2 lateral wires are used whereas the BOAST 11 guideline recommends 2mm wires where possible. The results clearly demonstrate a need for further education and awareness of the BOAST 11 guidelines. Of particular interest is the documentation of patients' neurovascular status for appropriate management and for medico-legal purposes. Long term outcome comparison of surgical fixation with 2mm and 1.6mm wires would be useful to support the use of 2mm wires as recommended by the professional consensus in the BOAST 11 guidelines

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.