Introduction: Trauma surgeons are often less exposed to large caseloads of primary osteoarthritis, compared to purely “elective”orthopaedic surgeons. The experience in total knee arthroplasty is thereby markedly On the other hand, posttraumatic knee arthrosis is often accompanied by severe deformity and axis deviation. In theory, navigated arthroplasty can overcome some of the problems in this setting. Aim: Evaluation of the navigated technique of total knee arthroplasty (TKA), including the technical difficulties, the learning curve and the feasibility in severe bony deformity. Setting is a level I trauma center. Study setup was prospective, follow up period on average 14.5 months (11–25 months). Patients: Between 7/04–6/05 we treated 36 patients with arthritis of the knee related to trauma. 18 patients were male. Average age at TKA was 59 (32–77) years. On average patients had 2.83 previous operations. Methods: The navigational system used is manufactured by PRAXIM (La Tronche/France). It uses infrared-tracking and bone-morphing software. The implant was a mobile bearing LCS knee (DePuy/USA). Follow up included radiographs, clinical examination and the knee society scores. Results: In three cases the procedure was finished in a conventional technique, reasons were suspicion of the surgeon about the cuts recommended by the system, a missing femoral cut block and a broken screw of the tracker-fixation. There was no failure of the navigational system. There was a clear learning curve regarding procedure time. Preop mean extension deficit was improved from av. 7.1° (0–30°) to 1.67° (0°–10°) postop., flexion contracture improved from av. 95° to 103°. The combined knee society score (max. 200 pts) improved from 77 pts preop to 156 pts at follow up. Conclusions: Navigated knee endoprosthesis is reliable tool for the trauma surgeon with few technical problems. Especially for surgeons with less experience in TKA, planning of implant size and position is very helpful. With posttraumatic deformity the surgeon can gain valuable information and assistance to improve alignment and ligamentous balancing

Aims. The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures. Methods. A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis. Results. Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up. Conclusion. Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process. Cite this article: Bone Joint J 2023;105-B(9):1020–1029

Aims. This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons?. Methods. A total of 15 orthopaedic trauma surgeons (seven juniors, eight seniors) evaluated 20 complex elbow fractures for their overall pattern (i.e. varus posterior medial rotational injury, terrible triad injury, radial head fracture with posterolateral dislocation, anterior (trans-)olecranon fracture-dislocation, posterior (trans-)olecranon fracture-dislocation) and their specific characteristics. First, fractures were assessed based on radiographs and 2D and 3D CT scans; and in a subsequent round, one month later, with additional 3D-printed models. Diagnostic accuracy (acc) and inter-surgeon reliability (κ) were determined for each assessment. Results. Accuracy significantly improved with 3D-printed models for the whole group on pattern recognition (acc. 2D/3D. = 0.62 vs acc. 3Dprint. = 0.69; Δacc = 0.07 (95% confidence interval (CI) 0.00 to 0.14); p = 0.025). A significant improvement was also seen in reliability for pattern recognition with the additional 3D-printed models (κ. 2D/3D. = 0.41 (moderate) vs κ. 3Dprint. = 0.59 (moderate); Δκ = 0.18 (95% CI 0.14 to 0.22); p ≤ 0.001). Accuracy was comparable between junior and senior surgeons with the 3D-printed model (acc. junior. = 0.70 vs acc. senior. = 0.68; Δacc = -0.02 (95% CI -0.17 to 0.13); p = 0.904). Reliability was also comparable between junior and senior surgeons without the 3D-printed model (κ. junior. = 0.39 (fair) vs κ. senior. = 0.43 (moderate); Δκ = 0.03 (95% CI -0.03 to 0.10); p = 0.318). However, junior surgeons showed greater improvement regarding reliability than seniors with 3D-printed models (κ. junior. = 0.65 (substantial) vs κ. senior. = 0.54 (moderate); Δκ = 0.11 (95% CI 0.04 to 0.18); p = 0.002). Conclusion. The use of 3D-printed models significantly improved the accuracy and reliability of recognizing the pattern of complex fractures of the elbow. However, the current long printing time and non-reusable materials could limit the usefulness of 3D-printed models in clinical practice. They could be suitable as a reusable tool for teaching residents. Cite this article: Bone Joint J 2023;105-B(1):56–63

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered. Cite this article: Bone Joint J 2023;105-B(2):112–123

Aims. Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age. Methods. A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons. Results. Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament. Conclusion. This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries. Cite this article: Bone Joint J 2023;105-B(11):1226–1232

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

The purpose of this project was to evaluate North American trauma surgeon preferences regarding patient positioning for antegrade fixation of mid shaft femoral shaft fractures. This project was a cross sectional survey taken of orthopaedic fellows and staff surgeons, belonging to three organizations across North America. An estimated sample size was calculated a priori, while various online techniques were utilized to reduce non responder and fatigue bias. The survey was distributed multiple times to optimize yield. Two hundred twelve (212) participants responded in full, 134 (56%) of whom practiced in Canada. The majority of surgeons worked in level one trauma centres (74%), while 72% treated more than one femoral shaft fracture per week. The most common patient position for mid shaft fixation amongst all surgeons was lateral positioning with manual traction (68%), however community surgeons were significantly more likely to use a fracture table. The most common difficulties faced with using a fracture table were inability to achieve fracture reduction and peroneal nerve palsies. The majority (64%) of surgeons quoted a complication rate with fracture tables of greater than 1 per 100 cases. Lateral position with use of manual traction is the preferred set up for antegrade fixation of femoral shaft fracture in this large North American cohort of trauma surgeons. However, a large subset of community and non academic surgeons still prefer use of the fracture table. Amongst all respondents, a high rate of fracture table complications, including malreduction, were quoted. To date, there is no prospective data comparing these two options for patient positioning, and a randomized controlled trial may be an appropriate next step

Aim. Infection rates after management of open fractures are still high. Existing guidelines regarding prevention of this complication are inhomogeneous. A survey directed to orthopaedic trauma surgeons worldwide aims to give an overview of current practices in the management of open fractures. Method. An international group of trauma surgeons and infection specialists with experience in the field of musculoskeletal infections developed a questionnaire that was distributed via email to all AOTrauma members worldwide. Descriptive statistical analysis was performed. Results. 1197 orthopaedic trauma surgeons answered the survey (response rate: 4,9% of all opened emails). Cephalosporins are the most commonly used antibiotics for systemic prophylaxis in open fractures (cefazolin: 51,46% cefuroxime: 23,6%, ceftriaxone: 14,54%). In Gustilo type III open fractures gentamicin (49,12%) and metronidazole (33,58%) are often added. 86% (n=1033) reported to give the first dosage of systemic antibiotics in the emergency department as soon as the patient arrives. Only 3% (n=34) reported pre-hospital administration at the scene of the accident or during transport to the hospital. While most respondents administer antibiotics over 24h in type I open fractures (34%, n=405), for type II open fractures the most often mentioned duration is 72h (26%, n=306). For type III a 7 days course was most often performed (38%, n=448). Overall, there is a tendency to longer durations with increasing severity. However, a vast majority agreed that the optimal duration is not well defined in the literature (71%, n=849). 20psi,”Jet-Lavage”). The amount of irrigation fluid has a bimodal distribution with two peaks at 4–6 liters (24%, n=286) and at 8–10 liters (24%, n=282). Conclusions. Results from our survey give an overview of current practices and identify certain aspects in the management of open fractures where treatment protocols are very heterogenous and guidelines not well accepted. These controversies demand for further research in this field to provide better evidence

Introduction. Current undergraduate trauma and life-support training inadequately equips medical students with the knowledge, practical skills and confidence to manage trauma patients. Often first to the scene of medical emergencies, it is imperative junior doctors feel confident and competent from day one. No UK university currently includes advanced trauma and life support (ATLS) in their curriculum. This study piloted an ATLS course for Cardiff final-year medical students to improve confidence and knowledge in management of the trauma patient. Aim. To assess the immediate effect of a one-day undergraduate ATLS course on medical student's confidence in management of the trauma patients. Methods. Twelve final-year students attended a one-day, practical-skills based and interactive course led by trauma surgeons. Students' confidence managing a trauma patient were assessed pre and post-course using a six-item-MCQ with a 5-point Likert scale. Paired t-tests were carried out on SPSS for comparison pre and post-course across the six items. Qualitative feedback was also collected. Results. The students' confidence in managing a trauma patient's ‘airway and breathing’, ‘circulation’ and ‘C-spine’ all significantly improved after attending the course (p=0.023, p=0.045 and p=000 respectively). Students felt significantly more confident completing practical skills related to trauma (p= 0.001) and their confidence in managing trauma patients overall at the level expected of a Foundation doctor increased significantly (p= 0.003). Qualitative feedback demonstrated high faculty-to-student ratio, practical and interactive teaching methods were particularly helpful. Conclusion. The content and delivery of this course proved beneficial for final-year medical students imminently becoming Foundation doctors, evidencing the requirement for increased trauma training. We advocate the expansion and continuation of this novel student course to continue improving the trauma training within the undergraduate curriculum

Aims. Besides conventional radiographs, the use of MRI, CT, and bone scintigraphy is frequent in the diagnosis of a fracture of the scaphoid. However, which techniques give the best results remain unknown. The investigation of a new imaging technique initially requires an analysis of its precision. The primary aim of this study was to investigate the interobserver agreement of high-resolution peripheral quantitative CT (HR-pQCT) in the diagnosis of a scaphoid fracture. A secondary aim was to investigate the interobserver agreement for the presence of other fractures and for the classification of scaphoid fracture. Methods. Two radiologists and two orthopaedic trauma surgeons evaluated HR-pQCT scans of 31 patients with a clinically-suspected scaphoid fracture. The observers were asked to determine the presence of a scaphoid or other fracture and to classify the scaphoid fracture based on the Herbert classification system. Fleiss kappa statistics were used to calculate the interobserver agreement for the diagnosis of a fracture. Intraclass correlation coefficients (ICCs) were used to assess the agreement for the classification of scaphoid fracture. Results. A total of nine (29%) scaphoid fractures and 12 (39%) other fractures were diagnosed in 20 patients (65%) using HR-pQCT across the four observers. The interobserver agreement was 91% for the identification of a scaphoid fracture (95% confidence interval (CI) 0.76 to 1.00) and 80% for other fractures (95% CI 0.72 to 0.87). The mean ICC for the classification of a scaphoid fracture in the seven patients diagnosed with scaphoid fracture by all four observers was 73% (95% CI 0.42 to 0.94). Conclusion. We conclude that the diagnosis of scaphoid and other fractures is reliable when using HR-pQCT in patients with a clinically-suspected fracture. Cite this article: Bone Joint J 2020;102-B(4):478–484

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

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

Tibial plateau fractures classically present in a bimodal distribution associated with high energy mechanisms in the younger population and fragility fractures in the elderly populations as a result they are well suited for looking at the effect major trauma centre status. Military trauma surgeons in training should be exposed to as much young high-energy trauma as possible to equip them for operations. Retrospective review of all tibial plateaus presenting to RVI 20 months before MTC status and 20 months following this. 61 patients pre, 66 post. Schatzker grade 1–4 were similar pre and post change. Post change there was an increase in Schatzker 5 (62%) and 6 (27%). High energy injuries were most common in younger males, cause was falls followed by RTAs. MTC status has meant an increase in high energy tibial plateaus (Schatzker 5–6) These were predominantly seen in younger males with high-energy mechanisms. As this is likely to be replicated across all injuries, we would recommend military trauma surgeons have a significant period of time training in major trauma centres to ensure adequate exposure to young high energy trauma

Routine metalwork removal, in asymptomatic patients, remains a controversial issue in our daily practice. Current literature emphasized the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice. To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal for limb trauma in asymptomatic patients, an analysis of the postal questionnaire replies of 36% (500 out of 1390) of randomly selected UK orthopaedic consultants was performed by two independent observers. 47.4% replies were received. A total of 205 (41%) were found to be suitable for analysis. The most significant results of our study I: 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients. II: 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under, while only 12% of trauma surgeons do routinely remove metalwork in the age group between 16–35 years. III: 87% of the practising surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more. IV: Only 7% of practising trauma surgeons replied to this questionnaire have departmental or unit policy. No policy is needed for metalwork removal, as most of the orthopaedic surgeons were complying with literature guidance supporting the potential risks associated with implant removal, in spite of the limited number of departmental or units’ policies on implant removal and the paucity of the literature documenting the current practice. However, there is a discrepancy among trauma surgeons in relation to metalwork removal between patient age groups. This indicates guidelines would be helpful to guide the surgeon for the best practice. This is important from a medico-legal standpoint because surgeons are being criticised for not achieving satisfactory results in negligence cases

Introduction. Orthopaedic trauma surgery is characterised by repetitive, forceful tasks that are physically demanding, thus theoretically increasing the risk of musculoskeletal injuries in these surgeons. The aim of this study is to assess prevalence, characteristics and impact of musculoskeletal disorders among orthopaedic trauma surgeons. Methods. A modified version of the physical discomfort survey was sent to surgeon members of the Orthopaedics Trauma Association (OTA) via e-mail. For data analysis, one-way ANOVA and Fisher Exact test were performed to compare the variables where appropriate. P values<0.05 were considered statistically significant. Results. A total of 86 surgeons completed the survey during the period of data collection. Of the respondents 84.9% were males and more than half were aged between 30–45 years old. The majority of musculoskeletal complaints and disorders were low back pain (29.3%), wrist or forearm tendinitis (18.0%), elbow lateral epicondylitis (15.4%), plantar fasciitis (14.7%). When data was analysed according to number of years in practice the results yielded a significant difference between the groups in both number of regions involved (p<0.05) and number of musculoskeletal disorders (p<0.05), as a higher proportion of these were documented in surgeons practicing for 16–20 years and more than 30 years. Also surgeons working in a private setting (p<0.005), surgeons working in more than one institute (p<0.005), increased number of regions involved (p<0.001) and increased number of musculoskeletal disorders (p<0.001) were significantly more likely to require time-off work. Conclusion. To our knowledge, our study is the first of its kind that shows a high percentage of orthopaedic trauma surgeons sustain occupational injuries some time in their careers. Cost of management and rehabilitation of these injuries, in addition to the amount of missed workdays due to these injuries indicate that these injuries have a significant economic burden on the health-care system

Objectives. To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. Methods. A questionnaire was piloted with six orthopaedic surgeons using a ‘think aloud’ process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. Results. There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist shoulder surgeons and treat fewer PROFHER-eligible fractures surgically. This group gave higher scores when assessing validity and applicability of PROFHER. In contrast, a quarter of the non-changers were critical, sometimes emphatically, of PROFHER. The strongest theme that emerged overall was the endorsement of evidence-based practice. Conclusion. PROFHER has had an impact on surgeons’ clinical practice, both through changing it, and through underpinning existing non-operative practice. Although some respondents expressed reservations about the trial, evidence from such trials was found to be the most important influence on surgeons’ decisions to change practice. Cite this article: L. Jefferson, S. Brealey, H. Handoll, A. Keding, L. Kottam, I. Sbizzera, A. Rangan. Impact of the PROFHER trial findings on surgeons’ clinical practice: An online questionnaire survey. Bone Joint Res 2017;6:590–599. DOI: 10.1302/2046-3758.610.BJR-2017-0170

Three dimensional printing is an emerging new technology in medicine and the current educational value of 3D printed fracture models is unknown. The delayed surgery and need for CT imaging make calcaneal fractures an ideal scenario for preoperative 3D printed (3Dp) fracture models. The goal of this study is to assess if improvements in fracture understanding and surgical planning can be realized by trainees when they are given standard CT imaging and a 3Dp model compared to standard CT imaging and a virtual 3D rendering (3D CT). Ethics approval was granted for a selection of calcaneal fracture imaging studies to be collected through a practice audit of a senior orthopaedic trauma surgeon. 3Dp models were created in house. Digital Imaging and Communications in Medicine (DICOM) files of patient CT scans were obtained from local servers in an anonymized fashion. DICOM files were then converted to .STL models using the Mimics inPrint 2.0 (Materialise NV, Leuven, Belgium) software. Models were converted into a .gcode file through a slicer program (Simplify3D, Blue Ash, OH USA). The .gcode files were printed on a TEVO Little Monster Delta FDM printer (TEVO USA, CO USA) using 1.75mm polylactic acid (PLA) filament. Study participants rotated through 10 workstations viewing CT images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. A questionnaire at each workstation assessed fracture classification, proposed method of treatment, confidence with fracture understanding and satisfaction with the accuracy of the 3Dp model or 3D volume rendering. Participants included current orthopaedic surgery trainees and staff surgeons. A total of 16 residents and five staff completed the study. Ten fracture cases were included in the analysis for time, confidence of fracture understanding, perceived model accuracy and treatment method. Eight fracture cases were included for assessment of diagnosis. There were no cases that obtained universal agreement on either Sanders classification or treatment method from staff participants. Residents in their final year of studies had the quickest mean time of assessment (60 +/− 24 sec.) and highest percentage of correct diagnoses (83%) although these did not reach significance compared to the other residency years. There was a significant increase in confidence of fracture understanding with increasing residency year. Also, confidence was improved in cases where a 3Dp model was available compared to conventional CT alone although this improvement diminished with increasing residency year. Perceived accuracy of the cases with 3Dp models was significantly higher than cases without models (7 vs 5.5 p < 0.0001). This is the first study to our knowledge to assess trainee confidence as a primary outcome in the assessment of the educational value of 3Dp models. This study was able to show that a 3Dp model aides in the perceived accuracy of fracture assessment and showed an improvement in trainee confidence, although the effect on confidence seems to diminish with increasing residency year. We propose that 3D printed calcaneal fracture models are a beneficial educational tool for junior level trainees and the role of 3Dp models for other complex orthopaedic presentations should be explored

The placement of the guide wire in the dynamic hip screw operation can be a challenging task to the trauma surgeon. Complications can arise related to incorrect guide wire entry point, making wrong tracks, or even accepting an unsatisfactory lag screw placement. Insisting to optimise the guide wire position can lead to increase in operation and radiation exposure times. A new non-invasive technique is described to assist precision placement of the guide wire in the dynamic hip screw fixation of the neck of femur fractures using no more than a size A4 plain folded paper and a non-permanent marker pen. The new non-invasive “no high tech” method can help the trauma surgeons to shorten the operation time and reduce the radiation exposure time needed to place the guide wire in the dynamic hip screw fixation of the neck of femur fractures

PURPOSE: To determine the capability of fellowship trained Orthopaedic Trauma surgeons to predict union or non-union of femoral and tibial shaft fractures. METHODS: A series of 50 patients with femur or tibia shaft fractures were evaluated. Patients were prospectively followed at 2,6,12, and 18 weeks after surgical intervention. At each interval surgeons evaluated factors related to fracture healing on AP and lateral radiographs and predicted the probability of union on a visual analog scale. Union was defined as radiographic evidence of healing three of four cortices, no tenderness with palpation of the fracture site, and full weight bearing without the use of assistive devices. RESULTS: Eight patients missed initial visits or were lost to follow-up, making for a total of 42 patients that were included in the results. Average patient age was 31 years. Eighty-one percent of the patients went onto union (N=34) and 19% went onto nonunion (N=8). Early clinical prediction for nonunion at 2 weeks had a sensitivity of 50%, a specificity of 91%, a positive predictive value (PPV) of 57%, and a negative predictive value (NPV) of 89%. At 6 weeks, there was a sensitivity of 75%, a specificity of 100%, a PPV of 100%, and a NPV of 94%. One patient treated with intramedullary nailing was 15 years old and despite minimal callous formation the physician incorrectly predicted future union given the young age. The other patient had a severely comminuted femur fracture and required a quad cane to ambulate and should perhaps have been predicted to go onto nonunion. At 12 and 18 weeks, sensitivity, specificity, PPV, and NPV were both 100%. CONCLUSIONS: Fellowship trained orthopaedic trauma surgeons at 6-week follow-up can predict union with a sensitivity of 75% and specificity of 100% and a PPV of 100%. Early clinical prediction at 6 weeks can be used to provide the patient with a secondary intervention such as a bone graft or bone stimulator and avoid months of delay

Objectives: To review the changing pattern of orthopaedic injury encountered by deployed troops with regard to the importance of hand trauma. Methods: A literature review of orthopaedic practice in recent conflict. The search period extended from 1990–2007. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded according to Levels of Evidence. Results: 210 published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. The evidence is overall level 5 with the majority of papers comprising reviews, individual sub-unit experiences, historical perspectives and individual database analyses. The evolving importance of extremity trauma is clear from the quantity of its reporting. The paucity of life threatening cavity trauma is highlighted. Casualty survival off the battlefield is increasing perhaps due to the impact of personal protective equipment. The combination of changing ballistics and increasing survivability leads to an apparent increase in limb threatening and complex hand trauma being encountered by military surgeons. Despite being rarely reported in isolation, the proportion of complex hand trauma is broadening with an increase in open fractures and mutilated soft tissue injuries resultant from high and low energy transfer ballistics. Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Sporting activities and inappropriate use of equipment are responsible for soft tissue and bony injury with considerable morbidity. The literature was analysed with regard to the classification of hand trauma. Articles relating to recent conflicts were notable for their lack of classification of these injuries. The bulk of papers retrieved concerning military hand trauma management were published prior to the conflicts of the last decade. It is within these papers that classification and treatment priorities including the nature of debridement and fracture stabilisation are discussed and highlighted as core knowledge. Conclusion: The nature of injuries sustained by troops in conflict is evolving. Changing survivability is resulting in increasingly complex hand trauma presenting to military surgeons. Despite a culture of ensuring that today’s trauma surgeons learn from mistakes made by their predecessors, in the field of hand trauma this is not the case. A comprehensive review of changing orthopaedic conflict related injury patterns with special regard to hand trauma and the key learning points from historical literature are highlighted. Proposals for improving management are discussed with regard to improved training opportunities and dialogue between military trauma surgeons

Purpose: The use of radiology is integral to Orthopaedic Trauma surgery and there has been increasing dependence on image intensifiers in the operating room. A study was undertaken to assess the radiation exposure of the surgeon. Methods: One full time orthopaedic trauma surgeon has worn a dosimeter on his waist since November 1996, under a lead apron when using a large image intensifier and when using a mini C-arm. Since November 2001, a second dosimeter was worn at the neck, unshielded in all cases. Since June 2005, a ring dosimeter was worn on the dominant ring finger and the all surgical cases were prospectively documented in regard to the type of intensifier used and the amount of fluoroscopy used. Results: In the nine years of monitoring the truncal dosimeter has never recorded any radiation. In four years of monitoring the neck dosimeter has recorded 5.72 mSv (average 1.4 mSv / yr). In last 2 months (6 months data will be available at the time of presentation), 99 operative cases were done. In 31 cases no intra-operative radiology was used, 33 cases used a mini C-arm and in 35 cases a large C-arm was used. A total of 40.2 minutes of mini fluoro time (average 1.22 minutes / case) and 118.09 minutes of full sized C-arm fluoro time (average 3.37 minutes / case) was used. In these 2 months the ring dosimeter recorded 5.4 mSv of radiation (annualized dose 32.4 mSv). Conclusions: The International Commission on Radiological Protection annual recommended dose limits for “radiation workers” are: whole body 20 mSv, eyes 150 mSv and skin / hands 500 mSv. For members of the public these limits are 1 mSv, 15 mSv and 50 mSv, respectively. The exposure of an Orthopaedic Trauma surgeon fall well below the annual recommended dose limits in the industry but begin to approach the limits for the public. From this study it would appear to be safe not to use a lead apron for mini C-arm cases. The surgeons hands are exposed to the most radiation and strategies to reduce this exposure should be pursued

Two discrete legal factors enable the surgeon to treat an injured patient the fully informed, autonomous consent of the adult patient with capacity via civil law; and the medical exception to the criminal law. This article discusses current concepts in consent in trauma; and also considers the perhaps less well known medical exception to the Offences against the Person Act 1861, which exempts surgeons from criminal liability as long as they provide ‘proper medical treatment’.

Cite this article: Bone Jt Open 2024;5(7):565–569.

Antiplatelet agents are widely prescribed for the primary and secondary prevention of cardiovascular events. A common clinical problem facing orthopaedic and trauma surgeons is how to manage patients receiving these agents who require surgery, either electively or following trauma. The dilemma is to balance the risk of increased blood loss if the antiplatelet agents are continued peri-operatively against the risk of coronary artery/stent thrombosis and/or other vascular event if the drugs are stopped. The traditional approach of stopping these medications up to two weeks before surgery appears to pose significant danger to patients and may require review. This paper covers the important aspects regarding the two most commonly prescribed antiplatelet agents, aspirin and clopidogrel

Background. Polypharmacy of elderly trauma patients entails further difficulties in addition to the fracture treatment. Impaired renal function, altered metabolism and drugs that are potentially delirious or inhibit ossification, are only a few examples which must be carefully considered for the medication in elderly patients. The aim of this study was to investigate, if medication errors could be prevented by orthogeriatric comanagement compared to conventional trauma treatment. Material and methods. In a superregional traumacenter based on two locations in Munich, all patients ≥ 70 years with proximal femur fracture were consecutively recorded in a period of 3 months. After the end of the treatment the medical records of each patient were analyzed. At the hospital location 1 the treatment was carried out without orthogeriatric comanagement, at the hospital location 2 with this concept (DGU-certified orthogeriatric center). In addition to the basic medication all newly added drugs were recorded as well as changes in the medication plan and also wether treatment was carried out by the geriatrician or the trauma surgeon. Based on the START / STOPP criteria for the medication of geriatric patients, we defined “no-go” drugs with the geriatrician of the orthogeriatric center which should be avoided in the orthogeriatric patient (including benzodiazepines, gyrase inhibitors, NSAID like Ibuprofen with impaired GFR). The statistical analysis was done with the chi-square-test (IBM SPSS Statistics 24). Results and conclusion. A total of 46 patients were included, 37 of them female and 9 male with an average age of 84,5 years (SD±6.8). At the location without a geriatrician (18 patients), a prescription of one or more “no-go” drugs was found in 9 patients, whereas in location 2 (28 patients) only in 3 patients (p=0.003). Besides that, at the location with the geriatrician, a change in the medication was made for 17 patients during their stay in hospital. This shows that with the fixed integration of the geriatrician into the trauma surgical team, errors in the medication of the patients could be significantly more frequent avoided or faster detected and corrected. Although this should not limit the responsibility of the rest of the team, there is no doubt about the importance of the interdisciplinary treatment of elderly trauma patients

Introduction. Orthopaedic and trauma surgeons not infrequently encounter the hallucal interphalangeal joint sesamoid (HIPJS) in irreducible traumatic dislocations. However, patients with the classic triad of plantar keratoma beneath a hyperextended interphalangeal (IP) joint associated with stiffness of the first metatarsophalangeal joint tend to present to podiatrists rather than orthopaedic surgeons. Methods. We present our experience with the HIPJS following first metatarsophalangeal joint (MTP1) arthrodesis in 18 feet of 16 women, aged 42 to 70 years old. Where CT scan was available, volume of the HIPJS was determined using Vitrea Software. Results. Two groups of patients were identified. Group 1 consisted of 12 feet in 11 women, who developed a painful keratoma beneath a gradually hyperextending IP joint of the great toe, at varying intervals (range 6 to 75 months) following MTP1 arthrodesis. Group 2 comprised 6 feet in 5 women who had undergone MTP1 arthrodesis but reported no symptoms in relation to an undetected and/or recognized, but unexcised HIPJS (range 15 to 97 months). We found no difference in average size of the HIPJS between Groups 1 and 2 (190.42 mm. 3. and 196.47 mm. 3. , respectively). Clinically, all toes had been fused in good position and no difference existed in the post-operative angle subtended by the proximal phalanx of the arthrodesed big toe with the first metatarsal between the 2 groups. A good outcome followed removal of metalwork and excision of the HIPJS in the symptomatic patients. Conclusion. Think of a HIPJS in the patient who presents with a painful plantar keratoma beneath a hyperextended interphalangeal joint following MTP1 arthrodesis. Do not rush into a Moberg osteotomy as this will only push the big toe higher against the toe-box. Consider prophylactic excision of a HIPJS prior to MTP1 arthrodesis

Management of 4-part fractures of the proximal humerus continues to challenge orthopaedic surgeons, shoulder surgeons, and trauma surgeons. Truly displaced 4-part fractures typically require surgery if the patient is medically able to undergo a surgical procedure. However, outcomes following surgery are not always as predictable as we would like. Results following hemiarthroplasty have led to more predictable pain relief than predictable functional recovery relying exclusively on the fate of tuberosity healing. Tuberosity healing failure leads to nearly universal catastrophic results with pain, dysfunction, and pseudoparalysis. Furthermore, conversion of failed hemiarthroplasty to reverse total shoulder arthroplasty leads to the highest incidence of complications and poorest outcomes of all groups of patients undergoing reverse total shoulder replacement. This is countered by the knowledge that if tuberosity healing occurs the outcome can be reliable with regard to pain relief and functional restoration. Reverse total shoulder arthroplasty, on the other hand, has emerged as a preferred surgical option for many surgeons due to the issues following hemiarthroplasty. The increased prevalence of RTSA for the management of 4-part fractures has come without overwhelming evidence that outcomes are superior especially in light of the increased cost, life-time weight bearing restrictions, and uncertain long-term durability. Long-term follow-up of patients treated with RTSA for 4-part fracture has shown concerning degradation of function and outcomes and remains a valid concern about the long-term durability. We must remain diligent therefore in continuing to better understand which fractures should be treated non-operatively and those that may be amenable to anatomic hemiarthroplasty and finally those which may be better served by using a reverse total shoulder replacement

Aims

Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

Introduction. Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives. Materials & Methods. We have designed a PROM especially for Trauma patients, in order to measure the extent of recovery to pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after any form of treatment. This PROM is not site specific and can be used for every Trauma condition. It uses simple wording, user friendly and accessed via phone conversation. The outcome score consists of eleven questions. The first ten questions use the 5-point Likert scale and the final question a scale from zero to ten. The questions are divided into three subgroups (Symptoms, Function and Mental status). The final question assesses the extent of return to pre-injury status. The SF-12v2 questionnaire was used for the validation of the COST questionnaire. We gathered COST and SF-12v2 questionnaires from patients who were at the end of their follow-up after treatment for various trauma conditions, treated either conservatively either operatively. Results. A total of 50 COST questionnaires were gathered in out outpatients department. The participants were 33 male and 17 female patients (aged 44.2 ±18.9 years) and the questionnaires collected at mean 9.7 months post-injury. A Cronbach's Alpha value of 0.89 was identified for the whole construct. The three dimensions of the scale had good internal consistency as well (Cronbach's Alpha test values 0.73, 0.85 and 0.81 for symptoms, function and mental status respectively). Strong/moderate correlation (Spearman's Rho test 0.45–0.65) was observed between the respective physical/mental dimensions of the COST and SF-12v2 questionnaires. Conclusion. There is a need for a specific PROM for Trauma pathology which is not site specific and easy to use and understand. COST is a useful tool to Trauma surgeons to measure the outcomes of their patients and has high internal consistency

While the Cochrane Collaboration have been busy over the last four months, only a handful of their published reviews have been of any relevance to orthopaedic and trauma surgeons. Those that are provide the reader with an overview of work on imaging modalities, antibiotic therapy, changes to the surgical site dressing and practices surrounding post-operative wound management, including post-op bathing and negative pressure wound therapy for use in the treatment of diabetic foot wounds.

Objectives. Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. Methods. The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons. Results. Two or more baseline radiographic views were obtained for each participant. The independent raters confirmed that all fractures would have been considered for surgery in contemporaneous practice. A full description of the fracture population based on the Neer classification was obtained. The agreement between the categorisation at baseline (tuberosity involvement) and Neer classification as assessed by the two raters was only fair (kappa 0.29). However, this disparity did not appear to affect trial findings, specifically in terms of influencing the effect of treatment on the primary outcome of the trial. Conclusions. A key reporting requirement, namely the description of the fracture population, was achieved within the context of a pragmatic multicentre randomised clinical trial. This article provides important guidance for researchers designing similar trials on fracture management. Cite this article: H. H. G. Handoll, S. D. Brealey, L. Jefferson, A. Keding, A. J. Brooksbank, A. J. Johnstone, J. J. Candal-Couto, A. Rangan. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.Bone Joint Res 2016;5:481–489. DOI: 10.1302/2046-3758.510.BJR-2016-0132.R1

In revision surgery of a neglected loose cemented stem, especially if long-standing infection is present, the bone may become extremely thin and fragile. A fracture during implant removal, therefore, occurs readily and the bone may simply disintegrate so that it cannot be reconstructed to produce intrinsic stability. In such cases, rather than try to put together a house of cards, the bail and nail technique may be used. I first described this in 1992. A large bore intramedullary nail is inserted into what is left of the femur and the bone fragments proximally or cerclage wires are around the nail. The patient is left with a Girdlestone. Most patients cannot weight-bear on a Girdlestone for about two months. After that time, they are encouraged to do so as load bearing speeds healing and bone regeneration. Generally, within six to nine months, the femur is reconstituted and a revision can be carried out. This is a simple operation as the medullary canal is already open and the regenerated bone is often of surprising good quality. It may even be possible to use a primary stem as opposed to a long revision stem, but this probably should not be done under nine months. The presence of an IM nail and cerclage wires does not prevent the elimination of infection. As our brothers, the trauma surgeons, will attest the treatment of an infected non-union of the femur is an intramedullary nail. This technique is seldom required. The author has used it in eight cases in the last 30 years. It is, however, extremely valuable in bailing out of an impossible revision, especially if strut allografts or modular long stems are not immediately available

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

The February 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Aims

Dual-mobility acetabular components (DMCs) have improved total hip arthroplasty (THA) stability in femoral neck fractures (FNFs). In osteoarthritis, the direct anterior approach (DAA) has been promoted for improving early functional results compared with the posterolateral approach (PLA). The aim of this study was to compare these two approaches in FNF using DMC-THA.

Aims

Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques.

Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

The February 2024 Trauma Roundup³⁶⁰ looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years.

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

Aims

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs.

Aims

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

The initial management of slipped upper femoral epiphysis (SUFE) can determine the occurrence of longterm disability due to complications. Previous surveys have concentrated on orthopaedic surgeons with a specialist paediatric interest. In many units in Scotland, the initial responsibility for management may be an admitting trauma surgeon with a different subspecialty interest. All Orthopaedic surgeons in Scotland participating in acute admitting were invited to complete a web based survey to ascertain current practice in the initial management of adolescents presenting with SUFE. 92/144 (64%) of surgeons approached responded. When faced with a severe stable slip, 53% of respondents were happy to pin in situ, whilst 47% would refer either to a colleague or specialist paediatric unit. With an unstable slip of similar magnitude, 38% would self-treat, 18% refer to a colleague and 44% refer to a paediatric orthopaedic unit. Of those treating, 58% stated their treatment was selected irrespective of timing of presentation. 79% of respondents had treated 5 or less cases in the preceding 5 years with 7% more than 10 cases. Universal prophylactic pinning was supported in 29%, selective in 62% and never in 9%. The responses obtained confirm the variance in management of SUFE that exists amidst acute admitting units in Scotland. Management of a stable slip is uncontroversial except possibly in severe cases. This contrasts with the acute unstable slip, in which various factors are thought to influence the outcome, such as instability and the issue of timing, which are not universally appreciated

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

Periprosthetic fractures after total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, bone loss and subsequent functional compromise. The prevention, early recognition and appropriate management of such fractures are therefore critical. The pathogenesis of periprosthetic factors is multi-factorial. There are a number of intrinsic patient influences such as poor bone stock, biomechanics and compliance. There are also a host of extrinsic factors over which the surgeon has more control. The key tenets for fracture avoidance include careful planning, identifying the risk, choosing the correct implant, understanding the anatomy, and using appropriate surgical technique. There are a number of recognised risk factors for periprosthetic hip fractures The prevalence of intraoperative fractures during total hip arthroplasty is higher in the patient with osteopenia / osteoporosis. Other conditions causing increased bone fragility, such as osteomalacia, Paget's disease, osteopetrosis, and osteogenesis imperfecta are also at a higher risk of intraoperative fracture. The use of more and more press fit cementless components has also increased the number of periprosthetic femoral fractures because of the force required to obtain such a fit. Complex deformities of the proximal femur, particularly when associated with a narrow medullary canal, may also increase the risk of intraoperative fractures. Revision surgery is associated with a higher risk of intraoperative fracture than primary hip replacement surgery. These fractures typically occur during hip dislocation, cement extraction, or reaming through old cement. Other risk factors for postoperative femoral fractures following total hip replacement include loosening of the prosthesis with cortical bone loss, local osteolysis, stress risers within the cortex, such as old screw holes, the ends of plates, or impingement of a loose stem against the lateral femoral cortex. The management of periprosthetic fractures requires appropriate preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intraoperatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past two decades have afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimization is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems, as well as biologically challenging transverse or oblique fractures at the tip of a stem. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilization if the patient cannot fully weight bear, and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues

Aims

Several studies have reported that patients presenting during the evening or weekend have poorer quality healthcare. Our objective was to examine how timely surgery for patients with severe open tibial fracture varies by day and time of presentation and by type of hospital. This cohort study included patients with severe open tibial fractures from the Trauma Audit and Research Network (TARN).

Aims

The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

Open reduction and internal fixation of acetabular fractures demands detailed preoperative planning, and given their frequent complexity, a thorough understanding of their three-dimensional (3D) form is necessary. This study aims to assess if the use of dynamic 3D models will improve preoperative planning of acetabular fractures. In this study, three experienced pelvic trauma surgeons were provided with computer based dynamic 3D models in addition to preoperative radiographs, CT scans and static 3D reconstructions of 17 acetabular fractures operatively managed at the Royal Melbourne Hospital. Surgeons, blinded to any previous operative plan or patient detail, then classified fracture type and made preoperative surgical plans. Comparison was then made to classification and operative approach documented in the patient's operation notes. Comparison was then made with regard to surgical plan and planning time with or without access to dynamic 3D models. In complex cases the additional information provided by dynamic 3D modelling was found to reduce planning time and, in some cases, change the surgical plan. For complex acetabular fractures we recommend that surgeons should have access to computer-based dynamic 3D models of the injuries for pre-operative planning

Ankle fractures are one of the most common bony injuries presenting to the trauma surgeon. The more severe ones result in disruption of the tibiofibular syndesmosis and hence worse outcome. The outcome depends on accurate reduction of syndesmosis. The two main options in managing these injuries are syndesmotic screws or tightrope. The aim of this study is to compare the rate of complications between these two techniques and their radiographic results. Retrospective data from 62 patients between September 2009 and March 2011 who had fixation of syndesmosis was obtained from theatre logbooks. 46 patients had syndesmotic screws inserted while 16 had tightrope. The average age was comparable in both groups (51 years v/s 41). 25 of the 46 syndesmotic screws inserted were removed. No tightropes had to be removed for any reason. 2 patients with syndesmotic screws had wound complications while 1 patient which tightrope insertion had a persistent diastasis. There were no differences in radiological outcome between the two groups with regards to reduction of syndesmosis (measured by talofibular clear space minus medial clear space) (p-value 0.283). The difference between the talocrural angles was also of no significance (p-value 0.344). Our results indicate that tightropes achieve radiologically similar reduction of syndesmosis as screws without any significant difference in complications. The need for a second operation is significantly lower with tightrope fixation

Introduction. Iliac crest bone marrow aspirate (ICBMA) is frequently cited as the ‘gold-standard’ source of MSCs. Mesenchymal stem cells have been shown to reside within the intramedullary (IM) cavities of long-bones and a comparative assessment with ICBMA has not yet been performed. Methods. Aspiration of the IM cavities of 6 patients' femurs with matched ICBMA was performed. The long-bone-fatty-bone-marrow (LBFBM) aspirated was filtered (70μm) and the solid fraction digested for 60min (37°C) with collagenase. Enumeration was performed via the colony-forming-unit-fibroblast (CFU-F) assay and using the CD45low CD271+ phenotype via flow-cytometry. Passaged (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages with their phenotype assessed using flow-cytometry CD33 CD34 CD45 CD73 CD90 CD105. Results. MSCs were isolated from all fractions. Using the CFU-F assay median number of colonies: ICBMA=8 (2–21), LBFBM-liquid=14 (0–53), LBFBM-solid=116 (23–171) per 200μl of sample; MSC frequency, as percentage of total cells, using flow-cytometry, provided similar results. Mesenchymal stem cells isolated from the LBFBM phases appeared to not be inferior to ICBMA in terms of osteogenic, chondrogenic or adipogenic differentiation. Passaged cells from all fractions had a phenotype consistent with other reported sources. Discussion. Intra-medullary cavities of long-bones are frequently accessed by the orthopaedic/trauma surgeon. This represents a ‘low-tech’ method of harvesting large numbers of MSCs with a favourable differentiation profile for autologous/allogenous uses

To determine if the term “back pain” has uniform meaning to spinal surgeons. A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain. An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting. 67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05). The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral. This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?

Introduction. The clinical and functional outcome following simultaneous fractures of the acetabulum and pelvic ring represent a challenge for the clinician and are currently obscure in the existing literature. Patients and Methods. Between January 2003 and July 2009 all patients with combined pelvic and acetabular fractures were included in this prospectively study. Demographic details, mechanism of injury, ISS, surgical procedures, post-operative course, length of hospital stay, and radiological (Matta's score) and functional outcomes (The Merle d' Aubigne hip score) were recorded. The minimum follow up was 12 months (12–72). Results. Out of 520 cases, 30 (21 males) patients met the inclusion criteria. The mean age was 32. 55% sustained lateral compression, 40% combined mechanism and 5% anterior/posterior type of injury pattern. 15 out of the 30 patients had sustained other injuries. The mean time from injury to definite reconstruction was 7 days (3–14). Ilioinguinal approach was used in 20 patients, Pfannestiel in 2 and Kocher-Langebeck in 4. A wheelchair was used initially in 22 cases. The median time to FWB was 3 months. One patient underwent a THR at 18 months. 19 patients scored the full 18 points of the Merle score. Matta radiological score was excellent in 16 patients, Good 11, Fair 2, Poor 1. Conclusion. The management of these injuries poses many difficulties to the trauma surgeon. With the available expertise in place good outcomes can be obtained as seen in this series of patients

Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only. Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome. Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function. The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail

Purpose: Radiographic healing is a common outcome measure in orthopaedic trials and adjudication by outcome assessors is often conducted using only plain radiographs. We explored the effect of adding clinical notes to radiographs in the adjudication process of a pilot trial of tibial shaft fractures. Method: Radiographic and clinical data from a multicenter clinical trial of 51 patients with operatively treated tibial fractures formed the basis of the study data. An independent adjudication committee of three blinded orthopaedic trauma surgeons evaluated radiographs for time to fracture healing. This committee then evaluated clinical notes associated with each radiographic follow up visit and were asked to either revise or maintain their initial impression. We calculated the proportion of time to healing consensus decisions that changed after evaluation of clinical notes. We further examined the contents of the clinical notes and its relative influence on the committee’s decisions. Results: Forty-seven of 51 patients were determined to have radiographic evidence of healing during the trial follow-up period, and consideration of the clinical notes resulted in a change of 40% (19 of 47) of time to healing consensus decisions; however, revised decisions were equally likely to support an earlier or a later time to healing. Conclusion: Addition of clinical notes changed the adjudication committee’s decision of radiographic fracture healing in a substantial number of cases. Our findings suggest that orthopedic trialists should consider the addition of clinical notes to adjudication material in studies of fracture healing

This paper presents the experience of a tertiary referral centre for pelvic and acetabular trauma. From August 1999 a tertiary referral centre was established in Christchurch to provide management for pelvic and acetabular trauma for the South Island. The experience of unit was reviewed. One hundred and twenty four unstable pelvic and acetabular fractures were treated between August 1999 and March 2005. Ninety two percent of fractures were treated by one or both of two fellowship trained trauma surgeons. While the rate of complications was low, there were 6 significant infections, 3 nerve injuries, and 2 non-unions. The experience of the unit is presented. A tertiary referral centre for pelvic and acetabular trauma has been able to provide a successful service to the South Island with satisfactory results

Fractures of the distal tibia metaphysis comprise a challenge for the orthopaedic trauma surgeon because of the poor blood irrigation they do not heal very easy leading sometimes to pseudarthrosis and many times arise problems with the skin. We compare the following techniques: LC-DCP and LCP plates, MIPO, External fixators (hybrids or simple one), intramedullary nailing with multiple screws at the distal end. 94 cases of distal tibia fractures from all AO types were treated during last 3 years (2005–2008) with the following techniques:. 16 ORIF with LC-DCP plates. 9 ORIF with LCP plates. 19 MIPO. 35 External fixators. 15 intramedullary nailing. The simple oblique or spiral fractures which treated with the 1st and 2nd method (ORIF), they do not seem any remarkable difference in healing but both methods demonstrate a delay in fracture healing over 5 months. The 3rd method display faster healing 2,5 months average in simple fractures with no skin wound at all. The 4th method display 3 pin track infections and dealt with removal of the material and 2 pseudarthrosis which encountered with ORIF and bone grafting from the iliac. The 5th method display 2 malunions but because of the small angle in varus we do not perform any treatment. Every technique has its own position on those type of fractures, depending of the personality of the fracture and the skill of the surgeon

Background. Non-union has traditionally been considered a rare complication following the non-operative management of clavicle fractures. A growing body of evidence has demonstrated higher rates of non-union in adults with displaced fractures. However, the variables that predict non-union in these patients remain unclear. We evaluated the prevalence and risk factors for non-union following displaced midshaft clavicle fractures in a large consecutive series of patients managed non-operatively in our Unit. Materials and Methods. 1097 consecutive adults (mean age 26.1yrs) with displaced midshaft clavicle fractures treated non-operatively in our Unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. All patients were managed in a simple sling for two weeks followed by early mobilization. All patients were followed-up until clinical and radiological confirmation of union. Non-union was defined clinically as the presence of pain or mobility of the fracture segments on stressing, and radiologically as failure of cortical bridging by 6 months. Results. 198 (18%) of patients had evidence of non-union at 6 months. Patient factors significantly associated with non-union included increasing age, smoking and the presence of medical comorbidities (p<0.05). Injury-related factors associated with non-union included Increasing fragment translation and displacement, and a severe pattern of injury (Edinburgh 2B2: comminuted segmental fracture)(p<0.01). Conclusions. We present the largest series reporting the prevalence and risk factors for non-union following conservatively treated, displaced midshaft clavicle fractures. These fractures can no longer be viewed as a single clinical entity, but as a spectrum of injuries each requiring individualized assessment and treatment. Increased understanding of the outcomes of these injuries will enable clinicians to better identify those patients that may be better served with primary operative reconstruction

Aims

The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

Purpose. Antibiotic prophylaxis plays an important role in minimizing surgical site infections as well as other nosocomial peri-operative infections in orthopaedic trauma patients. Pre-operative prophylaxis has been shown to be efficacious, but the role and duration of post-operative prophylaxis remains controversial. The goal of this study was to assess whether patients receive their antibiotic prophylaxis as prescribed. What dose and duration of antibiotics are typically ordered, what patients actually receive, and factors causing the ordered antibiotic regime to be altered were also investigated. This study did not investigate infection rates or the efficacy of various antibiotic prophylactic regimes. Method. This study presents data collected through a retrospective chart review of 205 patients treated surgically for a closed fracture at one institution. A national survey was also distributed to all surgeon members of the Canadian Orthopaedic Trauma Society (COTS) concerning antibiotic prophylaxis in the setting of surgical treatment for closed fractures. Results. Ninety three percent (179/193) of patients received an appropriate pre-operative dose, while less than 32% (58/181) of patients received their post-operative antibiotics as ordered. The most common stated reason for patients not receiving their post-operative antibiotics as ordered was patients being discharged before completing three post-op doses. There was a 70% (39/56) response rate to the survey sent to COTS surgeons. A single dose of a first-generation cephalosporin pre-operatively followed by three doses post-operatively is the most common practice amongst orthopaedic trauma surgeons across Canada, but several surgeons use only pre-operative prophylaxis. Conclusion. Adherence to multi-dose post-operative antibiotic regimens is poor. Meta-analyses have failed to demonstrate the superiority of multi-dose regimens over single-dose prophylaxis. Single-dose pre-operative antibiotic prophylaxis may be a reasonable choice for most orthopedic trauma patients with closed fractures

Background. The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. Methods. A cohort of 95 patients with AO type C tibial pilon fractures underwent primary ORIF. Of these patients, 21 had open fractures. Sixty-eight fractures were sustained in falls, 21 in motor vehicle collision, 5 in crushes and one in an aircraft crash. The principal outcome measure was wound dehiscence or infection requiring surgery. Radiological and functional outcomes were assessed at a mean of five years using the SF36 and the Foot and Ankle Outcome Score. Results. Primary ORIF was performed within 48 hours of admission in 98% cases. Reduction was anatomical in 90% cases. Six (6%) patients developed a wound infection or dehiscence that required surgical débridement, giving a wound complication rate of 4/21 (19%) for open fractures and 2/74 (2.7%) for closed fractures. Of the two closed fractures, one occurred in a patient with local scarring from previous trauma, insulin-dependent diabetes mellitus and chronic alcohol abuse, and the other in a patient with schizophrenia, diabetes and peripheral neuropathy. Radiographic follow-up revealed 74% patients had normal appearances or mild osteoarthritic degeneration only. Functional outcomes revealed a reduced level of general health and mild disability. Conclusions. Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, AO type C pilon fractures can be stabilised safely and effectively by primary ORIF, with very low rates of wound complications, a high quality of reduction, and a good long term outcome. These results compare favourably with the published results for all other methods of treatment

Purpose: We aimed to preliminarily validate a newly developed system, the radiographic union scale for tibial (RUST) fracture healing. We hypothesized that RUST would demonstrate better inter-rater reliability than assessment of the number of cortices bridged and correlate with functional outcomes at least as strongly as surgeon’s assessment of cortical bridging. Method: Three blinded orthopaedic trauma surgeons independently assigned a RUST score and a number of cortices bridged by callus (zero to four) to each set of AP and lateral radiographs at each follow up period. RUST is scored from four (definitely not healed) to 12 (definitely healed) based on the presence or absence of callus and of a visible fracture line at the total of four cortices visible. Results: For 549 sets of reviewed radiographs, inter-rater reliability for RUST scores were found to be substantially higher than for assessment of the number of cortices bridged (intra-class correlation coefficient=0.84; 95% CI, 0.80–0.87 versus kappa = 0.73; 95% CI, 0.64 – 0.81, respectively). Both methods of assessing radiographic healing were strongly correlated with weight-bearing status (r and ρ> 0.50), moderately correlated with patient-reported functional recovery and the SF-36 Physical Functioning component scores (r and ρ> 0.30), and minimally correlated with HUI Mark II scores, return to work, and the SF-36 Role Physical component and Physical Component Summary scores (r and ρ> 0.10). Neither assessment was correlated with patient-reported pain scores. All correlations were similar for RUST and the number of cortices bridged. Conclusion: This study provides preliminary evidence that RUST can be used as a valid and reliable alternative assessment of tibial fracture healing

Aims

Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes.

Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Detailed preoperative planning is essential for open reduction and internal fixation of acetabular fractures if a successful outcome is to be achieved. Decisions such as patient positioning, approach, reduction techniques and implant positioning are greatly influenced by fracture pattern and displacement. These fractures are frequently complex and a thorough understanding of their 3-Dimensional (3D) form is necessary for pre-operative decision making. A combination of biplanar x-rays, 2 Dimensional CT scans (Axial, Sagittal and Coronal multi-plane reformats) and, more recently, 3D CT reconstructions are provided routinely. However, the 3D reconstructions are provided to surgeons as static 2D pictures of the 3D model (up to 6 different views), rather than a true 3D representation. In this study we used dynamic 3D models to provide additional information to surgeons. The 3D models were generated on a standard desktop or laptop computer and can be used in the operating theatre (Osirix Dicom viewing software). These true 3D reconstructions allow the surgeon to manipulate the model himself in real time so that the fracture can be viewed at any angle and overlying fragments removed to expose deeper structures. 3 experienced consultant pelvic trauma surgeons reviewed plain radiographs and 2D Pelvic CT scans from 20 acetabular fractures. They were asked to make a preoperative plan with regard to fracture classification and planned surgical approach(s). At separate, time-spaced, sittings they were provided with a 3D Static and 3D Dynamic CT reconstruction in addition. They were blinded to any previous plan and the patients’ details. A comparison was then made with regard to surgical plan and the time taken to make that plan with or without access to dynamic 3D models. The additional information provided by dynamic 3D modelling was found to reduce planning time and, in some cases, change the surgical plan

The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children. We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery. We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion. The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable

To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities. Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence. Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses. The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma. Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons. This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten

Introduction: Compartment syndrome is one of the most devastating complications in orthopaedic trauma cases. The aim of this study is to investigate whether the intra-compartmental pressure changes rise and stay above the dangerous limits during percutaneous bridge plating of tibial shaft fractures necessitating fascial release or not. Patients and Methods: Between January 2007 and April 2009 17 isolated tibial fractures of the 17 patients were treated with percutaneous bridge plating technique by a single orthopaedic trauma surgeon. During the operation before, during and after the plating leg compartmental pressures were measured by using invasive blood pressure monitor. Demographic, trauma and fracture related data were also recorded. Analyses were performed by using SPSS 13. Findings: Mean age was 32 (19–55) years. Mean of ISS was 14 (10–27). Plating was performed at a mean of 3,3 (1–6) days after the trauma. Means of difference between systolic and diastolic blood pressure and leg anterior compartment pressures just before the plate insertion were 42 and 25,5 (16–32) mmHg respectively. During plating compartmental pressures rose to a mean of 51,5 mmHg (p=0,001) and dropped to 50 mmHg 10 minutes after implantation. Mean delta P was – 7 mmHg for the leg antertior compartment ten minutes after plating. No correlation was found between the blood pressure differences; ISS; age; type of anesthesia and delta P (r< 0,1 and p> 0,05). Although there is a trend of having decreased delta P with earlier surgery difference was not significant (r=0,18; p=0,058). Conclusion: Anterolateral percutaneous bridge plating of tibial shaft fractures significantly increases intracom-partmental pressures. Physician should carefully judge the risk of compartment syndrome in each patient separately and should not hesitate to perform percutaneous fascial release intraoperatively

Introduction. Iliac crest bone marrow aspirate (ICBMA) is frequently cited as the ‘gold-standard’ source of MSCs. MSCs have been shown to reside within the intramedullary (IM) cavities of long-bones [Nelea, 2005] however a comparative assessment with ICBMA has not yet been performed and the phenotype of the latter compartment MSCs remains undefined in their native environment. Methods. Aspiration of the IM cavities of 6 patients' femurs with matched ICBMA was performed. The long-bone-fatty-bone-marrow (LBFBM) was filtered (70μm) to separate liquid and solid fractions and the solid fraction was briefly (60min, 37oC) digested with collagenase. MSC enumeration was performed using the colony-forming-unit-fibroblast (CFU-F) assay and quantification of cells with the CD45low CD271+ phenotype by flow-cytometry. [Jones 2002, Buhring 2007] MSCs were cultured and standard expansion media and passage 2 cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages. Results. ICBMA and LBFBM-liquid had similar median frequencies of MSCs/CFU-Fs per 200μl of sample (median 8, range 2-21, and 14, 0-53, respectively). LBFBM-solid fraction contained ∼10-fold more MSCs (116, 23-171). Correspondingly, LBFBM-solid fraction contained the highest proportions of CD45low CD271+ cells (median 0.315, 0.221-0.874) compared with (0.052, 0.023-0.083 and 0.152, 0.063-0.956) for ICBMA and LBFBM-liquid respectively (N =4) - thus sharing this phenotype of ICBMA cells. LBFBM MSCs were negative for the CD34 marker which has previously been reported on extra-bone marrow fat sources [Lin 2008]. MSCs isolated from the LBFBM phases were equivalent to ICBMA in terms of their osteogenic, chondrogenic or adipogenic potencies and their phenotypes following expansion was consistent with MSCs (CD73+ CD90+ CD105+CD33-CD34- CD45-). Conclusions. Intra-medullary cavities of long-bones are frequently accessed by the orthopaedic/trauma surgeon. Aspiration of LBFBM prior to reaming insertion of prosthesis/nail is a ‘low-tech’ method of harvesting large numbers of MSCs that can be liberated by brief enzymatic digestion. LBFBM can be used as an alternative to ICBMA for autologous use in trauma surgery. Both the in vivo phenotypes and functionality of LBFBM and ICBMA are comparable

Introduction: It is said that God gave us paired bilateral anatomical structures so that the trauma surgeon can compare the injured side with its uninjured counterpart. The axial rotational alignment of fingers, when disrupted by injury, may lead to scissoring. During examination, comparison is made between the rotational alignment of injured and uninjured fingers. This assumes that the rotational alignment of the fingers is symmetrical. A study was performed to ascertain normal rotational alignment, and establish whether this assumption is valid. Materials and Methods: Standardised digital images were taken with fingers in extension. These were analysed using the angle-measuring tool on Adobe Photoshop software. The rotational angle used was that between a line joining the radial and ulnar borders of the nail plate, and the horizontal. Results: Mean angles of rotation were 13° for the index finger, 10° for the middle, 5° for the ring and 12° for the little. Differences in the angle for ring and little fingers between the sides were not significant; these fingers are symmetrical. Index and middle fingers demonstrated statistically significant asymmetry of 2.6° (SD +/− 4.2°). Discussion: Previous work has sought to quantify rotational alignment in cadavers or using wire markers and fluoroscopy. A new method, using digital photography and image analysis is described. We determined mean angles, showing symmetry of the ring and little but asymmetry of index and middle. Previous work has suggested that up to 10° of rotation can be tolerated. With only 2.6° of difference, clinical comparison of sides remains appropriate

Introduction: Displaced fractures of the pelvic ring represents challenge for the trauma surgeon. Patients: From January 1999 to December 2006, the treatment was given to 134 patients (81 males, 53 females, aged 18–73 years) with pelvic ring fracture and dislocation. According to the AO (1988) classification, B type were 95, C type were 39 in cases. Surgical technique: Closed reduction and retention of unstable pelvic injuries (type B and C injuries), in order to restore the form and function of the posterior pelvis by percutaneous iliosacral screw and when is necessary antegrad screw fixation of the anterior pelvic ring osteosynthesis, using conventional fluoroscopy. 134 patients with a posterior pelvic fracture or fracture dislocation underwent screw fixation with fluoroscopy with 8.0-mm, or 9.0 mm cannulated screws, placed in a transiliosacral position in the vertebral body of SI, and S II. Among these patient, 71 fixed with percutaneuos screw in the anterior pelvic ring fracture too. Results: The average operating time was 23 min, the average screening time 2,11 min. Iatrogenic nerve damage was not found. All fractures healed within 3 months. 17% of the patients had residual pain, which were permanent or intermittent. Partly the reason could be the SI arthrosis, as we can see in 13% of the patients, or the fracture healing caused foramen stricture. Unfortunately we have lost 11 patients. The Majeed functional scoring was applied. In conclusion we could say that 81% of our patients were in the excellent and good category. Conclusions: The technique of percutaneous cannulated screws internal fixtion for treating the posterior and anterior portion of the pelvis has the advantages of small trauma, less bleeding stiff fixtion, which is an ideal and minimally invasive technique

The incidence of acetabular fractures within the UK is about 3 in 100,000 of the population per year. Since Letournel and Judet first proposed that operative reduction and rigid internal fixation of displaced fractures will likely lead to better outcome, operative management of such fractures has become standard management in major trauma centres. Long term outcome results following acetabular surgery have been reported sparingly. Two hundred and fifty-seven displaced acetabular fractures underwent an open reduction and internal fixation at St. George’s Pelvic Unit between 1992 and 1997. All surgery was performed by a single surgeon. 161 patients were followed up prospectively for a minimum of 10 years. Those lost to follow up were excluded. Anthropometric data, fracture pattern, time to surgery, associated injuries, approach, complication and outcome recorded on a database. Modified Merle D’ Auberge score was utilized as outcome measures. The mean age was 36 years (15 to 85). Road traffic accident was the commonest mechanism of injury. We observed simple fractures in 34 % and associated fractures in 66%. 52% suffered polytrauma. Average time to surgery was 11 days and anatomic reduction was achieved in 73.9%. Results were excellent 46.8 %, good 25.5 %, fair 7.5 %, and poor 19.2 %. Poor prognostic factors were increasing age, delayed surgery, poor reduction, and posterior column, transverse posterior wall and T-shaped fracture patterns. Acetabular surgery poses a major challenge to the trauma surgeon. Complications in the immediate, mid and long term are not rare. Our results compare to other series with shorter follow-up. We believe that the gold standard treatment for displaced acetabular fractures must be open reduction internal fixation performed by a dedicated pelvic surgeon at the earliest time possible. Moreover whether we are merely postponing the inevitable post-traumatic arthritis is still unknown

Aim: To assess the ability of volar locking plates to maintain fracture reduction when used to treat dorsally displaced extra and intra-articular distal radial fractures. Methods: This prospective study was conducted over a 12 month period. Consenting patients who had sustained a closed, dorsally displaced distal radial fracture, treated by open reduction and internal fixation using a volar distal radial locking plate, were included in the study. Radial inclination, volar tilt and ulnar variance were measured from radiographs taken at least 3 months after surgery and compared with radiographs of the uninjured side. Only two of the eight participating surgeons have a specialist interest in upper limb surgery. Results: Thirty-three patients were included in the study. There were 23 females and 10 males. The mean age was 49.5 years, range 26–82 years. According to the OTA classification there were 19 Type A, 1 Type B and 13 Type C fractures. The mean restoration of volar tilt was 1° of under-correction, median 1.1° under-correction with a range of 7.3° of under-correction to 3.7° of over-correction, when compared with the uninjured side. The mean restoration of radial inclination was 1.9° of under-correction, median 1.6° under-correction with a range of 10° of under-correction to 8.4° of over-correction. As a group the mean ulnar variance was 0mm with a range of 2mm of relative ulnar shortening to 3.5mm of ulnar prominence when compared with the uninjured side. Conclusion: In the hands of general trauma surgeons, the volar approach combined with the application of a suitable volar locking plate is a good treatment for restoring and maintaining the anatomy of dorsally displaced intra and extra-articular distal radial fractures

Introduction. There is an ever increasing demand for Randomised Controlled Trials (RCTs) in Trauma and Orthopaedic Surgery. Patient recruitment is often challenging. Among other factors, individual surgeon's preference is often quoted as a major obstacle. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution, but could not help in everyday running of a trial. We wanted to develop a new trial eligibility assessment tool using the Collective Equipoise Principle. Methods. We developed an online system that quantifies collective uncertainty among a group of surgeons for an individual clinical case in real time. This data was collected for patients in the UK Heel Fracture Trial (UK HeFT) as an independent research project. Both patients who agreed or not to take part in the trial were approached in six weeks follow up clinic to avoid interference with clinical course. For those who agreed, anonymous clinical data together with images (Xrays and CT) was published on a secure on line forum and registered surgeons were alerted via email and SMS. Surgeons submitted their opinion instantly via specially designed interactive voting scale. 80:20 ethical uncertainty distribution limit was applied using Subjective Logic to calculate an Uncertainty Index (UnIx) for every patient. This approach was evaluated as an eligibility assessment tool for RCTs. Results. 70 consecutive patients (77 calcaneal fractures) were assessed by a panel of 12 Consultant Trauma surgeons from hospitals acros the UK. All patients were eligible for the UK HeFT according to standard eligibility criteria approach. UnIx demonstrated reliable correlation with level of uncertainty and confidence about treatment choice expressed by surgeons. The panel was certain about treatment for 9 (13%) patients. The assesment results were available within 48 hours from a case submission to the panel. Discussion and Conclusion. UnIx is an effective and ethical eligibility assessment tool based on surgeon's opinion. It can be calculated for every patient in Randomised Controlled Trials. This protects patients when there is no controversy about treatment choice. UnIx can potentially increase patient recruitment by including more patients for eligibility assessment and more sceptical surgeons in clinical trials. Patient's perception that his/her condition was assessed by surgical panel may also be important

Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The axillary nerve was most frequently injured neurological structure. We were unable to elicit any significant statistical differences between bifocal and trifocal injuries with regards to patient demographics. However, when compared with unifocal injuries, bifocal or trifocal injuries were more likely to occur in older, female patients resulting from low energy falls (p<0.05). Conclusions. We present the largest series reporting the epidemiology of injury patterns related to traumatic anterior shoulder dislocation. Increased understanding and awareness of these injuries among clinicians will improve diagnosis and facilitate appropriate treatment

Trochanteric femur fractures can be classified using the Jensen modification of the Evans’ classification or the AO/ASIF classification. This study compares the reproducibility of both classifications. Furthermore we evaluated the agreement on fracture stability, choice of osteosynthesis, fracture reduction and the accuracy of implant positioning. We used pre- and postoperative lateral and AP radiographs of 50 trochanteric femur fractures. The fractures were classified using both classifications with a three-month interval by five trauma surgeons and five residents. Inter-, and intra-observer variability was analysed using the multi-rater Fleiss’ kappa and the Cohen’ kappa tests. The AO/ASIF classification showed a kappa coefficient for the intra-observer agreement of 0.40 (SE 0.01). After leaving out classification-subgroups, AO/ASIF classification showed a coefficient of 0.68 (SE 0.02) and the Jensen classification a coefficient of 0.48 (SE 0.02). The kappa values of the intra-observer reliability of the AO/ASIF classification with and without subgroups were: 0.43 (SE 0.08) and 0.71 (SE 0.08) respectively. For the Jensen classification the kappa value was 0.56 (SE 0.09). Preoperative agreement on fracture stability and type of implant to be chosen showed kappa values of 0.39 (SE 0.05) and 0.65 (SE 0.04). Postoperative disagreement on the choice of implant was 15% (kappa 0.17, SE 0.08). Kappa values for postoperative fracture reduction and position of the implant were 0.29 (SE 0.09) and 0.22 (SE 0.05), respectively. Both the Jensen classification and the AO/ASIF classification showed poor reproducibility. However, without subgroups the AO/ASIF classification seemed more reliable. This study suggests that the definition of stability of trochanteric fractures remains controversial, which possibly complicates the choice of osteosynthesis. Refinement of the classifications or renewed definition of trochanteric fractures seems to be required

Periprosthetic fractures in total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, loss of bone and subsequent functional deficits. We face an epidemic of periprosthetic fractures as the number of cementless implants inserted continues to rise and as the number of revisions continues to increase. The management of periprosthetic fractures requires careful preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intra-operatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past decade has afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimisation is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The treatment of unstable peri-prosthetic femur fractures can be technically challenging due to the weak non-supportive bone stock. We have seen an increase in the frequency of Type B3 fractures that require complex reconstruction with modular tapers, interlocking implants and proximal femoral replacements. Our reconstructive practice has evolved; the aims of femoral reconstruction include rotational and axial stability of the stem, near normal hip biomechanics and preserving as much femoral bone as possible. The advent of modular prostheses that gain distal fixation but have proximal options has extended the scope of this type of fixation. We now favor modular tapered stems that afford us the opportunity to reconstruct such femora whilst attempting to preserve the proximal bone. In effect, distal cone or taper fixation provides the initial stability required for the procedure to be successful but the proximal modular implant subsequently load shares to decrease stress shielding, distribute stress more evenly through the femur and minimise the risk of stem fracture. Such systems provide the intraoperative versatility that these cases require. The use of interlocking stems with coated ingrowth surfaces offers a relatively appealing solution for some complex fractures and avoids the complications that would be associated with unstable fixation or resection of the proximal femur. Periprosthetic acetabular fractures are also increasingly recognised. This is in part due to the popularity of press fit components, which increase fracture risk both at the time of insertion and later due to medial wall stress shielding and pelvic osteolysis, and partly due to the increasing frequency of severe defects encountered at the time of revision surgery. These can present a very difficult reconstructive challenge and may require porous metal, cup-cage or custom reconstruction. Periprosthetic fractures continue to cause problems worldwide. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilisation if the patient cannot fully weight bear and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues

Purpose: Although blinding of outcome assessors is crucial to minimize bias in clinical trials, the majority of surgical trials do not blind these individuals in part due to practical difficulties inherent in surgical interventions. We devised and tested techniques to blind outcome assessors in trials of femoral neck fracture fixation. Method: We developed three techniques to mask radiographs of femoral neck fractures fixated with cancellous screws or dynamic hip screws: Blackout, Subtraction, and Overlay. 50 orthopaedic trauma surgeons assessed 32 radiographs blinded with each of these techniques. We considered:. The ability to mask the surgeons (the proportion of radiographs in which the surgeons were able to correctly identify the implant and the Bang Blinding Index);. Surgeons’ ability to accurately rate the quality of reduction in blinded images;. Surgeons’ perceptions of difficulties rating the blinded images. Results: All three techniques achieved low proportions of correct identification of cancellous or dynamic screws (14.9% for Blackout, 26.9% for Subtraction, 22.1% for Overlay) and high proportions of “don’t know” responses (72.3%, 48.4%, 52.8% respectively). The Bang Blinding Indices were close to 0 (perfect blinding) for all three techniques (−0.024 to 0.008). The interrater reliability of quality of reduction in the blinded images (ICC = 0.55 – 0.57) was similar to the reliability of the unblinded radiographs (ICC = 0.60). Surgeons perceived the Overlay images as much more difficult to rate in 6.9% of radiographs, compared with 9.7% of Subtraction images (p=0.25) and 28.0% of Blackout images (p< 0.001). Conclusion: Three techniques of blinding radiographs of femoral neck fractures successfully mask surgeons to the type of implant fixated, do not compromise reliability of reduction ratings, and do not make the rating process substantially more difficult. Trialists should explore creative approaches such as these to blind as many individuals as possible when designing trials, and should incorporate rigorous approaches to testing the success of blinding

Aims: Published series of traditional plate þxation of the femur note rates of up to 69% primary bone grafting, 13% infection, 15% nonunion, 68% late complications, and 25% secondary surgical procedures. A shift from traditional plating to submuscular plating has thus ensued. This series entails an all-inclusive review of the plate þxation experience by two orthopaedic trauma surgeons in a þve-year period at a university trauma center. Methods: Between June 1996 and May 2001, 40 acute diaphyseal femoral fractures in 37 patients were managed utilizing dynamic compression plating via traditional Ç biological È plating with a formal lateral incision (n = 19), or submuscular plate þxation utilizing only a proximal and distal incision (n = 21). A comparison of reduction quality, union rates, and infection rates between traditional plate þxation and submuscular þxation was performed. Results: Thirty-nine of forty femoral shaft fractures healed without need of a secondary procedure. One nonunion occurred in the ORIF group. There was one infection in each group. Two patients treated by submuscular þxation developed signiþcant heterotopic ossiþcation around the femoral shaft which signiþcantly impaired knee motion. There were 6 cases of malreduction in the submuscular group, and none in the ORIF Group. Conclusions: Although the theoretical advantages of submuscular plating are well established, its utilization in the femoral shaft did not have a clear clinical advantage. In addition, its use appears to be more technically challenging, and is associated with a high rate of sub-optimal reductions

Aims

Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

Supracondylar femoral fractures challenge even the most experienced trauma surgeon. Fracture comminution often extends into the articular surface, increasing the risk of joint stiffness and post-traumatic arthritis. This is a preliminary prospective report of 42 supracondylar femoral nailing procedures performed on 41 patients between July 2000 and March 2001. The mean age of the 21 women and 20 men was 62 years. Five fractures were compound. Classified according to AO classification, there were 28 type-AIII fractures, 10 type-AII, two type-CIII and two type-CII. In all cases a percutaneous surgical technique was used and a 13-mm x 250-mm supracondylar nail inserted. The mean operative time was 70 minutes. Mean follow-up was four months (2 to 10). There were no deep or superficial infections and no implant failures. Twenty fractures healed with no shortening within four months. The mean flexion arc was 105° (5° to 130°). Eight patients with osteoporosis had 1 cm to 2 cm of shortening, which did not affect functional outcome. Of the 20 patients whose fractures united, 17 had no pain and three had mild anterior knee pain. A single patient had 8° of valgus angulation at the fracture site. This study shows that supracondylar femoral nailing provides improved fracture stabilisation both in elderly patients with osteoporotic metaphyseal bone and in younger patients with extensively comminuted fractures. Percutaneous techniques eliminate the need for extensive surgical dissection, shorten operation times and reduce blood loss

The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by intramedullary fixation. The radiographs were selected from a database to represent fractures at various stages of healing. For each radiograph, the surgeon scored the degree of union, quantified the number of cortices bridged by callus or with a visible fracture line, described the extent and quality of the callus, and provided an overall rating of healing. The interobserver chance-corrected agreement using a quadratically weighted kappa (κ) statistic in which values of 0.61 to 0.80 represented substantial agreement were as follows: radiological union scale (κ = 0.60); number of cortices bridged by callus (κ = 0.75); number of cortices with a visible fracture line (κ = 0.70); the extent of the callus (κ = 0.57); and general impression of fracture healing (κ = 0.67). The intraobserver agreement of the overall impression of healing (κ = 0.89) and the number of cortices bridged by callus (κ = 0.82) or with a visible fracture line (κ = 0.83) was almost perfect. There are no validated scales which allow surgeons to grade fracture healing radiologically. Among those examined, the number of cortices bridged by bone appears to be a reliable, and easily measured radiological variable to assess the healing of fractures after intramedullary fixation

Background: The interpretation of safety data from clinical studies such as complication risks requires clear definition of targeted and documented complication events. In addition a standardized classification of complications is required to allow appropriate comparison of safety data between studies and treatment groups. This presentation highlights a proposal for a standardized management and classification of complication data to initiate and seek consensus among trauma surgeons active in clinical documentation and research. Methods: Complication events are examined regarding their timing of occurrence as well as their potential causal inter-relationship for any given patient. While independent events are numbered sequentially, directly associated events (e.g. a fracture collapse and implant screw perforation into a joint) receives the same complication number. Complications are described and categorized according to a pre-defined list of anticipated complication types, or as un-anticipated complications. They are further classified as local or general; local complications occur at or directly around the injuries and are further classified as being “Implant/Surgical procedure”, “Bone/Fracture” or “Soft tissue/Wound” events. Information regarding their operative and/or non-operative treatment and their outcome is recorded. Further assessments are made regarding their seriousness, their relation to the implant used. Final classification of complication events is better determined after independent review by a panel of experienced clinicians. Results: Our classification process was applied successfully to a series of clinical studies at our department. In a study of 185 distal radius fractures treated by LCP, at least one complication occurred in 21 patients, and in seven cases there was a combination of associated events (e.g. one CTS with tendon rupture). Complication risks ranging from 0% to 11.4% were noted depending on which complications and time frames were considered. There was no risk to obtain a LCP implant specific related complication, whereas the risk for a local complication within 6 months after surgery was 6% (95% CI: 3% – 11%). Conclusions: This management and classification system proved valuable in the documentation and analysis of safety data from clinical studies. It facilitates communication and understanding of definitions between clinicians, as well as allows a prompt, standardised and accurate analysis and reporting of complication events and risks. We encourage other clinical researchers and professionals to participate in the further development and acceptance of a universal classification system for complications in traumatology and orthopaedics

Summary. The ankle X-ray has moderate diagnostic power to identify syndesmotic instability, showing large sensitivity ranges between observers. Classification systems and radiographic measurements showed moderate to high interobserver agreement, with extended classifications performing worse. Introduction. There is no consensus regarding the diagnosis and treatment of ankle fractures with respect to syndesmotic injury. The diagnosis of syndesmotic injury is currently based on intraoperative findings. Surgical indication is mainly made by ankle X-ray assessment, by several classification systems and radiographic measurements. Misdiagnosis of the injury results in suboptimal treatment, which may lead to chronic complaints, like instability and osteoarthritis. This study investigates the diagnostic power and interobserver agreement of three classification methods and radiographic measures, currently used to assess X-ankles and to identify syndesmotic injury. Patients and Methods. Twenty patients (43.2 ± 15.3yrs) with an ankle fracture, indicated for surgery, were prospectively included. All patients received a preoperative ankle X-ray, which was assessed by several observers: two orthopaedic surgeons, one trauma surgeon and two radiologists. The ankle X-ray was assessed on syndesmotic injury/stability and presence of fractures (fibula, medial/tertius malleolus). Three classification systems were used: Weber, AO-Müller (short-version n=3 options; extended-version n=27 options), Lauge-Hansen (short-version n=5 options; extended-version n=17 options) and two radiographic measurements were done: tibiofibular overlap (TFO) and ratio medial clearspace/superior clear space (MCS/SCS). All observers were instructed about the assessments before the measurements. During surgery, a proper intraoperative description of the syndesmosis was noted. Agreement (%), Intraclass Correlation Coefficients (ICC) and Kappa were calculated to determine interobserver agreement. Kappa statistic was interpreted according to Landis and Koch. To test the diagnostic power of ankle X-rays to identify syndesmotic instability, sensitivity and specificity were calculated with intraoperative findings serving as golden standard. Results. Six of 20 ankles showed syndesmotic instability intraoperatively. An overall sensitivity of 43% (specificity: 78) was found for X-rays in identifying syndesmotic instability, showing a wide range in sensitivity between observers (17–83%), with radiologists performing better (range 50–83%) than surgeons (range: 17–33%). Overall, substantial to perfect interobserver agreement (range 70–100%) was found for all short classification systems, showing an average kappa ≥0.60. The agreement reduced for more extended classification systems. E.g. observer agreement for the AO-Muller classification with 3, 9 and 27 options was respectively 85% (kappa 0.66), 68% (kappa 0.57) and 55% (kappa 0.51). One observer deviated slightly from others in all classification assessments. Removing this observer resulted in excellent agreement for all classification systems (>90%). Radiographic measurements showed moderate to high interobserver agreement, with TFO performing best (avg. ICC 0.88). Discussion/Conclusion. In ankle fractures, a preoperative X-ray has low sensitivity in detecting syndesmotic instability, showing large sensitivity ranges between observers. Further study is needed to investigate the contribution of classification systems in determining the best treatment method for syndesmotic injury. Ankle X-ray assessment using the three classification systems and radiographic measures was consistent among observers. Disagreement between observers can be attributed to intrinsic differences among the systems (e.g. stepwise classification vs. single assessment). No preference for one specific classification was found, as all showed comparable interobserver agreement. However classification systems with few options are recommended, as the observer agreement reduced with more extending classifications

Introduction: The treatment of Complex Proximal Humeral Fractures and Fractures associated with Dislocation is not still resolved. Internal Fixation sometimes is not possible due to comminuted and osteoporotic bone which is commonly found in this kind of Fractures. The use of Hemiarthroplasty in this situation, not always achieves a good functional outcome, usually related to a Non Union or Malunion of the Tuberosities. We began using Reversed Shoulder Arthroplasty in this Fractures due to good results this implant had had in Glenohumeral Arthritis associated a Rotator Cuff Deficiency. Material and Methods: From January 2004 to December 2008 we have treated 50 patients with Complex Proximal Humeral Fractures with a Reversed Shoulder Arthroplasty,38 were women and 12 were men with a mean age of 76 (38–84). The mean follow-up time was 20 months (10–36). We have used a Lima Reversed Arthroplasty in all the cases. The dominant arm were involved in 65 % of the patients. The Deltopectoral approach were used in all the cases. Thirty-five patients (70 %) were treated in less than 30 days after the fracture and 15 (30 %) were treated 30 days or more since the fracture happened. The operations were performed by 6 surgeons, but only 3 of them have performed more than 10 operations. We used the Constant Score and the American Shoulder and Elbow Score to evaluate the outcome of the implant. The preoperative movement were estimated on the mobility score of the contralateral shoulder. Results: The mean Constant and the mean modified Constant Score were 55 (23 to 73) and 70 (34 to 95). The average range of motion was 105 (45–140) for anterior elevation and 100 (35–125) for abduction. The mean modified American Shoulder and Elbow Surgeon was 64 (44–82). The average operation time was 105 minutes with a range (60–170). The main clinical complications has been: Three intraoperative Fractures of Glenoid, 2 post operative Glenoid Fractures, 2 Brachial Plexus Paralysis, 2 cases of Cubital Neuroapraxia, 2 Dislocations of the Prosthesis,2 superficial infections and 1 deep infection. Radiography it has been found Scapular Notch in 17 patients (34%), Periprothesic Calcification in 42 (84 %) and migration of the Tuberosities in 22 (44%). Conclusions: We have had better results in acute situations than chronics ones. Most of the complications occurs in the group of patients treated in more than 30 days since the Fracture has happened. The Reverse Shoulder Arthroplasty is an alternative to the Hemiarthroplasty, and an important tool which an Orthopaedic Trauma Surgeon has to consider, to resolve this kind of Fractures specially in elderly patients

Introduction. Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral centre in Ireland. Methods. We identified all patients who were ten years following open reduction and internal fixation of an acetbular fracture in our centre. We invited all of these patients to attend the hospital for clinical and radiographic follow-up. As part of this, three scoring systems were completed for each patient; the Short-form 36 health survey (SF36), the Merle d'Aubigné score and the Short Musculoskeletal Functional Assessment (SMFA). Results. The data represents one year's activity at a new tertiary referral unit. We identified a total of 44 patients who were ten years following ORIF of acetabular fractures in our unit. 21 patients (48%) replied to written invitation and attended the hospital for clinical and radiographic follow-up. A further 7 patients were contacted by telephone and interviewed to gauge their rehabilitation. 3 patients had passed away. The remaining 13 patients were not contactable. Of those who attended in person for follow-up; 18 were male and 3 were female. The mean age at follow-up was 40.5 years (Range 27-60). In terms of fracture pattern epidemiology, 43% of patients sustained posterior column and wall fractures, 29% posterior wall, 14% posterior column alone, 9.5% transverse with posterior wall and 9.5% bicolumnar. 2 patients in the follow-up group had total hip replacements. Of the remaining patients the overall mean SF36 score was 78.8% (SD 16.4). The mean SMFA was 14.1% (SD 5). The mean Merle d'Aubigné score was 14.9 (SD 3.2) with 63% graded as good or excellent. Comparison of outcome between sub-groups according to fracture classification showed no significant difference. Traumatic sciatic nerve injury was sustained by four patients in the follow-up group and all patients continued to complain of ongoing weakness. Of the patients who were contacted via telephone, 2 had total hip replacements. The remaining 5 reported no significant problems with their hips and cited this as the reason for not attending follow-up. Conclusion. Overall the outcome of the patients was more favourable than expected. This was supported by the results of the clinical scoring systems. In some patients this also appeared to be despite poor radiographic findings. Our observations suggest that concomitant injuries, especially sciatic nerve injury have a profound negative influence on the patients' ability to fully rehabilitate. These data provide a valuable tool for the trauma surgeon in providing the patient with an educated prognosis

Introduction. Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral Centre in Ireland. Methods. We identified all patients who were ten years following open reduction and internal fixation of an acetbular fracture in our centre. We invited all of these patients to attend the hospital for clinical and radiographic follow-up. As part of this, three scoring systems were completed for each patient; the Short-form 36 health survey (SF36), the Merle d'Aubigné score and the Short Musculoskeletal Functional Assessment (SMFA). Results. The data represents one years activity at a new tertiary referral unit. We idenfied a total of 44 patients who were ten years following ORIF of acetabular fractures in our unit. 21 patients (48%) replied to written invitation and attended the hospital for clinical and radiographic follow-up. A further 7 patients were contacted by telephone and interviewed to guage their rehabilitation. 3 patients had passed away. The remaining 13 patients were not contactable. Of those who attended in person for follow-up; 18 were male and 3 were female. The mean age at follow-up was 40.5 years (Range 27-60). In terms of fracture pattern epidemiology, 43% of patients sustained posterior column and wall fractures, 29% posterior wall, 14% posterior column alone, 9.5% transverse with posterior wall and 9.5% bicolumnar. 2 patients in the follow-up group had total hip replacements. Of the remaining patients the overall mean SF36 score was 78.8% (SD 16.4). The mean SMFA was 14.1% (SD 5). The mean Merle d'Aubigné score was 14.9 (SD 3.2) with 63% graded as good or excellent. Comparison of outcome between sub-groups according to fracture clasification showed no significant difference. Traumatic sciatic nerve injury was sustained by four patients in the follow-up group and all patients continued to complain of ongoing weakness. Of the patients who were contacted via telephone, 2 had total hip replacements. The remaining 5 reported no significant problems with their hips and cited this as the reason for not attending follow-up. Conclusion. Overall the outcome of the patients was more favourable than expected. This was supported by the results of the clinical scoring systems. In some patients this also appeared to be despite poor radiographic findings. Our observations suggest that concomitant injuries, especially sciatic nerve injury have a profound negative influence on the patients' ability to fully rehabilitate. These data provide a valuable tool for the trauma surgeon in providing the patient with an educated prognosis

Displaced proximal humeral fractures are notoriously difficult to treat. We performed internal fixation of 55 such fractures with the Polarus locked intramedullary nail. 43 (78%) were women; the mean age was 74 (range 15–91). The mechanism of injury was RTA in four, sporting injury in a further four and a simple fall in 47 (85%). According to Neer’s classification, 25 were two part fractures, 20 three part and 10 four part. 47 fractures were fixed acutely (within seven days). The average operative time, including patient positioning was 60 minutes. In 43 cases the standard size nail was used (11mm diameter, 150mm length). In the majority of cases (80%) either two or three proximal locking screws were used. In 15 cases (27%) open reduction was necessary. Patients were followed up for an average of eight months. Three patients needed removal of backed out proximal screws under local anaesthetic. In one patient the nail migrated superiorly and was removed once the fracture had united. One patient developed symptomatic avascular necrosis of the humeral head, successfully treated by removing the proximal screws. Two patients developed fracture malunion and underwent conversion to hemiarthroplasty. One patient required arthroscopic release of a secondary frozen shoulder. Patients completed an Oxford Shoulder questionnaire at an average of 18 months postoperatively (range 5–42 months). The median Oxford Shoulder score was 33 (95% CI 25–38) with a mean score of 34.6. Previous studies of Polarus nailing have reported satisfactory results, but with limited follow up of a small number of patients. Our study of 55 cases with an average 18 month follow up confirms good functional rapid recovery in the majority of patients. Only five patients required removal of the metalwork and only two patients required conversion to hemiarthroplasty. We recommend the Polarus nail as a useful addition to the shoulder trauma surgeon’s armamentarium

Objectives: tibial plateau fractures are a therapeutic challenge for the trauma surgeon. Arthroscopically assisted surgical treatment (AT) is an option in these fractures that is used more and more frequently even in more complex lesions. The objective of this study is to determine if, at a minimum 1 year follow up, arthroscopic treatment is comparable to open treatment (OT) in respect to radiologic and functional outcomes. Materials and Methods: We have prospectively reviewed our first 50 arthroscopic cases and compared them with 50 open surgery cases examined retrospectively. The cases in the second group were selected from a database of 87 patients and were matched for Schätzker type, degree of displacement, age and sex with cases of the first group. In each group there were 50 patients (33 male/17 female; mean age: 45,4 years in the AT group and 43,6 years in the OT group). Of the 50 cases in each group, ten were Schätzker I tibial plateau fractures, sixteen were type II, seven type III, eleven type IV, three type V and three type VI. In the AT group all fractures were reduced and fixated with cannulated screws under direct arthroscopic control and in 6 cases a percutaneous plate was added. In the OT group all fractures were reduced and fixated with cannulated screws under direct vision (n=41) or radiologic control (n=9) and in 37 cases a plate was added. Associated lesions were identified and treated accordingly in both groups. Results were evaluated with the following scales: Rasmussen, Honkonen, ICDK, Lysholm, SF-36 and Knee Society scores. Results: All cases were available for follow up a minimum of 12 months after surgery (2.6 +/−1.4 years in AT and 3.7+/−1.5 years in OC). The patients in the AT group had lower hospital stances (p< 0.05) and lesser postoperative wound complications (zero versus 3). Radiological reduction and alignment was considered excellent or good in 92% of AT cases and 88% of OT cases. Knee society scores were 191+/−18 in AT and 176+/−21 in OT. Lysholm scale scores were 85+/−20 in AT and 72+/−21 in OT. Rasmussen scale scores were 29+/−2.2 in AT and 26+/−3.9 in OT. Most of the differences between both groups was related to range of motion but pain scores were similar. Conclusions: Arthroscopically assisted treatment of tibial plateau fractures seems to offer better results than open surgery with less hospital stay, lesser postoperative complications and clearly improved range of motion. It can be considered an adequate alternative to traditional open reduction and fixation even in complex fractures

Introduction A complex challenge to trauma surgeon is the choice of clinical pathway management in hemodynamic unstable patients with pelvic ring disruption and potential intraperitoneal or other extrapelvic hemorrhage. Aim of the study In multi-trauma bleeding patients with pelvic ring injuries causing increased pelvic volume, the main source of hemorrhage is the fracture itself; in biomechanical stable the priority is to search and to treat extrapelvic sources of hemorrhage; CESCT is critical in the selection of appriopriate therapeutic approach in the case of bleeding pelvic injury. Material and Methods Patients admitted as major trauma are immediately evaluated by a multidisciplinary team in a dedicated room where ABC resuscitation, plain radiographs, abdominal ultrasound/DPL may be all performed. The comprehensive Tile pelvic disruption classification combines the mechanism of injury and the degree of pelvic stability. Previous works correlated pelvic fracture pattern with the risk of pelvic fracture hemorrhage. Classically, APC and VS mechanisms were associated with pelvic hemorrhage and LC mechanims with abdominal organ injuries. In this work we included in group A patterns of pelvic fracture where increased pelvic volume and major ligamentous disruption (Tile B1, B3 and C or APC and VS), Patterns of pelvic fractures with low risk of bleeding, such as those without ligament lacerations (Tile A) or with reduced pelvic volume (Tile B2 or LC) or isolated acetabular fractures, have been included in group B. Results Between October 2002 and January 2004, significant bleeding was observed in 87 of 142 pelvic fractures (61.26%). Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B. All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p< .001). Conclusion Pattern of pelvic seems to be suggestive of the predominant site of bleeding; early application of measures of temporary pelvic stabilization should be considered a completion of resuscitation protocol; CESCT is the best diagnostic tool to choice the appropriate way to manage bleeding pelvic injuries and associated intraperitoneal injuries; availability of equipped CT scan and angiographic suitesand of short response time interventional radiologist is a crucial point for this diagnostic and therapeutic work-up