Introduction

Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions.

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients.

Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries.

The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836).

Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups.

The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement.

Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36).

In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up.

This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions.

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

Introduction

Clavicle fractures can cause pain and functional impairment if not managed appropriately. This paper evaluates the prevalence of clavicular fractures, estimates number of cases requiring operative treatment, whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative group.

Introduction

Pelvic fractures are indicators of severe trauma and high energy absorption. They are associated with multiple local or distant concomitant injuries, which explain their high mortality and morbidity. The aim of this study is to investigate the late sequel of traumatic-pelvic-fractures (PFX) focusing on quality-of-life and sexual-function.

Introduction

Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario.

Background

The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept.

Objectives

To evaluate management, direct-medical-costs and clinical outcome profile of a large trauma unit with respect to simple elbow dislocations.

Introduction

The aim of this study was to evaluate the health quality of life and return to sports activities following pelvic ring injuries.

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.

Introduction

The aim of this study was to investigate the differences between open vs closed femoral fractures with regard to the epidemiology, classification and outcome.

Introduction

Grade IIIa/b open tibial fractures (OTF) result mostly following high energy trauma and may be accompanied by significant associated injuries. Aim of this study was to compare the characteristics and the outcome of OTF between patients of different injury severities.

Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting. The efficacy of BMP-7 in the treatment of recalcitrant aseptic femoral non-unions was studied.

Since 2003 a multicenter registry (bmpusergroup.co.uk) was created collecting details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.

Seventeen patients, who had undergone a median of 1(1 to 4) prior revision operations, over a median period from the injury of 17 months(9 to 42), were included in this observational study. In 76.4%(13/17) the BMP7 was combined with revision of the fixation. Non-union healing was verified in 14/17 cases(82.3%) in a median period of 6.5 months(3–15). Over 80% of these patients returned to their pre-injury level of activities, the median overall health state score was 82.5(35 to 100). No adverse events or complications were associated with the BMP7 application over the median follow-up of 24 months(12–68).

The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.

Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the EuroQol-5D questionnaire were documented over a median period of follow-up of 40 months (12–206).

Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5 years (16–80). Half of them were posterior-wall fractures, 21.6% bicolumn, 14.7 %posterior-wall and column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.

Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome

Anterior wall and/or column acetabular fractures (AW/ C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre.

Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64).

15 patients (10 males) met the inclusion criteria (mean age 55.5 years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14 days(10–21 days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7 days), and 21 days(14–37 days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis.

Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favourable outcome resulting in early mobilization with limited patient morbidity

To evaluate the effectiveness of Pulsed-Lavage and of Versajet-hydrosurgery in removing two Staphylococcus aureus strains from porcine tissue and graphite powder from simulated fractures.

Overnight broth cultures (NCTC-6571) and S.aureus strains were diluted to yield inocula containing 1x103c. f.u. ml-1. Initially 8 porcine legs were used; porcine tissues were inoculated with 10ml of either of the two S.aureus strains. Control tissues were inoculated with PBS. All inoculated samples were irrigated with 300ml of saline using the pulsed-lavage system or using the Versajet. 10ml of each of the following were plated out in triplicate:

inoculum pre-incubation

Eight additional porcine legs were used where 2 incisions were made down to bone in a cross-hatch pattern. 1g of graphite powder was infiltrated into each fracture site to simulate a contaminated open fracture. Each fracture site was irrigated with 500ml saline through pulsed-lavage or Versajet.

The average microbiological reduction using Pulsed-Lavage or Versajet was 2% and 15% respectively. The clinical S.aureus strain was more adherent than the laboratory strain. The Versajet maintained a 12–16% reduction of S.aureus, whereas pulsed-lavage did not reduce contamination. The number of graphite particles was significantly reduced with the use of the Versajet system compared with the pulsed-lavage.

Versajet system was more effective in removal of foreign particles and more effectively reduced the micro-biological load of both examined S.aureus strains in a porcine model. Further studies are indicated to evaluate the efficacy of this system in clinical practice

Purpose: The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.

Patients & Methods: Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the Euro-Qol-5D questionnaire were documented over a median period of follow-up of 40months (12–206).

Results: Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5years (16–80). Half of them were posterior-wall fractures, 21.6% both column, 14.7% posterior-wall and posterior-column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intraoperative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At final follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.

Discussion/Conclusion: Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome.

The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing.

22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group.

The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay > 5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03).

Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process.

Purpose: Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting procedures. The purpose of this study was to investigate the efficacy of BMP-7 (biological enhancement) in the treatment of recalcitrant aseptic femoral non-unions.

Material & Methods: Since 2003 a multicenter registry (bmpusergroup.co.uk) was created to collect details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.

Results: Thirty patients, who had undergone a median of 1 (1 to 5) prior revision operations, over a median period from the injury of 24 months (9 to 65), were included in this observational study. In 76.7% (23/30) the application of BMP7 was combined with a revision of the fixation. Non-union was verified in 26/30 cases (86.7%) in a median period of 6 months (range 4–10). Over 70% of these patients returned to their preinjury level of activities, the median overall health state score was 82.5 (45 to 95). No adverse events or complications were associated with the BMP7 application over the median follow-up of 30 months (12–68).

Discussion/Conclusion: This case series has verified the safety and efficacy of the use of BMP7 in a manner comparable to the scarce existing evidence on femoral non-unions. The establishment of multicenter networks and the systematic and long-term follow-up of these patients are expected to provide further information and significantly improve our understanding on this promising osteoinductive bone substitute.

Introduction: Locking plate technology for fixation of periarticular fractures has been adopted widely since its development. Distal tibial/pilon fractures represent one of the major indications of this method of fixation. The recent development of polyaxial locking systems has offered more versatility to the surgeon.

Patients and Methods: In this cohort prospective study we present our early experience of a new polyaxial locked plating system in the treatment of complex ankle and distal tibial fractures (anatomic locked plating systems– ALPS, DePuy). Demographic, mechanism of injury, AO-OTA classification, surgical procedure, postoperative course, complications, rehabilitation scheme, clinical and radiological healing as well as functional outcome (SF-36, Olerud & Molander Ankle Score, AOFAS Ankle-Hindfoot Scale, VAS pain score) were all recorded over a minimum follow-up period of 9 months.

Results: Between July 2008 and July 2009, there were 21 patients with complex ankle and distal tibial fractures who were treated with this method of fixation. There were 16 males and 5 females. The mean age was 42.9 years (16–90). All female patients were over 60 years. The majority of these injuries were related to falls or RTAs (11 and 8 cases respectively). The mean time from injury to operation was 5 days (range 1 to 14 days), and in the majority of these cases a temporary bridging external fixator was applied (in 17/21 cases). All injuries were closed fractures. There were 11 patients with 43-A, 5 with 43-B, 5 with 43-C. Fractures were treated with a choice of medial ALPS tibial plate (12 patients), anterolateral ALPS tibial plate (9 patients). There were 8 associated distal fibular fractures, which were also fixed with a plate. The mean length of stay was 8 days (range 4 to 27 days). One patient had to be converted to a circular external fixator due to local deep sepsis, while two other patients had local wound healing problems managed without implant removal. The overall healing rate was over 95%, with one case of non-union at 9 months. Fifteen of them have returned to their work, while the recorded functional scores at the last follow-up visit were good in the majority.

Conclusions: The overall clinical and functional outcome of this cohort of patients over the short-term follow-up was recorded to be comparable to existing similar case series of open reduction internal fixation of pilon fractures. The surgical advantages of the new system lie in its versatility, and short learning curve.

Introduction: Anterior wall and/or column acetabular fractures (AW/C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre.

Methods: Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64).

Results: 15 patients (10 males) met the inclusion criteria (mean age 55.5years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14days(10–21days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7days), and 21days(14–37days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis.

Conclusion: Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favorable outcome resulting in early mobilization with limited patient morbidity.

Purpose: The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.

Patients and Methods: Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the Euro-Qol-5D questionnaire were documented over a median period of follow-up of 40months (12–206).

Results: Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5years (16–80). Half of them were posterior-wall fractures, 21.6%bicolumn, 14.7%posterior-wall and column, 6.8%transverse, 5.7%anterior-column, 1.1%anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.

Conclusion: Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome

Our aim was to assess the outcome of the treatment of Segmental fracture of the humerus in adult patients.

From January 1994 to December 2003, 24 (17 females) consecutive adult patients with segmental humeral fractures were treated in our unit. Segmental fracture was defined as a two-level humeral fracture with at least one intermediate segment (AO type 12C). The mean age of the patients was 56.5 years(range 29–95) and the mean ISS was 14.1(range 9–29). The causes of injury included 8 vehicular accidents, 15 falls from heights, and 1 skiing injury. Thirteen patients had associated injuries. Three fractures were open (1 grade II, and 2 grade IIIA). At final follow up all patients were assessed in terms of radiological result and functional capacity (range of motion).

The mean follow up was 36 months (range 24–60). There were 5 radial nerve palsies. Seven cases involved 4 fracture segments. The mean length of segment was 7 cm (range 5–16). All fractures but 5(20.8%) progressed to union (1 infected non-union, 1 hypertrophic after ex-fix, 1 atrophic after stabilization with rush pins, one was associated with failure of fixation proximally and required hemiarthroplasty). The mean number of procedures to achieve union in total was 1.6(range 1–3). There was one implant failure and one persistent non-union. At final follow up, the mean abduction was 1100 (900–1400) and the mean forward flexion was 1200 (1000–1500). Internal external rotation was 700 (50–90) and 250 (20–45).

The risk of non-union is as high as 20.8 % and additional procedures often required to achieve union of the fragments. The method of stabilization depends on several factors including fracture configuration, the available bone stock and the surgeons’ expertise. Despite the severity of this injury a satisfactory outcome can be expected.

We investigated whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable. Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LC I injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries.

All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement > 2 cm of the anterior or posterior elements. The minimum follow up was 12 months.

Of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LC1 type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retro-pubic screws, external fixator or plating anteriorly. 17 patients (group 2) exhibited minimal displacement less than 5mm and were not stabilised. Rotational instability > 2cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 hours from surgery, early ambulation and discharge from the hospital.

This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision making progress.

The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months).

Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases).

In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded.

The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients.

A study to evaluate the efficacy of combined grafting (iliac crest autograft – ICAG, and human recombinant osteogenic protein 1 – rhOP1/BMP7) for long bone fracture non-unions (LBFNUs).

At both institutions prospective and retrospective data were collected. (Between Oct 2001 and Aug 2004 all LBFNUs that were grafted with a combination of BMP7 and ICAG). The records of the initial injury incident, treatment course, all operative interventions before and after the combined grafting and the follow up till final clinical & radiological union have been analysed. X2 test was used to analyse the results.

Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBFNUs were identified. The mean follow-up was 21.4 months (12–65). 7 were humeral, 13 femoral, and 29 tibial LBFNUs. Eleven were open (3 grade II, 8 grade IIIa–b). All non-unions were atrophic, and 8 had significant bone defects. The mean number of operations prior to the combined grafting was 2.5 (0–6). Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. All of the fractures united. One patient, with an infected tibial non-union after an open fracture, ultimately underwent a below knee amputation. No complications or adverse effects from the use of BMP-7 were encountered.

BMP-7 was used as a bone-stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBFNUs. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

The purpose of this study was to evaluate the efficacy of autologous cancellous bone grafting (ABG) for the treatment of long bone fracture non-unions. Patients who were treated with ABG for fracture non-unions of the lower extremities were identified from our prospectively entered database. Non-union was defined as failure of the fracture to unite within a period of 9 months. Demographics, comorbidities, medications, complications and surgical outcomes were all recorded and subsequently analysed. Chi square test was used to analyse the results.

In total 82(54 male) patients met the inclusion criteria. The mean age was 43.6 years (range 18–78). Ten patients were diagnosed with femoral and 72 with tibial fracture non-unions. Fifty three (64.6%) were open fractures at presentation. In the tibial non-union group, initially, 67 fractures were stabilised with IM nailing and 5 with plating. During revision surgery, 33 patients underwent exchanged nailing and ABG whereas 34 received ABG without revision of the metal work.

All five tibial plantings required re-plating and ABG. In the femoral non-union group, five fractures were initially stabilised with IM nailing and the rest with plating. During revision surgery, six patients underwent change of fixation (exchange nailing) and ABG and four received only ABG. Overall 73/82 patients progress uneventfully to union and the success rate was 89%. A second and a third attempt of ABG was made for 6/86 patients (7.31%) and 2/82 patients (2.44%) respectively, till clinical and radiological union. All but one of the patients united their fractures. One patient underwent amputation due to underlying osteomyelitis.

The mean time to union following the ABG procedures was 8.4 months (range 3–18). Autologous bone grafting is an effective method of treating fracture non-unions. Success rates of as high as 89% can be achieved as seen in this series of patients.

We aim to define the role of pelvic fractures (PFx) due to falls, in auditing Trauma Care. We present a retrospective case-control study, based on autopsy. Univariate analysis was used to identify factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships.

Of 970 patients who sustained a fatal fall, 209 (21.5%) constituted the PFx-group, and the remaining 761 the control-group. The PFx-group had a median age of 55 years (15–96), while the control 66 years (1–99). The multivariate analysis revealed that gender, age, intention, and height of fall were risk factors for PFx after a fall. An approximately 300% higher odds of suffering a psychiatric history was found in the PFx-group, (p< 0.001).

The median ISS of the PFx-group was 50(17–75), and was significant higher than the 26(1–75) of the control-group, (p< 0.0001). The “potentially-preventable” deaths (ISS< 75) constituted 78%, while the “non-preventable” 22%.

The most common AIS 3–5 injuries in the “potentially-preventable” deaths were located in the: lower extremities 133(81.6%), thorax 130(79.7%), abdominal and pelvic contents 99(60.7%), head 95(58.3%) and the spine 26(15.9%) of the patients. A subset of 126 (60.3%) “potentially-preventable” deaths of the PFx-group had at least one AIS-90 code other than the PFx denoting major hemorrhage. Deaths directly attributed to pelvic fractures were limited to 6 (2.9%).

The post-traumatic median survival-time for the PFx-group was 30 minutes, while for the control group 20 hours and 15 min. For one group increment in the range of ISS-groups, the probability of post-traumatic survival rate was reduced by 57% (p< 0.0001). Multiplicity, severity and the short posttraumatic survival time in the PFx group render PFx an index-injury for audit of polytrauma.

A reproducible method of autopsy-data analysis was outlined. Pelvic fracture is a paradigm of injury that selected an index-population among 970 fatal falls and an appropriate basis to construct a template for evaluation of trauma & polytrauma care.

Our aim was to investigate the incidence and outcome of chest injuries after blunt trauma in patients admitted in a level I trauma centre over a 6-year period. This is a review of prospectively collected data (1996–2002); part of the (TARN-UK) data. Patients divided in 6 subgroups based on the chest AIS. Univariate analysis identified factors predicting mortality and a backward stepwise logistic regression multivariate analysis determined relationships with outcome.

There were 1,164 patients with chest injuries. The mean overall severity of chest injuries was 3.15+/−1.01. The commonest mechanism of injury was RTAs (57.01%). Rib fractures were the most common injuries (395 patients, 34%) associated with lung contusions in 12.9%. Admission GCS was highest in chest-AIS subgroup 2 and was significantly higher in groups 1 and 3. Complications, invasive operations, and investigations were more common with increasing chest-AIS. The ICU-admissions and the mean length-of-stay were similar for chest-AIS1 and 2, but significantly higher for the rest. Half of the AIS1 patients had associated head injuries; the lowest percentage was in subgroup 2 (18.8%). There was a variable correlation of abdominal injury severity with severity of chest injury. There was a significant difference in mortality rates between group 2 and group 1 and -3. The average time to death in those with chest-AIS1 was significantly lower than the average time in those with AIS4 and 5.

Patients in the higher AIS groups had both a higher overall ISS and mortality rate. Minimal chest injury severity (AIS1) showed higher ISS and significantly higher mortality compared with chest-AIS2,3. This has been attributed to the fact that the chest is spare as most of the impact during the course of the accident is been absorbed by the head (head injury). This theory also explains the shorter time period of death seen in patients belonging to the chest AIS1 group.

In order to assess the effect of osteoporosis on healing time we retrospectively reviewed the files of 165 patients with femoral shaft fractures that were treated in our service by locked, intramedullary nailing. Patients were divided in two age groups; Group A (study group) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (control group) of patients between 18 and 40 years old with no signs of osteoporosis.

Sixty-six out of 165 patients fulfilled the inclusion criteria for this study. Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co morbidities were excluded. Twenty-nine patients were classified in group A and 37 in group B. All patients had been assigned the Injury Severity Score (ISS) and had been followed-up clinically and radiographically until fracture union.

In all patients the Singh Index Score for osteoporosis was assigned. In all group A patients Singh score 4 or less was assigned, suggesting the presence of installed osteoporosis, whereas group B patients were assigned with Sighn score 5 or 6. Fracture healing was significantly different between the groups.

Fractures of Group A healed in 19.38±5.9 weeks (12–30) and in group B 16.19±5.07 weeks (10–28) (P=0.02) Fracture healing of nailed femoral diaphyseal fractures significantly delays in older osteoporotic patients. Further studies are mandatory to clarify the exact impact of osteoporosis in the whole healing process and the possible future therapeutic strategies.

Aim: To evaluate the effect of fasciotomies following compartment syndrome on the healing of closed tibia diaphyseal fractures.

Patients and Methods: Between January 2002 and January 2005 165 patients were treated in our institution with closed tibial diaphyseal fractures. Patients were divided in to two groups; Group A (study group) consisted of patients that, after surgery, developed compartment syndrome and were submitted to fasciotomies and group B (control group) of patients who underwent reamed IM nailing and did not require such intervention. Patients with open fractures, pathological fractures, revision surgery, severe brain injuries, prolonged ITU stay and severe co-morbidities were excluded. Fracture pattern, ISS score, smoking habits, drugs intake, mode of mobilization and additional procedures were prospectively documented. Fracture healing more than 24 weeks was defined as delayed union and over 36 weeks as non-union. All patients had been followed-up clinically and radiologically until fracture union.

Results: One hundred twenty five out of 165 patients fulfilled the inclusion criteria for this study. 30 patients were classified in group A and 95 in group B. 18 patients of group A required skin graft coverage after the fasciotomies. There was no difference between the two groups in terms of the studied parameters. 4 patients from group A and 1 from group B, went to non-union and required second procedures to achieve union. These patients were excluded from the final analysis. Delayed union occurred in 11(percentage) patients in group A and in 10 (percentage) patients in group B (P< 0.05). Overall, fracture healing was prolonged in the fasciotomy group but the difference was not statistical significant, 24.27 weeks (10 – 48) versus 22.19 (12 – 40), (P= 0.157) in group A and group B respectively.

Conclusions: Compartment syndrome and fasciotomies is associated with delayed fracture healing. Nevertheless, this delay was not statistically significant different.

Purpose: Proximal tibia fractures present a difficult treatment challenge with historically high complication rates. The purpose of this study is to report the clinical outcome of proximal tibial fractures treated with of a variable-axis locking plate.

Patients and Methods: Between 2004 and 2007, 42 patients (23 males) with a mean age of 50 (21–67) with a total of 42 proximal tibia fractures were included in this prospective documented study. Fractures were classified according to the OTA system. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). Besides radiography, CT scanning was obtained for type B and C fractures. Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and time to union were recorded. Functional outcome was measured using the Knee Society Score. Malalingment was defined the presence of more than 5°angulation in any plane at the post-op X-ray and at the final F.U. The mean follow up was 11 months (6–36).

Results: According to the OTA classification, there were 7 41-A, 11 41-B and 24 41-C fractures. There were 6 open and 36 closed fractures. The majority were isolated injuries 38/42. 19 cases required bone grafting. Fractures were treated percutaneously in 30% of the cases (MIPO). Double plating was utilised in 8 cases. All fractures but 2 progressed to union at a mean time of 3.8 months (3–5). The two fractures who failed to unite were complicated by deep sepsis and required further intervention. One patient required fasciotomies for compartment syndrome. Superficial infection was treated successfully with a short course of antibiotics in 2 cases. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was 1 case of lateral joint collapse (more than 10o) in a patient with open bicondylar plateau fracture. The mean Knee society score at the time of final follow-up was 89 points (59 – 100) and the mean functional score was 83 points.

Conclusion: The polyaxial locking plates provided stable fixation of extra-articular and intra-articular proximal tibia fractures and good functional outcomes with a low complication rate. These plates offer more fixation options without an apparent increase in mechanical complications or loss of reduction.

Aim: To investigate whether lateral compression type I injuries of the pelvic ring are inheritably mechanically stable.

Patients and Methods: Between January 2005 to January 2007 all consecutive admissions of a tertiary referral center for pelvic ring reconstruction with a LC I injury pattern were eligible for inclusion. Exclusion criteria were other patterns of pelvic ring injuries. All patients underwent radiological assessment including AP pelvis, inlet/outlet views and CT. Patient demographics, mechanism of injury, other associated injuries, ISS, length of hospitalisation, type of operation, mode of mobilization, preoperative and postoperative visual analogue score pain VAS and follow up until fracture union were prospectively documented. Mechanical stability of the pelvic ring was assessed in the operating theatre under general anaesthesia. Instability was defined as displacement > 2 cm of the anterior or posterior elements. The minimum follow up was 12 months.

Results: Out of 210 patients admitted with pelvic fractures, 40 fulfilled the inclusion criteria (LC1 type). There were 23 female 17 male and with a mean age of 33.5 (range 18–68). The mean ISS was 10 (range 9–19). 23 patients (group 1) were found to have more than 2 cm rotational displacement during EUA and were stabilised with SI screws posteriorly and a combination of retropubic screws, external fixator or plating anteriorly. 17 patients (group 2) exhibited minimal displacement less than 5mm and were not stabilised. Rotational instability > 2cm was characterised by complete fracture of the sacrum posteriorly. Stabilisation of the pelvic ring in group I was associated with a significant reduction of the VAS within 72 hours from surgery, early ambulation and discharge from the hospital.

Conclusion: This study supports the view that not all LCI fracture patterns are mechanically stable. Examination under anaesthesia of the pelvic ring can assist the clinician in the decision making progress.

Purpose: To evaluate the effect of osteoporosis on healing time of long bone fractures.

Methods: Between January 2002 to January 2004 patients with femoral shaft fracture treated in our institution by locked reamed IM nailing were eligible for inclusion in this study. Patients were divided in two age groups; Group A, consisting of patients between 18 and 41 years of age and group B consisting of patients over 65 years old with radiological evidence of osteoporosis. Exclusion criteria were open fractures, pathological fractures, patients with head injuries and patients with systematic inflammatory diseases. In addition to the demographic details such parameters were documented as fracture classification, Injury Severity Score, mode of mobilization, time to clinical and radiological union, complications, and length of hospital stay. In all patients the Singh Index Score for osteoporosis was assigned. Following discharge from the hospital, all patients were followed up at regular intervals for clinical and radiological assessment in the trauma clinics. The minimum follow up was 12 months.

Results: Out of 112 patients, 90 met the inclusion criteria. Group A consisted of 48 and group B of 42 patients. The mean age in group A was 24.5 years (18 – 41) and in group B 78.3 years (65 – 93). The mean ISS was 13.3 (9 – 32) and 9.07 (9–10) respectively, (p> 0.05). According to OTA fracture classification in group A there were 16 type 32A, 19 type 32B and 13 type 32C fractures, whereas in group B there were 25 type 32A, 15 type 32B and 2 type 32C fractures respectively. In 96% of patients in group A, a Singh score of 5 or 6 was assigned, whereas 85.5% of group B patients had a Singh score of 4 or less, indicating the presence of installed osteoporosis. Overall, the incidence of complications was similar among the studied groups. Delayed union occurred in 6 patients of group B and in 1 patient of group A (P=0.113). All fractures eventually progressed to union without further intervention. In group A the mean time to union was 15.73±0.52 weeks (7–22) and in group B 19.45±1.5 weeks (10–52) from surgery (P=0.0156).

Conclusion and Significance: This study indicates that fracture healing of nailed femoral shaft fractures is significantly delayed in older osteoporotic patients. Further studies are mandatory to clarify the exact mechanism of osteoporosis in the fracture healing response and the possible future therapeutic strategies.

Purpose: The aim of this study was to investigate whether growth factors essential for fracture healing are released in the immediate aftermath following fracture and whether reaming of IM cavity causes increased liberation of these autocoids.

Methods: Consecutive adult patients with femoral shaft fractures forming two groups (a group who received unreamed nail (n=10) and a second group who received reamed nail (n=10) were recruited for this study. Peripheral blood samples and samples from the femoral canal before and after reaming and before and after the solid nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor I (IGF-I) Transforming Growth Factor beta 1 (TGF-²1) and BMP-2 levels was measured.

Results: In total 20 patients were studied. The mean age was 38 years (range 20–63). Reaming substantially increased all studied growth factors locally in the femoral canal. VEGF and PDGF were increased after reaming by 111.2% and 115.6% respectively. IGF-1 was increased by 31.5% and TGF-b1 was increased by 54.2%. In the unreamed group the levels of PDGF-BB, VEGF and TGF-²1 were not changed while the levels of IGF-I were decreased by 10%. The levels of these factors in peripheral circulation were not altered despite the technique used. BMP-2 levels during all time points were below the detection limit of the immunoassay.

Conclusion and Significance: This study indicates that reaming of IM Canal is associated with increased liberation of growth factors. The osteogenic effect of reaming could be secondary not only to grafting debris but also to the increased liberation of these molecules.

Purpose: To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock.

Methods: Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively.

Results: Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14–70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, and 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6–50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience.

Conclusion and Significance: Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present.

Purpose: To estimate and compare the direct medical cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7.

Methods: Patients who were successfully treated for fracture non-unions between 2001 and 2005 were enrolled. Exclusion criteria included a diagnosis of an infected nonunion, children, malignancy, or chronic debilitating disease. The decision to use BMP-7 or autogenous bone graft was guided by the defect size as well as the treating surgeon’s preferred method of treatment. Group 1 received iliac crest bone grafting (ICBG) and Group 2 received recombinant human Bone Morphogenetic Protein-7 (BMP–7) as the first line of treatment. The direct medical costs of treatment – including hospital stay, implants, theatre costs, drains, antibiotics, investigations and outpatient appointments were documented and analysed.

Results: The study sample consisted of 27 patients (14 females). Group 1 and Group 2 included 12 patients (4 females) and 15 patients (5 females) respectively. The mean age was 41.4 and 38.5 years respectively. The average hospital stay was 7.66 for the ICBG and 5,66 for the BMP7 patients (p=0.051). The follow-up period for Group 1 was 2.84 and 2.4 years for Group 2. The average time to union was 15.3 and 10.6 weeks respectively and this was statistically significant (p< 0.05). The overall direct medical costs on average reached the sum of £6,830.73 and £7,294.1 respectively. The hospital’s, operating theatre’s and outpatient’s direct medical costs were statistically significant (p< 0.05) more for the ICBG group. The implants costs did not significantly differ between the 2 groups and the second group’s costs were mostly raised due to the actual cost of the BMP7 (£3,002.2).

Conclusion and Significance: In this study, the average cost of treatment of a tibial fracture non-union with BMP7 was 6.7% higher than the cost incurred with autologous bone grafting. Most of the costs incurred (41.1%) in the BMP7 group were related to the actual price of BMP7. The direct medical cost difference between the two groups of patients wasn’t statistically significantly higher.

Purpose: The purpose of this study was to evaluate the efficacy of a combined application of iliac crest autograft (ICAG) and human recombinant osteogenic protein 1 (BMP-7) for the treatment of non-unions of long bones fractures (LBF).

Patients and Methods: At both institutions we have prospectively and retrospectively collected and analysed data of patients admitted between October 2001 and August 2004 with a LBF nonunion (humerus, femur, tibia) and whose nonunion sites have been grafted with a combination of BMP7 and ICAG. All the records of the patients’ initial injury incident and treatment course, together with following operative interventions till and after the BMP7 application, and their follow up till final union have been analysed. Painless full weight bearing or use of the upper limp in the case of humerus (clinical union), and presence of bridging callous of two cortices visible on two x-ray views (radiological union). Chi square test was used to analyse the results.

Results: Forty-nine patients (31 males) with a mean age of 43 years (18–79) with LBF non-unions were identified. The mean follow-up was 21.4 months (range 12–65). 7 were humerus, 13 femurs, and 29 tibias. Eleven cases were open (3 grade II, and 8 grade IIIa-b). All non-unions were atrophic, and 8 were initially associated with bone loss. The mean number of operations performed prior to the combined ICAG and BMP7 application was 2.5 (0–6), including ICAG in 12 cases and bone marrow injection in 1 case. All but one of the fractures have united. Clinical and Radiological union occurred within a mean time of 4.4 (3–12) months and 5.4 (4–16) months respectively. One patient, with an infected tibial non-union following an open fracture, ultimately underwent a below knee amputation, secondary to recurrence of deep sepsis. The only patient whose (tibial) fracture has not still united is currently on an Ilizarov frame and slow progression has been reported following a recent CT. No complications or adverse effects from the use of BMP-7 were encountered.

Conclusion: BMP-7 was used as a bone stimulating agent combined with conventional iliac crest bone grafting with a success rate of 98% in this series of patients with LBF non-unions. This study supports the view that this combination of BMP-7 is safe and a power adjunct to be considered in the surgeon’s armamentarium for the management of such difficult cases.

Purpose: To evaluate the assumption that reaming is the main reason for problems of shoulder function (pain – restricted range of motion) after antegrade intramedullary nailing of humerus (unless impingement of fixation material on the rotator cuff or acromion occurs).

Materials – Methods: From January 1999 until March 2003 55 patients underwent unreamed antegrade intra-medullary nailing for treatment of recent fractures of the humeral shaft. Two different intramedullary nailing systems were used, that do not protrude from the humeral shaft and that do not require reaming for insertion. Patients with concomitant problems or complications that could affect the final functional result were excluded from the study (e.g. multiple injuries, brachial plexus lesions, etc.). The remaining 32 patients were examined for postoperative pain and functional problems in the shoulder joint.

Results: No patient complained of persistent shoulder pain. Range of motion was found comparable to that of the other shoulder.

Conclusions: Reaming seems to exert a harmful influence on the rotator cuff, due to direct injury caused by the reamers as they are inserted and withdrawn from the humeral head. Furthermore it is possible that bone reaming products, accumulating under the rotator cuff, contribute to the persistence of pain and loss of motion.

Purpose: To describe a technique that allows “closed” reduction and “percutaneous” fixation of intertrochanteric fractures that were unable to be reduced preoperatively, with the use of the Trochanteric Gamma Nail.

Materials-methods: From October 2001 until March 2003 we treated 11 patients with intertrochanteric fractures that were unable to be reduced with preoperative manipulation. To achieve “closed”, intaoperative reduction of fractures, the Trochanteric Gamma Nail was used as a lever. The operation was performed through a 2–3 cm long skin incision (“percutaneous technique”).

Results: There were no particular difficulties with this method. Stable fixation was achieved in all cases and mobilization, full-weight bearing, was allowed from the first day postoperatively. No intraoperative or postoperative complications occurred. Intraoperative blood loss averaged 150 cc.

Conclusion: Use of the TGN in the treatment of pre-operatively unreducible fractures can help to avoid an “open” reduction. Furthermore, placement of the nail through a minimal cutaneous incision can offer all the advantages of closed intramedullary nailing, such as reduced complications, small blood loss, and unrestricted, early mobilization of the patient.