Aims. The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. Methods. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. Results. At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. Conclusion. The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. Cite this article: Bone Joint J 2023;105-B(1):72–81

INTRODUCTION. The introduction of hard-on-hard bearings and the consequences of increased wear due to edge-loading have renewed interest in the importance of acetabular component orientation for implant survival and functional outcome following hip arthroplasty. Some studies have shown increased dislocation risk when the cup is mal-oriented which has led to the identification of a safe-zone1. The aims of this prospective, multi-centered study of primary total hip arthroplasty (THA) were to: 1. Identify factors that influence cup orientation and 2. Describe the effect of cup orientation on clinical outcome. METHODS. In a prospective study involving seven UK centers, patients undergoing primary THA between January 1999 and January 2002 were recruited. All patients underwent detailed assessment pre-operatively as well as post-op. Assessment included data on patient demographics, clinical outcome, complications and further surgery/revision. 681 primary THAs had adequate radiographs for inclusion. 590 hips received cemented cups. The primary functional outcome measure of the study was the change between pre-operative and at latest follow up OHS (OHS). Secondary outcome measures included dislocation rate and revision surgery. EBRA was used to determine acetabular inclination and version. The influence of patient's gender, BMI, surgeon's grade and approach on cup orientation was examined. Four different zones tested as possibly ± (Lewinnek Zone, Callanan's described zone and zones ± 5 and ±10 about the study's mean inclination and anteversion) for a reduced dislocation risk and an optimal functional outcome. RESULTS. There were 21 dislocations (3.1%) and 8 (1.2%) patients required revision at a mean follow up of 7 years. Experienced surgeons (2=0.047) and those operating with the patient in the lateral decubitus position (p=0.04) were more likely to achieve a cup orientation within any of the tested zones. Surgical approach (2=0.14) and patient's BMI (2=0.93) had no influence on whether a cup was within or outside any zone. There was no difference in dislocation rate between the posterior and anterio-lateral approaches (2=0.88). None of the zones tested had a significantly reduced dislocation risk (2=0.13), nor revision risk (2=0.55). OHS was not different for patients with cups within or outside any of the zones tested (p=0.523). DISCUSSION. There was a wide variation in cup orientation. Despite the wide scatter in cup orientation, no safe zone could be identified that would reduce dislocation and revision rate, nor improve patient reported outcome (OHS). Hence, these data suggest that acetabular component orientation should not be considered predictive of patients' early/mid-term complication/revision rate and outcome following THA

This prospective study explores the outcomes of the Forth Valley Protocol (FVP) for the management of acute Achilles tendon ruptures. The protocol uses ultrasound as the primary mechanism to guide treatment. All patients presenting with acute tendoachilles rupture over a three-year period were included. Patients under 18 years of age, chronic ruptures, or prior surgery to the Achilles tendon were excluded. Patients with a gap ≤2cm had conservative management following an Early Rehabilitation Protocol (ERP) and >2cm underwent surgery (if an appropriate surgical candidate). Achilles Tendon Rupture Scores (ATRS) were obtained retrospectively. Fischer's exact test was used to determine statistical significance. 158 patients were included with a mean age of 53 (range 20–89). Ultrasound scans were obtained for 121 patients (76.5%), demonstrating a mean tendon gap of 1.61cm. 143 patients managed conservatively and 15 surgically. The overall re-rupture rate was 3.8% (n=6). All the re-ruptures occurred in patients treated conservatively, but this was not found to be statistically significant (n=6, P=1.0). The overall complication rate (excluding re-ruptures) was 1.9%. ATRS was comparable between both treatment modalities (P=0.382, 0.422), with a mean score of 86.6 in the conservative group and 81.4 in the surgical group. The FVP demonstrates low re-rupture and complication rates in line with other published studies. Patients with gaps ≤2.0cm on the ultrasound can be successfully treated conservatively with an ERP. This has potential benefits in terms improved patient outcomes, satisfaction, and preservation of resources

Hip fractures are a major cause of morbidity and mortality, and malnutrition is a critical determinant of these outcomes. This systematic review and meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with hip fracture. An electronic systematic literature search was conducted in August 2022 using four databases. Randomized trials documenting ONS in older patients with hip fracture (aged 50+) were included. Two reviewers evaluated study eligibility, data extraction and assessed study quality. There were 812 studies identified of which 18 studies involving 1,512 patients met the inclusion criteria. The overall meta-analysis demonstrates that ONS was associated with a significant risk reduction in infective complications (odds ratio (OR) 0.54, 95%CI 0.38, 0.76), pressure ulcers (OR 0.54, 95%CI 0.33, 0.88), total complications rate (OR 0.57, 95%CI 0.42, 0.79). Length of hospital stay (LOS) was also significantly reduced (weighted mean difference (WMD) −2.01, 95%CI −3.52, −0.5), particularly in the rehabilitation LOS (WMD −4.17, 95%CI −7.08, −1.26). There was a tendency towards lower risk in mortality (OR 0.93, 95%CI 0.62, 1.4) and readmission (OR 0.52, 95%CI 0.16, 1.73), though statistical significance was not achieved. The overall compliance to ONS ranged from 64.1% to 100%, but no factors influencing compliance were identified. This systematic review was the first to quantitatively demonstrate that ONS reduces half the risk of infective complications, pressure ulcers, total complication rate and reduces LOS. ONS should be a regular and integrated part of medical practice, especially given that the compliance to ONS is acceptable

Aims. There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. Methods. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. Results. Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges’ g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. Conclusion. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953–962

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

COVID 19 led to massive disruption of elective services across Scotland. This study was designed to assess the impact on elective service that the COVID-19 pandemic had, to what extent services have been restarted and the associated risks are in doing so. This is a retrospective observational study. The primary outcomes are the number of operations completed, 30-day mortality, 30-day complication rates and nosocomial infection with COVID-19 compared to previous years. Data was collected from 4 regions across Scotland from 27th March 2020 - 26th March 2021. This was compared to the same time period the previous year. 3431 elective operations were completed in the year post-pandemic compared with 12255, demonstrating a reduction of 72%. Both groups had comparable demographics. Major joint arthroplasty saw a 72% reduction, with TKR seeing a reduction of 82%. Each of the 4 health boards were affected in a similar fashion. Nosocomial COVID-19 infection was 0.4% in the post covid group. 30 day mortality was the same at 0.1%. Total complications rose from 5.7% to 10.1% post covid. This study shows that there has been a substantial reduction in elective activity across Scotland that is disproportionate to the level of COVID-19. The risk of developing COVID-19 from elective surgery is low at 0.4%, however all complications saw a significant rise. This is likely multifactorial. This study will inform decision makers in future pandemics, that it is safe to continue elective orthopaedic surgery and of the potential impact of cessation of services

Our unit historically performed total hip replacement (THR) through either posterior or anterolateral approaches. In November 2020 a group of 5 consultants transitioned to utilising the Direct Anterior Approach (DAA). Appropriate training was undertaken and cases were performed as dual consultant procedures with intraoperative radiography or robotic assistance. Outcomes were collated prospectively. These included basic demographics, intraoperative details, complication rates and Oxford Hip Scores. A total of 48 patients underwent DAA THR over 1 year. Mean age was 67 and ASA 2. Over this time period 140 posterior approach and 137 anterolateral approach THR's were performed with available data. Propensity score matching was performed on a 1:1 basis using BMI, Age, Sex and ASA as covariates to generate a matched cohort group of conventional approach THR (n=37). Length of stay was significantly reduced at 1.95 days (p<0.001) with DAA compared to Anterolateral and Posterior approach. There was no significant difference with length of surgery, blood loss, Infection, dislocation and periprosthetic fracture rate. There was no significant difference in Oxford Hip Score between any approach at 3 months or 1 year. The transition to this approach has not made a negative impact despite its associated steep learning curve, and has improved efficiency in elective surgery. From our experience we would suggest those changing to this approach receive appropriate training in a high-volume centre, and perform cases as dual consultant procedures

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture. A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period. The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction. Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures

Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

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

Arthrodesis of the 1st metatarsophalangeal joint (MTPJ) is a common procedure used for the treatment of end stage arthritis. We studied a cohort of patients who underwent an isolated 1st MTPJ Fusion for the treatment of hallux rigidus. Here we report the 10-year clinical outcomes, complication rate, requirement for further surgery and patient experience. All patients, who underwent an isolated 1st MTPJ Fusion for osteoarthritis from June 2008 until November 2011 were included. Demographics, clinical outcome data and subsequent procedures performed were collected from a departmental database (Bluespier). Patients were contacted and asked to complete the MOxFQ questionnaire and rate their satisfaction using pain, function and if they would undergo the surgery again. Mean follow up was 10.85 (range 9–12) years. A total of 161 patients (183 feet) underwent an isolated 1st MTPJ fusion during this time period. 156 of the feet showed a successful arthrodesis (85.2% fusion rate); 27 patients required revision surgery, 19 (10.4%) for a symptomatic non-union and 8 (4.4%) for mal-union. Those patients with co-morbidities (diabetes and gout) required revision earlier than those without (p<0.01). Average MOxFQ score was 16.6 (0–64) and 28 out of the 38 (73.6%) said they would have the operation again. Overall, the long-term results of the 1st MTPJ fusion had good outcomes with a successful fusion rate and minimal complications, both in line with the corresponding literature. In this series, fusion provided high patient satisfaction with the majority of patients opting to undergo fusion with the gift of hindsight

Cheilectomy is a recommended procedure for early stage osteoarthritis of the 1st metatarsophalangeal joint. Although improvement in symptoms has been reported in many studies, long term performance is not well understood. It is thought that significant numbers of patients require subsequent arthrodesis or arthroplasty. We report on a large cohort of patients receiving this procedure and on complications, and mid-term outcome. This is a retrospective study looking at all patients undergoing cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to record outcome measures including: postoperative wound infection, patient reported improvement in pain and incidence of further surgical interventions like revision cheilectomy, conversion to arthrodesis and arthroplasty. Osteoarthritis was staged radiographically using PACS (Hattrup and Johnson classification). A total of 240 feet in 220 patients (20 bilateral surgeries) were included with 164 females (75%) and 56 males (25%), the median age being 55 years (range 22–90 years). Radiological assessment showed 89 stage 1 arthritis (42%), 105 stage 2 (50%), 17 stage 3 (8%) and 9 patients were excluded due to unavailable radiographs. 5 patients (2%) had superficial wound infections. There were 16 further surgeries (7%); 12 arthrodesis (5%), 3 revision cheilectomy and 1 conversion to arthroplasty. 157 patients were found to be pain-free at the latest post-operative visit (77%), 48 reported minimal pain (23%), 15 patients were excluded due to incomplete data. Cheilectomy appears to effectively reduce pain with low complication rates. Rates of conversion to arthrodesis/arthroplasty are lower than in many reported studies

Despite multiple published reviews, the optimum method of correction and stabilisation of Blount's disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. This technique was developed to minimise cost in a context of limited resources. This study was conducted between 2016 and 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32tibiae) who had correction of late-onset tibia by proximal tibial osteotomy and Ilizarov external fixator. All cases were followed up to 2 years. The mean proximal tibial angle was 65.7° (±7.8) preoperatively and 89.8° (±1.7) postoperatively. The mean mechanical axis deviation improved from 56.2 (±8.3) preoperatively to 2.8 (±1.6) mm postoperatively. The mean femoral-tibial shaft angle was changed from – 34.3° (±6.7) preoperatively to 5.7° (±2.8) after correction. Complications included overcorrection (9%) and pin tract infection (25%). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity. This simple procedure provides secure fixation allowing early weight bearing and early return to function. It can be used in the context of health care systems with limited resources. It has a relatively low complication rate. Our results suggest that acute correction and simple circular frame fixation is an excellent treatment choice for cases of late-onset tibia vara, especially in severe deformities

Aims. Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment. Patients and Methods. This was a retrospective case control study of consecutive patients with periprosthetic femoral fractures between 2007 and 2017. Two observers identified 16 PAFF cases (mean age 73.9 years (44 to 88), 14 female patients) and 17 typical periprosthetic fractures in patients on bisphosphonate therapy as controls (mean age 80.7 years (60 to 86, 13 female patients). Univariate and multivariate analysis was performed to identify predictors of PAFF. Management and complications were recorded. Results. Interobserver agreement for the PAFF classification was excellent (kappa = 0.944; p < 0.001). On univariate analysis compared with controls, patients with PAFFs had higher mean body mass indices (28.6 kg/m. 2. (. sd. 8.9) vs 21.5 kg/m. 2. (. sd. 3.3); p = 0.009), longer durations of bisphosphonate therapy (median 5.5 years (IQR 3.2 to 10.6) vs 2.4 years (IQR 1.0 to 6.4); p = 0.04), and were less likely to be on alendronate (50% vs 94%; p = 0.02) with an indication of secondary osteoporosis (19% vs 0%; p = 0.049). Duration of bisphosphonate therapy was an independent predictor of PAFF on multivariate analysis (R. 2. = 0.733; p = 0.05). Following primary fracture management, complication rates were higher in PAFFs (9/16, 56%) than controls (5/17, 29%; p = 0.178) with a relative risk of any complication following PAFF of 1.71 (95% confidence interval (CI) 0.77 to 3.8) and of reoperation 2.56 (95% CI 1.3 to 5.2). Conclusion. AFFs do occur in association with prostheses. Longer duration of bisphosphonate therapy is an independent predictor of PAFF. Complication rates are higher following PAFFs compared with typical PFFs, particularly of reoperation and infection. Cite this article: Bone Joint J 2019;101-B:1285–1291

The aim was to report operative complications, radiographic and patient-reported outcomes following lateral tibial plateau fracture fixation augmented with calcium phosphate cement (CPC). From 2007–2018, 187 patients (median age 57yrs [range 22–88], 63% female [n=118/187]) with a Schatzker II/III fracture were retrospectively identified. There were 103 (55%) ORIF and 84 (45%) percutaneous fixation procedures. Complications and radiographic outcomes were determined from outpatient records and radiographs. Long-term follow-up was via telephone interview. At a median of 6 months (range 0.1–138) postoperatively, complications included superficial peroneal nerve injury (0.5%, n=1/187), infection (6.4%, n=12/187), prominent metalwork (10.2%, n=19/187) and post-traumatic osteoarthritis (PTOA; 5.3%, n=10/187). The median postoperative medial proximal tibial angle was 89o (range 82–107) and posterior proximal tibial angle 82o (range 45–95). Three patients (1.6%) underwent debridement for infection and 27 (14.4%) required metalwork removal. Seven patients (4.2%) underwent total knee replacement for PTOA. Sixty percent of available patients (n=97/163) completed telephone follow-up at a median of 6yrs (range 1–13). The median Oxford Knee Score was 42 (range 3–48), Knee injury and Osteoarthritis Outcome Score 88 (range 10–100), EuroQol 5-Dimension score 0.812 (range −0.349–1.000) and Visual Analogue Scale 75 (range 10–100). There were no significant differences between ORIF and percutaneous fixation in patient-reported outcome (all p>0.05). Fixation augmented with CPC is safe and effective for lateral tibial plateau fractures, with a low complication rate and good long-term knee function and health-related quality of life. Percutaneous fixation offers a viable alternative to ORIF with no detriment to patient-reported outcome

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

Aims. Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. Methods. The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group. Conclusion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72–78

Introduction. Managing open tibial fractures according to national guidelines is a primary focus for major trauma centres, however pressures of capacity and expertise limit the capability to achieve all of these standards for every patient. Debate remains over the impact of particular aspects of guidance, especially in relation to the timing of surgical interventions. Evaluation of these tenants of care predominantly hinge on trends derived from low level scientific evidence, mainly due to the difficulty in completing high level studies. The aim of this study is to assess the complication rates and the associations with difficulties in achieving the national guidance standards. Methods. Retrospective analysis of the 2015/2016 cohort of 3B open tibial fractures treated at the Queen Elizabeth Hospital Birmingham. Data collected, through the use of the patient electronic records, cross referenced against hospital coding and trauma injury database, included patient demographics, injury details, clinical interventions, surgical management, complications and time to bony union. Results. During the studied period, 40 patients were identified with 3B open tibial fractures. 2 patients died during the period of management, 3 patients were lost to follow up. Median time to definitive soft tissue coverage was achieved at 5 days post injury, definitive fixation at 6 days post injury. 25% of the cohort breached the 7 day maximum recommended limit. Overall complication rate was greater than 50%, with deep infection rate of 11% and non-union rate of 9%. Median time to union was 9 months. Conclusions. Missed opportunities to provide optimal patient care for severe lower limb open fractures are contributing to the high complication rates for these injuries. In order to aim for improvements in clinical outcomes, considered multispecialty clinical decision making needs to be coupled with institutional support and resources to adequately provide care for this injury cohort

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.