Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

Introduction. Osteoarthritis (OA) of the hip is an important cause of pain and morbidity. The mechanisms and pathogenesis of OA'sdevelopment remain unknown. Minor acetabular dysplasia and subtle variations in proximal femoral morphology are increasingly being recognized as factors that potentially compromise the joint biomechanically and lead to OA. Previous studies have shown that risk of hip OA increased as the femoral head to femoral neck ratio (HNR) decreased. Previous work has described the evolutionary change in inferior femoral neck trabecular density and geometry associated with upright stance, but no study has highlighted the evolutionary change in HNR. The aim of this study was to examine evolutionary evidence that the hominin bipedal stance has lead to alterations in HNR that would predispose humans to hip OA. Methods. A collaboration with The Natural History Museums of London, Oxford and the Department of Zoology, University of Oxford provided specimens from the Devonian, Jurassic, Cretaceous, Miocene, Palaeolithic and Pleistocene periods to modern day. Specimens included amphibious reptiles, dinosaurs, shrews, tupaiae, lemurs, African ground apes, Lucy (A. Afarensis), H. Erectus, H. Neaderthalis and humans. Species were grouped according to gait pattern; HAKF (hip and knee flexed), Arboreal (ability to stand with hip and knee joints extended) and hominin/bi-pedal. Imaging of specimens was performed using a 64 slice CT scanner. Three-dimensional skeletal geometries were segmented using MIMICS software. Anatomical measurements from bony landmarks were performed to describe changes in HNR, in the coronal plane of the different specimens over time using custom software. Measurements of HNR from the specimens were compared with HNR measurements made from AP pelvic radiographs of 119 normal subjects and 210 patients with known hip OA listed for hip arthroplasty. Results. Species from the HAKF group that ambulate via sprawling had the smallest HNR (1.10, SD: 0.09) (p<0.001). Species of the arboreal group (tree dwelling) had the biggest HNR (1.63, SD: 0.15) (p=0.006). The earliest bipedal species (1.41, SD: 0.04) had significantly bigger HNR (p=0.04) in comparison to the normal human subjects (1.33, SD: 0.08). Lower HNR was observed in the OA group (1.3, SD: 0.09). Discussion. The adoption of an upright stance during evolution has created an associated change in the femoral neck bone stock to adapt to the altered loading environment. These data would suggest that the HNR peaked in the Miocene period (10–15 million years ago). The trade-off between mobility and the bony density required to support gait has lead to a decreasing HNR throughout hominid evolution. Evolutionary theory would suggest that modern environmental pressures might pre-dispose future hominid evolution to an increased risk of hip OA

Aims

The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

Introduction. Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation. Methods. Between September 2012 and January 2016, more than 120 patients with open tibial fractures were admitted to our unit. Patients were identified through prospective databases. Data collected included patient demographics, injury details, orthopaedic and plastic surgery procedures. Major complications were recorded. Paediatric cases were excluded and one patient was lost to follow up. Results. Fifty-seven patients (median age 41 years (range 16–95)) were identified with open tibial fractures classified grade IIIB or IIIC requiring soft tissue coverage. Of these 57 patients, 39 were treated by initial temporary external fixation, soft tissue cover, and circular frame and 18 by initial temporary external fixation, soft tissue cover and internal fixation (ORIF). Of the 57 patients, 51 were acutely managed by Leeds MTC, and 6 were tertiary referrals primarily managed elsewhere. Soft tissue cover constituted free tissue transfer in 43 patients (19 gracilis, 15 ALT, 6 LD, 2 radial forearm and 1 groin flap), pedicled flap in 12 patients (6 gastroc, 4 fasciocutaneous, 1 soleus, 1 EDB), and skin graft in 2 patients. Complications included flap failure (n=3), return to theatre (n=1). Long term soft tissue cover was definitely achieved in 100% of cases. Chronic deep infection was reported in 1 acutely managed case. There were no cases of soft tissue failure after delayed circular frame fixation following soft tissue reconstruction. Conclusions. Evolution of orthopaedic techniques has meant that the management of these complex fractures using delayed definitive fixation with a circular frame is increasingly commonplace. This case series demonstrates that a joint orthoplastic approach, with circular frame application undertaken a short time after soft tissue reconstruction (including free flap surgery) is safe and can be undertaken without risk to the soft tissue coverage

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Introduction. Monomicrobian necrotizing cellulitis affects the skin and subcutaneous tissue as starting point the deepest level of the superficial fascia. The pathogen inoculation is by skin disruption, abrasions, burns, injections or bites. The free base cocaine is used with homemade pipes that generate pulps fingers skin microabrasions. We present 3 patients (one bilateral) with cellulitis necrotizing of the thumb caused by pricking and dermoabrasive trauma secondary to different manipulation methods for drogue use. Material and Method. Experience in 3 patients free base cocaine addicts treated in our Hospital. Medical examination shows febrile syndrome (corporal temperature over 38C), and elevation of heart rate. They present cellulitis in thumb's first and second phalanx, with thenar swelling and digital necrosis with abundant purulent discharged. All of them had a pricking trauma 36 to 48 hours before. They were under surgical intervention, by surgical cleaning with necrotic and devitalized tissue's debridement. In 3 of the 4 patients amputation of the distal phalanx was mandatory. Tissue and bone culture was made in all patients. Intravenous antibiotic was performed. Two patients miss total antibiotic treatment by early no medical discharged. Results. Due necrotizing cellulitis is an acute and aggressive pathology, that compromised general condition and the 3 patients had important and advanced lesions was mandatory to made 3 thumb amputations with 1 aggressive debridement. The specific antibiotic postoperative treatment was ciprofloxacin + clindamicin because the isolated pathogen in all the samples was Stafilococo Aureus Meticilin Resistent from the community. Conclusion. The high consume of drugs in young people and the unprotective features (social, cultural and economics) of this group, is increasing the incidence of this pathology. Due to his fast and hiperacute evolution plus the delay in consultation, a radical treatment (amputation) is require. That's why we think the prevention of this illness could avoid ending in an important disability

Slipped capital femoral epiphysiolysis (SCFE) is a rare condition with a unknown aetiopathogenesis. An early diagnosis and treatment is essential to minimize premature degeneration of the joint. The authors reviewed the cases treated between 1980 and 2005 in our institution. This study was aimed at evaluating patients with hip epiphysiolysis surgically treated by canullated screws or pinning and previously controlled by short-term follow-up, in order to evaluate radiographic medium/ long term evolution, looking for evidence of degenerative arthritis or femoroacetabular impingement. We performed a retrospective review of the clinical notes and radiographs of all patients with slipped upper femoral epiphysis who were surgically treated at our institution between January 1980 and December 2005. These patients performed radiographs to detect evidence of osteonecrosis, chondrolysis, degenerative arthritis or femoroacetabular impingment. To grade the radiological osteoarthritic changes the grading system of Kellgren and Lawrence was used. These changes were correlated with the existence of femoroacetabular impingement. The radiological results were correlated with the Loder'sclassification of stability and the morphological classification. 43 patients were reviewed, corresponding to 47 treated hips. AP and Lowenstein x-ray views were taken in all patients. The alfa angle and the head-shaft angle were measured in the Lowenstein view (frog-leg). Of 16 patients with impingement only 1 patient didn't present pistol grip deformity. 4 contralateral hips also presented the deformity. The mean alfa angle was 99,4. 43% of the patients with unstable hips have impingment. In stable hips this percentage is of 35%. The Patrick test was positive in 30% of the hips with SCFE and only 17% of the unafected hips. The Kellgren and Lawrence scale was very diferent between trhe SCFE and control groups, with 43% grade 2, 17% grade 3 and 6% grade 4, versus 30% grade 2, 6% grade 3 and 0% grade 4. Some patients show bilateral pistol grip deformity and clinical signs of impingment, despite only having one hip with SCFE

Introduction. Osteoporosis is a metabolic disease of the bone responsible for a loss of bone resistance and an increase in fracture risk. World Health Organization (WHO) estimations are about 6.3 millions of femoral neck fractures in the world by 2050. These estimations make osteoporosis a real problem in term of public health. Knowledge in biological tissues mechanical behaviour and its evolution with age are important for the design of diagnosis and therapeutic tools. From the mechanical aspect, bone resistance is dependent on bone density, bone architecture and bone tissue quality. If the importance of bone density and bone architecture has been well explored, the bone tissue quality still remains unstudied because of the lack of biomechanical tools suitable for testing bone at this microscopic dimension. Therefore the goal of this study is to estimate the osteoporotic cancellous bone tissue mechanical behaviour at its microscopic scale, using an approach coupling mechanical assays and digital reconstruction. Materials and methods. The experimental study is based on cancellous bone tissue extracted from human femoral head. Forty 8mm diameters bone cylinders have been removed from femoral head explanted after a femoral neck fracture treated by arthroplasty. These cylinders have been submitted to a digitally controlled compressive trial. Before and after the trials, microscanner analyses with an 8 μm spatial resolution have been realized in order to determine the micro structural parameters. The cylinders have been rebuilt with the digital model-building in order to estimate the mechanical behaviour and the bone quality. Results. The results will be presented from a macroscopic and microscopic point of view and will show the relationship between gender and age of the patients. At the macroscopic scale, we will look at that apparent young modulus heterogeneity and the cracking strength. At the microscopic scale, we will confirm that the cancellous bone tissue mechanical behaviour is close to the Haversian bone tissue mechanical behaviour. Finally, the parametric study will permit us to point out the main microstructural components influencing cancellous bone tissue quality. Conclusion. This study allows a precise estimation of the osteoporotic cancellous bone tissue mechanical behaviour. It seems to be a great step in the understanding of this disease and it could probably lead to great improvements in the diagnosis, prognostic, medical and surgical approaches of osteoporosis

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control. This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery. Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability

Aims

The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip.

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Aims

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.

Patients with transfemoral amputation (TFA) often experience problems related to the use of socket-suspended prostheses. The clinical development of osseointegrated percutaneous prostheses for patients with a TFA started in 1990, based on the long-term successful results of osseointegrated dental implants.

Between1999 and 2007, 51 patients with 55 TFAs were consecutively enrolled in a prospective, single-centre non-randomised study and followed for two years. The indication for amputation was trauma in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical procedure was used to introduce a percutaneous implant to which an external amputation prosthesis was attached. The assessment of outcome included the use of two self-report questionnaires, the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) and the Short-Form (SF)-36.

The cumulative survival at two years’ follow-up was 92%. The Q-TFA showed improved prosthetic use, mobility, global situation and fewer problems (all p < 0.001). The physical function SF-36 scores were also improved (p < 0.001). Superficial infection was the most frequent complication, occurring 41 times in 28 patients (rate of infection 54.9%). Most were treated effectively with oral antibiotics. The implant was removed in four patients because of loosening (three aseptic, one infection).

Osseointegrated percutaneous implants constitute a novel form of treatment for patients with TFA. The high cumulative survival rate at two years (92%) combined with enhanced prosthetic use and mobility, fewer problems and improved quality of life, supports the ‘revolutionary change’ that patients with TFA have reported following treatment with osseointegrated percutaneous prostheses.

Cite this article: Bone Joint J 2014;96-B:106–13.

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of avascular necrosis. The majority of the fractures (84 patients; 90%) followed one of the following four patterns: posteromedial (varus) impaction in 50 patients (54%), lateral (valgus) impaction in 13 (14%), isolated greater tuberosity in 15 (16%), and anteromedial impaction fracture in six (6%). Head orientation, impaction of the surgical neck and displacement of the tuberosity correlated strongly with the outcome.

In fractures with posteromedial impaction, a poor outcome was noted as the articular surface displaced inferiorly increasing its distance from the acromion. A poorer outcome was noted as a fractured greater tuberosity displaced medially overlapping with the posterior articular surface. Lateral impaction fractures had a worse outcome than other patterns of fracture.