Aims. The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients. Patients and Methods. Seven centres recruited patients into the study. Patients were eligible if they were greater than 65 years of age with a distal femoral fracture, and if the surgeon felt that they were suitable for either form of treatment. Outcome measures included the patients’ willingness to participate, clinicians’ willingness to recruit, rates of loss to follow-up, the ability to capture data, estimates of standard deviation to inform the sample size calculation, and the main determinants of cost. The primary clinical outcome measure was the EuroQol five-dimensional index (EQ-5D) at six months following injury. Results. Of 36 patients who met the inclusion criteria, five declined to participate and eight were not recruited, leaving 23 patients to be randomized. One patient withdrew before surgery. Of the remaining patients, five (23%) withdrew during the follow-up period and six (26%) died. A 100% response rate was achieved for the EQ-5D at each follow-up point, excluding one missing datapoint at baseline. In the DFR group, the mean cost of the implant outweighed the mean cost of many other items, including theatre time, length of stay, and readmissions. For a powered RCT, a total sample size of 1400 would be required with 234 centres recruiting over three years. At six months, the EQ-5D utility index was lower in the DFR group. Conclusion. This study found that running a full-scale trial in this country would not be feasible. However, it may be feasible to undertake an international multicentre trial, and our findings provide some guidance about the power of such a study, the numbers required, and some challenges that should be anticipated and addressed. Cite this article: Bone Joint J 2019;101-B:1408–1415

Background: Hemiarthroplasty of the hip is a common procedure, but information about implants and outcome is scarce. In Sweden the number of hemiarthroplasties has increased from 200 in 1998 to 4181 in 2007. Material and Methods: Nationwide registration started in 2005. 100% of the hospitals participates, and 96% of the hemi-procedures are registrered. An analysis of 12 245 cases operated 2005–07 is presented. Results: In the Register the mean age at surgery is 84 years (SD 7.0, 73% female). 93% are operated due to acute fracture and 6% due to failed internal fracture fixation. Cemented fixation has been used in 92% and a posterior approach in about half of the cases (52%). The Lubinus and Exeter stems are most common (41 and 23%). The Austin-Moore design has decreased from 9 to 2% during the study period. 3.2% of the patients (hips) have been reoperated, most commonly because of dislocation. Multiple reoperations are common. Male gender, secondary procedure and uncemented stem are associated with increased reoperation risk with 1.2, 1.7 and 1.8 times (1.2, CI: 1.0–1.6; 1.7, 1.3–2.3; 1.8 1.4–2.5). Use of uncemented fixation resulted in increased risk of reoperation, also with exclusion of uncemented Austin-Moore prostheses (1.8 times, 1.1–2.8). In a separate analysis of the two most frequent designs, use of bipolar head increased the risk of revision twice (1.4–2.8) compared to unipolar head when adjusting for other risk factors. This may reflect that fitter and more active individuals get a bipolar prosthesis and are more prone to become revised should complications occur or a true increase of complications when using bipolar head. A further analysis is in progress. Use of dorsal approach (1.6, 1.2–2.2), Austin-Moore (1.8, 1.1–3.1) and Thompson prostheses (1.8, 1.5–2.8) increased the risk of revision because of dislocation. Summary: When treating fracture patients with hemi-arthroplasty we recommend that a well documented cemented implant with different off-set options should be used via an anterolateral approach. Use of bipolar heads may increase the risk of revision

Magnesium calcium alloys are promising candidates for an application as biodegradable osteosynthesis implants [1,2]. As the success of most internal fracture fixation techniques relies on safe anchorage of bone screws, there is necessity to investigate the holding power of biodegradable magnesium calcium alloy screws. Therefore, the aim of the present study was to compare the holding power of magnesium calcium alloy screws and commonly used surgical steel screws, as a control, by pull-out testing. Magnesium calcium alloy screws with 0.8wt% calcium (MgCa0.8) and conventional surgical steel screws (S316L) of identical geometries (major diameter 4mm, core diameter 3mm, thread pitch 1mm) were implanted into both tibiae of 40 rabbits. The screws were placed into the lateral tibial cortex just proximal of the fibula insertion and tightened with a manual torque gauge (15cNm). For intended pull-out tests a 1.5mm thick silicone washer served as spacer between bone and screw head. Six animals with MgCa0.8 and four animals with S316L were followed up for 2, 4, 6 and 8 weeks, respectively. Thereafter the rabbits were sacrificed. Both tibiae were explanted, adherent soft tissue and new bone was carefully dissected around the screw head. Pull-out tests were carried out with an MTS 858 MiniBionix at a rate of 0.1mm/sec until failure of the screw or the bone. For each trial the maximum pull-out force [N] was determined. Statistical analysis was performed (ANOVA, Student's t-test). Both implant materials were tolerated well. Radiographically, new bone was detected at the implantation site of MgCa0.8 and S316L, which was carefully removed to perform pull-out trials. Furthermore, periimplant accumulations of gas were radiographically detected in MgCa0.8. The pull-out force of MgCa0.8 and S316L did not significantly differ (p = 0.121) after two weeks. From 6 weeks on the pull-out force of MgCa0.8 decreased resulting in significantly lower pull-out values after 8 weeks. Contrary, S316L pull-out force increased throughout the follow up. Thus, S316L showed significantly higher pull-out values than MgCa0.8 after 4, 6 and 8 weeks (p<0.001). MgCa0.8 showed good biocompatibility and pull-out values comparable to S316L in the first weeks of implantation. Thus, its application as biodegradable osteosynthesis implant is conceivable. Further studies are necessary to investigate whether the reduced holding power of MgCa0.8 is sufficient for secure fracture fixation. In addition, not only solitary screws, but also screw-plate-combinations should be examined over a longer time period. Acknowledgements. The study is part of the collaborative research centre 599 funded by the German Research Foundation

An estimated 10% of patients have problems with fracture healing. Initial studies have revealed that it is likely that both the innate and specific immune systems play a role in fracture repair, but this has not been attributed to particular components, cells or their products. It is known that the functionality of the immune system is impaired with age and this may account for the higher rate of delayed union in elderly patients. We used a validated mouse model of a reproducible closed tibial fracture. In order to prevent any foreign body inflammatory/immune response no artificial internal fracture fixation was used and instead external support was provided using a Plaster of Paris cast. The role of the specific immune system was studied using an immunodeficient Balb/c SCID (Severe Combined Immuno Deficient) mutant mouse. The SCID mice were matched for age, sex (all males) and weight to the control, wild type Balb/c mice. Mechanical (4 point bending) and radiographic (Radiographs scanned and calculations of callus area, index and density made with image analysis software) measures were used to assess fracture repair at 21 days. Mechanical measurements revealed an enhancement of fracture healing in the SCID mouse strain compared to the control strain, with stress at yield and Young’s modulus higher in SCID mice than controls. (Stress at yield: 4.2 +/− 0.23MPa in Controls, 7.1 =/− 0.6MPa in SCIDs, P< 0.01; Young’ Modulus: 22.1 +/− 2.99MPa in Controls, 60+/− 9.9MPa in SCIDs P< 0.01). There were no significant differences seen in mechanical properties of unfractured bone between the two strains. Radiographic analysis revealed no significant differences in callus area or index (both measurements of callus size) but callus density was significantly higher (P< 0.01) in the SCID subjects compared to controls (2.6 +/− 0.06E5 Greyscale in SCIDs vs. 2.2 +/− 0.09E5 in controls). We conclude that an abnormality of the immune system due to either lack of the specific immune system (T and B cells) or an enhancement of the innate system results in increased mineralization, stiffness and strength of fracture healing, and that further investigation might result in novel therapies directed toward avoidance of non/delayed-union

Introduction: Pediatric radial neck fractures account for 5 to 10 % of all elbow fractures. Depending on the degree of radial head displacement either operative intervention or conservative treatment is recommended. Open reduction offers anatomic fracture fixation but compromises the vulnerable blood supply. Intramedullary nailing combines the advantages of closed reduction and stable internal fracture fixation. The purpose of the presented study was to evaluate the outcome of treatment of a series of pediatric radial neck fractures. Special contributions in our algorithm were made to the age dependant capacity for spontaneous fracture remodelling. Materials and Methods: The medical data of all children with fractures of the radial head between 1999 and 2008 were retrospectively analyzed. Fractures were classified according to the classification system described by Judet et al. Depending on the angulation of the fracture and on the age of the patient the treatment algorithm was defined. Type I fractures were treated conservatively and Type IV fractures operatively independent of age. Type III fractures in patients younger than 6 years of age were treated conservatively without reduction and Type II fractures were reduced in children older than 12 years of age. The functional outcome was graduated from excellent to poor according to the score of Linscheid and Wheeler. Results: In our study 168 patients, 88 male and 80 female, were included. The average age of the patients was 9 years (range 3 to 16 years). There were 103 Type I injuries, 21 Type II, 30 Type III and 14 Type IV injuries. Conservative treatment was possible in 124 (73.8%) patients (103 Type I, 12 Type II, 9 Type III injuries). Operative intervention was performed in 44 (26.2%) patients (9 Type II, 21 Type III, 14 Type IV injuries). In 10 patients a K-wire was used to leverage the radial head percutaneous. Open fracture reduction was required in 4 patients. Necrosis of the radial head was found in 2 patients with open reduction. One child presented with hypoesthesia in the area of the superficial radial nerve. The latest follow up examination was performed after 26 months mean (range 11 months to 7 years). We found excellent results in 158 patients, good results in 5, fair in 3 and poor in 2 patients. Discussion: An intact vascular supply to the radial head is essential to avoid complications. The iatrogenic impact to the nutritive vessels should be kept to a minimum. Closed fracture reduction and intramedullary nailing has improved the prognosis. Spontaneous fracture remodeling might successfully replace unnecessary maneuvers for fracture reduction. However, the proximal physis of the radius is responsible for only 20–30% of the growth of the radius and therefore spontaneous fracture remodeling is restricted. Following our treatment algorithm we found excellent results in the majority of cases

Introduction: In 2003 the Ministry of Health in Israel added hip fractures to the DRG listing. The rational behind this move was aiming at the shortening of hip fractures waiting time to surgery and shortening of hospitalization period. Some hospitals in Israel have assigned an additional OR shift for this purpose. Hip fracture patients consist of two main sub-groups: patients who undergo hemi-arthroplasty (HA Group) and those who undergo internal fracture fixation (IFF Group). The new policy determines that DRG of internal fixation patients ends at the fifth day of their initial hospitalization after surgery. The aim of this study was to evaluate the practical effect of this policy on hip fracture management. Patients and Methods: We retrospectively compared two major groups of patients (total 808) with hip fractures: the first group of patients was treated in 2001 (377 patients) (before the new policy came into effect) and the second in 2005 (431 patients). Each of these groups included the HA group and the IFF group. In each of the groups we compared the time to surgery, length of hospitalization, mortality rates after six months and the diurnal distribution of the operations. Results: The length of hospitalization in 2005 was found to be shorter in the IFF group by 2.82 days (2001 – mean stay of 12.52, 2005 - 9.7 days) as opposed to the HA group where hospitalization was shorter in 2005 by a mean of only 0.42 day. Mortality rates at six months following surgery, when comparing the two major groups, were 11.3% in 2001 and 7.9% in 2005. 90% of the operations in 2005 were performed between 15:00–19:30 compared to 2001 when 90% of surgeries were evenly distributed between 15:00 and 24:00. We did not find statistically significant differences between the groups in relation to the time to surgery before and after the new policy. There was a trend towards a longer waiting time to surgery in the HA group in 2001 as well as in 2005. Discussion: The presence of a dedicated shift, according to the new policy, made more room available for other emergency list surgeries. Hospitalization stay became shorter due to the fact that the insurer is committed to discharge patients from the IFF group after 4 days of hospitalization and to finance each additional day. In spite of the fact that waiting time to surgery was not shortened following the new policy, the majority of surgeries were performed during the afternoon sessions. It should be noted that in 2001 waiting time to surgery was already very short. Mortality data are interesting and necessitate further investigation

The August 2014 Trauma Roundup³⁶⁰ looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world.

Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage.

Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.