Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

The term os-acromiale denotes the failure of fusion of acromial apophysis to the scapular spine. The prevalence of os is considered to be about 8% in the general population with higher prevalence in African Americans and males. The treatment options for a symptomatic os acromiale range from arthroscopic excision to decompression to ORIF and bone grafting. In this study, we reviewed retrospectively patients who had undergone ORIF and bone grafting for a painful os acromiale. Patients surgically treated for os acromiale from 1998 to 2009 were included in the study. All patients were diagnosed to have a symptomatic os acromiale clinically and radiologically. A pre operative MRI of the affected shoulder was done in all patients. All patients had failed conservative management. The surgical technique was standard in all patients. The rotator cuff was repaired if it was torn. Patients were followed up at 3, 6 and 12 months postoperatively. Post operative X-rays were done at 3 months to assess healing. An ASES scoring was done at the final follow up at a mean of 30.5 months post op. 16 patients with 17 shoulders which included 10 males and 6 females were available for the last follow up. 11 shoulders involved dominant hand, 15 shoulders had a history of trauma. Surgery was performed after an average of 7.2 months of conservative management. 11 out of the 17 shoulders had associated rotator cuff tears. Out of the 6 patients with intact cuff, 2 had associated clavicle fractures and 1 patient had an Acromio clavicular joint dislocation. A clinical and radiographic union was achieved in all patients. Mean ASES score in patients without rotator cuff tear was 89 whereas patients with associated rotator cuff tear had an ASES score of 74. Pain score and percentage ADL score were better in patients without rotator cuff tear (92 and 1.3) as compared to those with a cuff tear (83 and 2.2). There was no significant difference in scores in patients who had second surgery at final follow up. 15 of the 16 patients were satisfied with the surgery and would have the surgery on the other side for a similar problem. Open reduction and internal fixation of symptomatic os acromiale yields predictable clinical outcome. Bigger studies randomising treatment methods in similar group of patients may be needed to find out the superiority of one method over the other

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65-year-old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the postoperative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65 year old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the post-operative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

The Failed Femoral Neck Fracture

For the young patient: Attempt to preserve patient's own femoral head. Clinical results reasonably good even if there are patches of avascular necrosis. Preferred methods of salvage: valgus-producing intertrochanteric femoral osteotomy: puts the nonunion under compression. Other treatment option: Meyer's vascularised pedicle graft.

For the older patient: Most reliable treatment is prosthetic replacement. Decision to use hemiarthroplasty (such as bipolar) or THA based on quality of articular cartilage, perceived risk of instability problem. In most patients THA provides higher likelihood of excellent pain relief. Specific technical issues: (1) hardware removal: usually remove after hip has first been dislocated (to reduce risk of femur fracture); (2) Hip stability: consider methods to reduce dislocation risk: larger diameter heads/dual mobility/anteriorly-based approaches; (3) Acetabular bone quality: poor because it is not sclerotic from previous arthritis; caution when impacting a pressfit cup; low threshold to augment fixation with screws; don't overdo reaming; just expose the bleeding subchondral bone. A reasonable alternative is a cemented cup.

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population. Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA. While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful

Introduction. The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN). Methods. 13 consecutive patients treated with fibular nails (FN) were compared with 13 age-matched patients that underwent open reduction and internal fixation (ORIF). All patients were followed to union. Study outcomes were time from admission to surgery, length of stay, wound failure, implant failure, revision surgery, OMAS and SF-36. Results. There was no difference in age or sex distribution between groups. There was no difference in OMAS at 1 year (83 ± 9 in FN group; 80± 21 in ORIF group) and SF-36 (94 ± 11 and 90 ± 20). There were 2 implant failures in the ORIF group and none in the FN group. There was one wound failure in the ORIF group and none in the FN group. Patients treated with FN had a shorter time to surgery (1 day ± 24 hours vs 3 days ± 24 hours) and shorter length of stay (1 day ± 24 hours vs 4 days ± 96 hours). Conclusion. FN is a safe method to treat patients with displaced distal fibular fractures that may have a poor soft tissue envelope and risk factors for wound healing. FN reduces the time to surgery and overall length of stay compared with similar patients treated with conventional ORIF

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Abstract. Introduction. We aimed to compare the outcomes of elderly patients with periarticular distal femur or supracondylar periprosthetic fractures treated with either open reduction internal fixation or distal femoral replacement. Methods. A retrospective review of patients over 65 years with AO Type B and C fractures of the distal femur or Su type I and II periprosthetic fractures treated with either a DFR or ORIF was undertaken. Outcomes including Length of Stay, PROMs (Oxford Knee Score and EQ 5D), infection, union, mortality, complication and reoperation rates were assessed. Data on confounding variables were also collected for multivariate analysis. Patients below 65 years and extra articular fractures were excluded. Results. 23 patients (11 in DFR group and 12 in ORIF group) fulfilled inclusion criteria and were included in the analysis. There was no difference between the DFR and ORIF groups with respect to SDI, demographic variables, ASA grade, FCI, preoperative Hb and renal function. There was no difference in 30 day mortality, reoperation rates, 30 day readmission rates and LOS between the two groups. Mean follow up was 12.7 and 15.9 months respectively in the DFR and ORIF groups. At final follow up after accounting for all confounding variables on multivariate analysis, functional outcomes using OKS (adjusted mean: 29.5 vs 15.8) and Health related Quality of Life outcomes using EQ 5D (adjusted mean: 0.453 vs −0.07) were significantly better in the DFR group. Conclusion. DFR for periarticular and periprosthetic distal femoral fractures in the elderly are associated with better patient reported outcomes

Abstract. Introduction. In our quality improvement project we implemented a novel pathway, performing acute fixation in mid-third clavicle fractures with >15% shortening. Patients with <15% shortening reviewed at 6 weeks, non-union risk identified as per Edinburgh protocol and decision to operate made accordingly. Methods. Retrospective pre-pathway analysis of patients presenting 04/2017–04/2019. Prospective post-pathway analysis of patients presenting 10/2020–10/2021. Fracture shortening measured using Matsumura technique. QuickDASH and recovery questionnaires posted to >15% shortening patients and done post-pathway at 3 months. Results. Pre-pathway retrospective cohort included 141 patients; 69 <15%, 72 >15% shortening. Acute ORIF performed in 15(22%) <15% and 34(47%) >15%. In those conservatively managed, non-union occurred in 2 patients with <15% shortening, and 5 with >15% shortening. Union time was significantly longer in >15% treated non-operatively compared to those requiring ORIF and <15% (18.4 vs 13.4 vs 12.0 weeks; p<0.05). QuickDASH significantly worse in >15% managed conservatively than operatively (17.6 vs 2.8; p<0.05). >15% ORIF had significantly fewer number of weeks until undisturbed sleep than those treated non-operatively (2.3 vs 10.1; p<0.05). Post-pathway prospective cohort included 37 patients; 17 <15% (of which 1 underwent delayed ORIF), 20 >15% shortening (of which 15 underwent acute ORIF). No significant increase in proportion ORIF performed (43% vs 38%). No non-unions occurred. Conclusion. Acute fixation in >15% shortening was associated with better QuickDash scores and reduced union times than those treated non-operatively. Implementation of our pathway resulted in no nonunions compared to 5% pre-implementation and thus identifies patients benefitting from acute fixation

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

Surgeons must explain the risk of complications to prospective patients and get informed consent. If a complication that occurred was omitted in the process or given the wrong risk level, culpability of the surgeon is judged in court against what a “reasonable patient” would like to know to give or refuse consent. ObjectivesThe concept “reasonable patient” is widely used, no attempt has been made to define it objectively. We assessed insight of patients, presumed “reasonable”, about risks of certain complications after they underwent one of five orthopaedic procedures. Questionnaire was administered with procedures: femur IMN, tibia IMN, ankle ORIF, distal radius ORIF and hip arthroplasty. Four common/serious complications were chosen per procedure, and matched against life events with documented risk levels. There were 230 participants 163 males and 67 females. We found 19.1% of patients above age 40 and 33.3% with tertiary education wouldn't accept nerve injury as reported in literature. With infection risk, 18.1% above 40 and 52.9% with pre-tertiary education would not accept. All patients below 40 and 7.4% pre-tertiary education wouldn't accept the risk of death as reported. However, 37.1% above 40 and 76.9% with pre-tertiary education would accept that risk at a higher level. It is hard to predict what risk of complication a patient may accept. This study highlights that some patients will not accept risks as reported in literature, even though they need the procedure. Therefore, surgeons need to explain complications fully, so that patients knowingly accepts or refuses consent. The subset of patients who are not willing to accept any level of risk, should be the subject of another study

Constrained implants with intra-medullary fixation are expedient for complex TKA. Constraint is associated with loosening, but can correction of deformity mitigate risk of loosening?. Primary TKA's with a non-linked constrained prosthesis from 2010-2018 were identified. Indications were ligamentous instability or intra-medullary fixation to bypass stress risers. All included fully cemented 30mm stem extensions on tibia and femur. If soft tissue stability was achieved, a posterior stabilized (PS) tibial insert was selected. Pre and post TKA full length radiographs showed. i. hip-knee-ankle angles (HKAA). ii. Kennedy Zone (KZ) where hip to ankle vector crosses knee joint. 77 TKA's in 68 patients, average age 69.3 years (41-89.5) with OA (65%) post-trauma (24.5%) and inflammatory arthropathy (10.5%). Pre-op radiographs (62 knees) showed varus in 37.0%. (HKAA: 4. o. -29. o. ), valgus in 59.6% (HKAA range 8. o. -41. o. ) and 2 knees in neutral. 13 cases deceased within 2 years were excluded. Six with 2 year follow up pending have not been revised. Mean follow-up is 6.1 yrs (2.4-11.9yrs). Long post-op radiographs showed 34 (57.6%) in central KZ (HKKA 180. o. +/- 2. o. ). . Thirteen (22.0%) were in mechanical varus (HKAA 3. o. -15. o. ) and 12 (20.3%) in mechanical valgus: HKAA (171. o. -178. o. ). Three failed with infection; 2 after ORIF and one with BMI>50. The greatest post op varus suffered peri-prosthetic fracture. There was no aseptic loosening or instability. Only full-length radiographs accurately measure alignment and very few similar studies exist. No cases failed by loosening or instability, but PPF followed persistent malalignment. Infection complicated prior ORIF and elevated BMI. This does not endorse indiscriminate use of mechanically constrained knee prostheses. Lower demand patients with complex arthropathy, especially severe deformity, benefit from fully cemented, non-linked constrained prostheses, with intra-medullary fixation. Hinges are not necessarily indicated, and rotational constraint does not lead to loosening

The purpose of this study was to define the risk and incidence of eventual ankle arthroplasty or fusion after documented ankle fracture in a large cohort, and compare that rate to matched healthy patients from the general population. The Ontario health insurance plan (OHIP) physician billing database, Institute for Clinical Evaluative Sciences (ICES) Physician Database, the Canadian Institute for Health Information (CIHI) databases, Discharge Abstract Database (DAD) and Same Day Surgery (SDS) were used to identify patients treated surgically and non-surgically for ankle fractures. Each patient was matched to four individuals from the general population (13.5 million) with no documented prior treatment for ankle fracture, according to age, sex, income, and urban/rural residence. Fusion and replacement incidence was compared using time-to-event analysis (Kaplan-Meier). A Cox Proportional Hazards model was used to explore the influence of patient, provider and surgical factors on time to surgery. We identified 45,444 (58.8% female, mean age 48.7 years) and 140, 629 (53.9% female, mean age 47.1 years) patients who had undergone open reduction internal fixation (ORIF) or non-operative management of an ankle fracture (NOA), respectively. Among ORIF patients, n=237 (0.5%) and n=69 (0.15%) patients underwent fusion or arthroplasty after a median 2.8 and 6.9 years, respectively. Among non-operatively treated ankle fractures, n=198 (0.14%) and n=36 (0.03%) patients underwent fusion or arthroplasty after a median of 3.2 and 5.6 years, respectively. Surgical treatment (vs. non-operatively treated fracture), older age, greater co-morbidity and a history of infection post fracture significantly increased the risk of eventual fusion or arthroplasty (HR 3.6 (3.1–4.3), p < 0 .001, HR 1.01 (1.01–1.02), p=0.009, HR 1.2 (1.1–1.3), p < 0 .001, HR 11.3 (6.8–18.7), p < 0 .001, respectively). Compared to matched controls, the risk of fusion/arthroplasty was not independent of time, following an exponential decay pattern. ORIF patient risk was 20 times greater than the general population in the first three years post-ORIF, and approached the risk of non-operatively treated patients (HR 4.5 (95CI: 3.5–5.8), p < 0 .0001) by approximately 14 years out from injury on time and comorbidity adjusted KM curves. Rates of fusion/arthroplasty are very low after ORIF and non-operative treatment of an ankle fracture in the general population of a public healthcare system. Utilization patterns suggest fusion is more common earlier, and arthroplasty remote, which may be a factor of patient age, injury severity, and complications from initial injury/surgery. Patients who underwent ORIF have >20 times the risk of fusion/arthroplasty in the short-term, however, the risk decreases over time eventually approaching that of non-operatively treated patients (∼4.5x the general population) when compared to non-fractured controls

This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations. A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction and return to activity. Range of motion and several standardized outcome measurement tools were also included in the final analysis. Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improved postoperative objective scores (i.e., patient-reported outcome scores and active range of motion). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%. This study reports on the largest sample of patients who have undergone surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good patient satisfaction. Such patients should be aware that they are at increased risk of requiring a second procedure due to symptomatic hardware following ORIF

Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile

Distal radius fractures (DRFs) are one of the most common types of fracture and one which is often treated surgically. Standard X-rays are obtained for DRFs, and in most cases that have an intra-articular component, a routine CT is also performed. However, it is estimated that CT is only required in 20% of cases and therefore routine CT's results in the overutilisation of resources burdening radiology and emergency departments. In this study, we explore the feasibility of using deep learning to differentiate intra- and extra-articular DRFs automatically and help streamline which fractures require a CT. Retrospectively x-ray images were retrieved from 615 DRF patients who were treated with an ORIF at the Royal Brisbane and Women's Hospital. The images were classified into AO Type A, B or C fractures by three training registrars supervised by a consultant. Deep learning was utilised in a two-stage process: 1) localise and focus the region of interest around the wrist using the YOLOv5 object detection network and 2) classify the fracture using a EfficientNet-B3 network to differentiate intra- and extra-articular fractures. The distal radius region of interest (ROI) detection stage using the ensemble model of YOLO networks detected all ROIs on the test set with no false positives. The average intersection over union between the YOLO detections and the ROI ground truth was Error! Digit expected.. The DRF classification stage using the EfficientNet-B3 ensemble achieved an area under the receiver operating characteristic curve of 0.82 for differentiating intra-articular fractures. The proposed DRF classification framework using ensemble models of YOLO and EfficientNet achieved satisfactory performance in intra- and extra-articular fracture classification. This work demonstrates the potential in automatic fracture characterization using deep learning and can serve to streamline decision making for axial imaging helping to reduce unnecessary CT scans