The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring. As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases

Background. There is doubt regarding resection compared to curettage for pelvic metastases. Previous studies have reported that curettage is associated with decreased survival compared with wide resection, and have justified a radical surgical approach to achieve pain palliation and tumor control. Aim. To evaluate the role of wide en bloc resection compared to curettage/marginal resection for patients with pelvic metastases. The rationale was that wide resection does not improve survival even in patients with solitary pelvic metastases. Method. Between 1985 and 2009, 21 patients (6 women, 15 men; age, 34–76 years) were treated for pelvic metastases. Histology included thyroid carcinoma in 5 patients, bladder carcinoma in 4 patients, renal and endometrium in 2 cases each and colon, ovarium, cerebral and lung carcinoma in 1 case each; the primary tumor was undiagnosed in 4 patients. Three patients had sacral and 1 patient had sacroiliac joint metastasis. According to Enneking's classification of the anatomical site involved, 5 patients had type I, 1 patient had type II, 6 patients had type III, 1 patient had type I and II, and 4 patients had type II and III pelvic metastasis. Metastatic disease was localized in the pelvic ring in 15 patients and multifocal in 6 patients. Eight patients had surgical treatment only; 13 patients had surgical treatment in addition to radiation therapy (2 patients), chemotherapy (1 patient), embolization (3 patients), or combined adjuvant treatments (7 patients). 21 patients with pelvic metastases were treated with wide resection (12 patients) and curettage/marginal resection (9 patients) and adjuvants. Sixteen patients had solitary pelvic metastases. Reconstruction of the hip joint was performed in three patients. Results. At a mean of 27.6 months (range, 2–152 months), the overall survival to death and local recurrence was 15% at 66 months and 47% at 26 months, respectively. Survival to death of patients treated with wide en bloc resection was 18% at 46 months compared to 62% at 12months of patients treated with curettage/marginal resection; no difference in survival to death between wide en bloc resection and curettage/marginal resection was observed (p=0.570). Survival to local recurrence of patients treated with wide en bloc resection was 67% at 24 months compared to 26% at 24 months of patients treated with curettage/marginal resection; this was also not statistically significant (p=0.0683). One patient treated with wide en bloc resection for a solitary pelvic bone metastasis had a postoperative complication. Conclusion. This series showed that neither the combination of surgical and adjuvant treatments nor the type of surgical resection were statistically significant parameters for local recurrence. We found no difference in survival to death or local recurrence 1 with wide en bloc resection compared to curettage or marginal resection, even in patients with solitary pelvic metastases

Introduction. Femorotibial malalignment exceeding ±3° is a recognised contributor of early mechanical failure after total knee replacement (TKR). The angle between the mechanical and anatomical axes of the femur remains the best guide to restore alignment. We investigated where the femoral head lies relative to the pelvis and how its position varies with respect to recognised demographic and anatomic parameters. We have tested the hypothesis of the senior author that the position of the centre of the femoral head varies very little, and if its location can be identified, it could serve to outline the mechanical axis of the femur without the need for sophisticated imaging. Patients & Methods. The anteroposterior standing, plain pelvic radiographs of 150 patients with unilateral total hip replacements were retrospectively reviewed. All patients had Tönnis grade 0 or 1 arthritis on the non-operated hip joint. All radiographs were obtained according to a standardised protocol. Using the known diameter of the prosthetic head for calibration, the perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured with use of TraumaCad software. Anatomic parameters, including, but not limited to, the diameter of the intact femoral head, were also measured. Demographic data (gender, age, height, weight) were retrieved from our database. Results. There were 72 men and 78 women with a mean age of 67.0 years. The mean distance of the centre of the femoral head to the pubic symphysis was 89.1 mm (standard deviation [SD], 5.8 mm). This distance was higher in men (mean, 90.5 mm; SD, 5.6 mm) than in women (mean, 87.7 mm; SD, 5.8 mm) (p=0.003). No statistically significant correlations between this distance and body-mass index or age (p=0.57 and p=0.28, respectively) were revealed. However, height was strongly correlated with this distance (r=0.52, p < 0.01), as was the diameter of the femoral head (r=0.61, p < 0.01). The latter was significantly larger in men than in women (p < 0.01). Conclusion. This is the first study to demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. As expected, it varies with patient's height and gender. Although statistically significant, the difference between genders is < 3 mm and can be explained by the smaller femoral head size of females. Our findings should prove useful during TKR surgery, as they facilitate intra-operative identification of the centre of the femoral head. Based on these results, simple trigonometry shows that if a surgeon measures 9 cm from the symphysis pubis, a line from this point to the centre of the knee will be within 2° and 2.2° of the true mechanical axis in 98% (i.e. ± 3 SD of the mean) of male and female patients, respectively

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions

A patient is described with a ligamentous disruption at the L4/L5 level in association with bilateral, traumatic dislocations of the hip. The diagnostic evaluation, acute intervention, and definitive stabilisation are reported. The unstable spine posed a problem in treatment with regard to the timing and technique of the reduction of the hips.

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Introduction

Radiation exposure to the eye causes cataracts. Few orthopaedists wear leaded glasses when using fluoroscopy despite regulatory limits for maximum annual eye exposure.

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.

Increasing the accuracy of information provided through X-Rays maximises pre-operative planning. Aim of this project is to determine the necessity of calibration probes that would improve the accuracy of pre-operative templating. This is a retrospective study involving leg length and pelvis X-Rays performed across the NHS Lanarkshire from 01/03/2023 until 31/04/2024. A total of 87 leg length X-Rays were identified, 18 had a calibration probe present. Leg length was measured on each and the X-Rays were calibrated against the existing probe. In 66.7% of cases there was a major leg length discrepancy of over 2cm between the pre-calibrated and post-calibrated X-Rays. Pelvic X-Rays of 80 patients that underwent total hip replacement were reviewed. Preoperative templating was compared to the implants inserted. An average of 1.94 discrepancy in the size of the acetabular implant was identified whilst in 30 cases the size of the femoral stem was incorrect by at least 1 size. Magnification of 119.7% on X-Rays was found to provide the most accurate templating. Seventy seven cases of pelvic X-Rays before and after hip hemiarthroplasty were also reviewed. The implant head was templated incorrectly in 74% of cases and the stem in 51%. It was identified that pelvic X-Ray magnification of 121.7% would provide the most accurate results. X-Rays with no calibration probes provide inaccurate measurements leading to faulty preoperative planning. Standardised use of a calibration sphere is strongly suggested and whenever that is not available, we suggest magnification of 121%

The Thompson hemiarthroplasty is a common treatment option for acute neck of femur fractures in the elderly population. Our department noted a significant number of patients returning with thigh pain, radiographic loosening and femoral osteolysis following cemented implantation of the titanium alloy version of the Thompson hemiarthroplasty. We are not aware of any previous reports documenting complications specific to the titanium Thompson implant and a retrospective cohort study was therefore initiated following clinical governance approval. 366 titanium alloy Thompson prostheses were implanted for hip fracture treatment between 2017 and 2020. As of February 2023, 6 of these have been revised at our hospital. 5 were revised for symptomatic femoral osteolysis and 1 presented with an acute periprosthetic fracture. All revised cases were determined to be aseptic. 32 living patients were excluded from recall on compassionate grounds due to permanent nursing home residence. 47 living patients were identified of which 33 attended for xray. 28 deceased and/or nursing home resident patients who had pelvis x-rays in the previous 12 months were also included in the analysis. Including the 6 index hips already revised, a total of 61 hip xrays were analysed, of which 19 hips (31.1%) showed radiographic evidence of femoral osteolysis or loosening. We conclude that there is a concerning incidence of femoral osteolysis and implant loosening associated with the titanium Thompson implant. We have discontinued use of the implant and reported our experience to the MHRA. We encourage other Scottish Health-Boards who use this implant to consider enhanced follow-up

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP. Cite this article: Bone Joint J 2015; 97-B:696–704

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (. sd. 2.6) vs 0.1 mm (. sd. 0.3), p < 0.001; and mean gap 11.5 mm (. sd. 6.5) vs 0.8 mm (. sd. 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access

Aims

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.