Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

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

Background. Hip resurfacing arthroplasty (HRA) has seen a recent revival with third generation Metal-on-Metal prostheses and is now widely in use. However, safety and effectiveness of hip resurfacing are still questioned. We systematically reviewed peer-reviewed literature on hip resurfacing arthroplasty to address these issues. Objective. To evaluate implant survival and functional outcomes of hybrid Metal-on-Metal hip resurfacing arthroplasty (HRA). Method. Electronic databases and reference lists were searched from 1988 to May 2010. Identified abstracts were checked for inclusion or exclusion by two independent reviewers. Data were extracted and summarized by one reviewer and verified by a second reviewer. Main study endpoint was implant survival, which we compared with the National Institute of Clinical Excellence (NICE) benchmark. We also evaluated radiological and functional outcomes, failure modes and other adverse events. The quality of evidence was judged using the Grading of Recommendations Assessment, Development and Evaluation system (GRADE). Results. We identified 539 articles, of which 29 met the inclusion criteria. The studies included one randomised clinical trial, 27 prospective case series and one retrospective case series. Data were extracted from these 29 articles, totalling 10621 resurfaced hips, providing details on five out of 11 resurfacing devices on the market. Mean follow up ranged from 0.6 to 10.5 years and implant survival ranged from 84% to 100%. Of the 10621 hips, 370 were revised (3.5%), with aseptic loosening as most frequent failure mode. None of the HRA implants used to date met the full 10 year NICE benchmark. Thirteen studies showed satisfactory implant survival percentages compared to the three year NICE entry-benchmark. These 13 studies used the BHR implant (eight studies), the Conserve plus (two studies), the Durom implant (one study), the Cormet 2000 implant (one study) or both the McMinn and the BHR implant (one study)

Introduction. Venous thromboembolism (VTE) is an uncommon complication of foot and ankle surgery but has the potential for significant morbidity and mortality. The incidence, risk factors and prevention of VTE in foot and ankle surgery is not clear. Materials and methods. We conducted a systematic review of the literature using MEDLINE, EMBASE, CINAHL, the Cochrane library and reference lists of retrieved articles without language or date restriction upto 31st July 2010. The Coleman methodology score was used to evaluate the quality of studies. From 985 citations, 38 full text articles fulfilled the inclusion criteria. Conclusions were drawn on the incidence, risk factors and prevention of VTE in foot and ankle surgery. Results. The incidence of symptomatic VTE in foot and ankle surgery in general is low; higher incidence has been reported in tendoachilles surgery. There is some evidence that history of prior VTE, immobilisation, non-weight bearing, obesity, hormone replacement therapy and oral contraceptives predispose to VTE in foot and ankle surgery. The evidence on the efficacy of different thromboprophylaxis agents and the optimum duration of treatment is unclear. Conclusion. The current evidence on VTE prophylaxis in foot and ankle surgery is insufficient to draw any firm conclusions. Long term effects of VTE in foot and ankle surgery need to be investigated further. Further large scale, multicentre studies are needed to delineate the role of VTE prophylaxis in foot and ankle surgery

Background. Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms. Methods. Based on a systematic literature search of the medical literature from 1950 to 2010, three randomized and two quasi-randomized controlled clinical trials comparing surgical stabilization with non-operative treatment for patients with primary patellar dislocation were selected. The Risk of Bias Tool (Cochrane Handbook, 2008) was used to assess the quality of the studies included. Study results were pooled using the fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Q test and I-square statistic. A sensitivity analysis was performed by assessing the change on effect size by eliminating each single trial. Results. In total, 341 patients from 5 trials were included. 158 patients were treated non-operatively and 183 patients were treated operatively. For primary outcome of patellar redislocation, while significant heterogeneity was found using the random-effects model, no significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI 0.8–2.31, p=0.25). No significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI0.8–2.31, p=0.25). No significant differences were found between both groups for symptoms ofinstability (RR of 1.24, 95% CI 0.96–1.59, p=0.10), Kujala knee score (−5.66, 95% CI −15.51 −4.19, p=0.26) or requirement for later surgery (RR=0.92, CI 0.61–1.39, p=0.69). Conclusions. This meta-analysis found no differences in patellar redislocation rate, patient reported instability symptoms, Kujala Knee score and rate of later surgery after initial treatment, between operative and non-operative treatment of primary patellar dislocation. Level of evidence. Level II

Introduction. The treatment of clavicle fractures remains controversial. Although most clavicle fractures can be treated successfully nonoperatively, no consensus exists for the complete range of lesions. A systematic literature review was performed to summarize and compare the results of different treatments. Material and Methods. A Pubmed search on ‘clavicle’ and ‘fracture’ was performed and relevant papers collected. Predefined inclusion/exclusion criteria had to be met and parameters were extracted. The articles were regrouped according to fracture location: midshaft; lateral; or location not specified. Main parameters were: Edinburgh classification; treatment type; complications; pseudarthrosis; cosmetic satisfaction and pain. Results. From 105 papers retrieved, 41 were included representing 4959 patiens with a median follow-up of 33 months. Patients lost to follow-up was 20.2%. The rate of displacement was higher in the lateral fracture group (63.5% versus 50.5% for the midshaft group and 33.5% for location not specified. Of all patients, 75.9% were treated nonoperatively. The lateral fracture group was operated on most (48.4%). Nonoperative treatment led to pseudarthrosis in 3.1% of midshaft fractures compared to 12.6% for lateral fractures. Operative treatment led to 7% and 2.7% of pseudarthrosis for the midshaft and lateral fractures respectively. Cosmetic dissatisfaction was frequent (13.6% for the nonoperatively treated fractures and 7.9% for surgically treated fractures). Surgical complications occurred frequently, especially wound infections (5.8%). Operatively treated patients had better pain scores at final follow-up. Conclusions. A considerable number of patients treated nonsurgically have suboptimal outcome at follow-up. In selected cases, especially displaced lateral fractures, surgery may be warranted

Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

Introduction

There is considerable uncertainty about the optimal treatment of displaced four-part fractures of the proximal humerus. Within the last decade locking plate technology has been considered a breakthrough in the treatment of these complex injuries.

BACKGROUND

Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures.

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

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

Aims. Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. Methods. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages. Results. The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively. Conclusion. Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture. Cite this article: Bone Joint J 2023;105-B(7):801–807

Objectives. Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property. Methods. A systematic literature search was performed in PubMed, EMbase, CINAHL and PsycINFO databases to identify relevant clinimetric studies. Two reviewers independently assessed the methodological quality of the studies on measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Level of evidence (strong / moderate / limited / lacking) for each measurement property per PROM was determined by combining the methodological quality and the results of the different clinimetric studies. Results. In all, 19 out of 1508 identified unique studies were included, in which 12 PROMs were rated. The Patient-rated wrist evaluation (PRWE) and the Disabilities of Arm, Shoulder and Hand questionnaire (DASH) were evaluated on most measurement properties. The evidence for the PRWE is moderate that its reliability, validity (content and hypothesis testing), and responsiveness are good. The evidence is limited that its internal consistency and cross-cultural validity are good, and its measurement error is acceptable. There is no evidence for its structural and criterion validity. The evidence for the DASH is moderate that its responsiveness is good. The evidence is limited that its reliability and the validity on hypothesis testing are good. There is no evidence for the other measurement properties. Conclusion. According to this systematic review, there is, at best, moderate evidence that the responsiveness of the PRWE and DASH are good, as are the reliability and validity of the PRWE. We recommend these PROMs in clinical studies in patients with distal radial fractures; however, more clinimetric studies of higher methodological quality are needed to adequately determine the other measurement properties. Cite this article: Dr Y. V. Kleinlugtenbelt. Are validated outcome measures used in distal radial fractures truly valid?: A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Bone Joint Res 2016;5:153–161. DOI: 10.1302/2046-3758.54.2000462

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling. Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results. Cite this article: Bone Joint J 2016;98-B:690–5

Aims. Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used. Patients and Methods. A systematic search strategy of several journal databases and recent proceedings from the American Academy of Orthopaedic Surgeons was performed. Clinical articles were included for analysis if sufficient implant description was provided. All articles were reviewed by two reviewers. A review of fundamental investigations of implant load-to-failure was performed, with the intent of identifying similar conclusions from the clinical and fundamental literature. Results. In total 596 articles were initially identified, with 34 being eligible for analysis. Aggregate analysis of 1691 PFFs in 342 719 primary THAs revealed a significantly higher number of PFFs with cementless femoral implants (p < 0.001). Single-wedge and double-wedge (fit-and-fill) femoral implants were associated with a threefold increase in PFF rates (p < 0.001) compared with anatomical, fully coated and tapered/rounded stems. Within cemented stems, loaded-taper (Exeter) stems were associated with more PFFs than composite-beam (Charnley) stems (p = 0.004). Review of the fundamental literature revealed very few studies comparing cementless component designs. Conclusion. Very few studies within the PFF literature provide detailed implant information. Cementless implants, specifically those of single-wedge and double-wedge, have the highest PFF rates in the literature, with most investigations recommending against their use in older patients with osteoporotic bone. This review illustrates the need for registries and future PFF studies to record implant name and information for future analysis. Furthermore, future biomechanical investigations comparing modern implants are needed to clarify the precise contribution of implant design to PFF risk. Cite this article: Bone Joint J 2017;99-B(1 Supple A):50–9

Background. In a systematic review of 1125 distal tibia fractures treated with an intramedullary nail, the reported incidence of malalignment was 14%. The purpose of our study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved radiological outcomes. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing. Methods. We searched computerised records at a UK level 1 major trauma centre. The joint alignment was measured on the immediate post-operative radiograph and compared to the most recent radiograph. We used a difference of 2 degrees to indicate a progressive deformity and a RUST score greater or equal to 10, to indicate radiographic fracture union. Results. Twenty-seven patients were included. Nineteen patients had no blocking screw and 8 patients had a blocking screw. Five patients had a difference in their coronal plane alignment of 2 degrees or more (3/5 had no blocking screw). The results were analysed and found to be not statistically significant (p=0.88). The addition of a blocking screw has also been shown not to have an effect on the time to union. Conclusion. We have changed our surgical practice. We use a 2.5mm blocking wire to aid in fracture reduction prior to reaming / nail insertion and then remove the wire when the nail has been adequately locked. Implications. This could save surgical procedure time, radiation exposure for the patient, implant costs and potential complications

Aims

The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients.

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.