Open long bone fractures have been considered orthopaedic emergencies requiring immediate irrigation, debridement and stabilization. Concomitant traumatic brain injuries may preclude the immediate operative treatment of open fractures. The purpose of this study was to review patients with open tibial diaphyseal fractures whose operative tibial fracture management was delayed because of a concomitant traumatic brain injury to determine if there is an increased rate of infection or non-union. After obtaining IRB approval, the trauma registry was scanned for patients who sustained both traumatic brain injury with an Abbreviated Injury Scale (AIS) equal to two or greater and an open tibial diaphyseal fracture. From January 1, 1996 to June 1, 2001, 28 patients with 31 open tibial shaft fractures were identified (Grade I=1, II=6, IIIA=17, IIIB= 7). There were 24 males and 4 females with an average age of 35 years (range 13–69 years of age). The mechanism of injury was motor vehicle collision or pedestrian versus motor vehicle accident for all patients. The mean time to operative irrigation, debridement, and stabilization was 11 hours (range 2–152 hours). Thirteen patients underwent operative orthopaedic treatment within 8 hours (mean 4.4 ± 1.3 hours), and 15 patients underwent delayed debridement (mean 35 ± 35 hours). Twenty fractures were stabilized with intramedullary nailing, 9 fractures were stabilized with external fixation, one fracture was stabilized with a compression plate, and one fracture treated in a cast. A review of clinic records and telephone follow-up interviews was used to determine the rates of infection or non-union. Infection was defined as a positive deep surgical culture for bacteria upon repeat irrigation and debridement. Non-union was defined as any clinically and radiographically unhealed fracture requiring further operative procedures. The average length of follow up was 2.9 years (range 1 month to 6.5 years). Of the 31 open tibial diaphyseal fractures, four fractures (12.9%) were complicated by infection and four fractures (12.9%) went on to non-union. There was no statistical difference in the rates of infection or non-union in patients who underwent irrigation and debridement within eight hours and those that underwent irrigation and debridement after eight hours from the time of initial presentation (odds ratio=1.02, p=0.15). Furthermore there was no correlation between the ultimate presence of infection/non-union and grade of open tibial shaft fracture, initial method of fixation, timing of wound closure (immediate, delayed primary closure, or split-thickness skin graft or flap), severity of overall injury, and epidemiological characteristics. In this subset of 28 patients with 31 open tibial shaft fractures and concomitant traumatic brain injuries, there was no difference in the incidence of infection or non-union in patients who underwent operative treatment within eight hours of admission to hospital and those who underwent operative treatment after eight hours. The results of this study should be considered in the prioritization of care for the multiply injured trauma patient

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones

In patients with traumatic brain injury and fractures of long bones, it is often clinically observed that the rate of bone healing and extent of callus formation are increased. However, the evidence has been unconvincing and an association between such an injury and enhanced fracture healing remains unclear. We performed a retrospective cohort study of 74 young adult patients with a mean age of 24.2 years (16 to 40) who sustained a femoral shaft fracture (AO/OTA type 32A or 32B) with or without a brain injury. All the fractures were treated with closed intramedullary nailing. The main outcome measures included the time required for bridging callus formation (BCF) and the mean callus thickness (MCT) at the final follow-up. Comparative analyses were made between the 20 patients with a brain injury and the 54 without brain injury. Subgroup comparisons were performed among the patients with a brain injury in terms of the severity of head injury, the types of intracranial haemorrhage and gender. Patients with a brain injury had an earlier appearance of BCF (p < 0.001) and a greater final MCT value (p < 0.001) than those without. There were no significant differences with respect to the time required for BCF and final MCT values in terms of the severity of head injury (p = 0.521 and p = 0.153, respectively), the types of intracranial haemorrhage (p = 0.308 and p = 0.189, respectively) and gender (p = 0.383 and p = 0.662, respectively). These results confirm that an injury to the brain may be associated with accelerated fracture healing and enhanced callus formation. However, the severity of the injury to the brain, the type of intracranial haemorrhage and gender were not statistically significant factors in predicting the rate of bone healing and extent of final callus formation

Aims

The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral 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

Fractures of the odontoid in children with an open basilar synchondrosis differ from those which occur in older children and adults. We have reviewed the morphology of these fractures and present a classification system for them. There were four distinct patterns of fracture (types IA to IC and type II) which were distinguished by the site of the fracture, the degree of displacement and the presence or absence of atlantoaxial dislocation. Children with a closed synchondrosis were classified using the system devised by Anderson and D’Alonzo. Those with an open synchondrosis had a comparatively lower incidence of traumatic brain injury, a higher rate of missed diagnosis and a shorter mean stay in hospital. Certain subtypes (type IA and type II) are likely to be missed on plain radiographs and therefore more advanced imaging is recommended. We suggest staged treatment with initial stabilisation in a Halo body jacket and early fusion for those with unstable injuries, severe displacement or neurological involvement

The beneficial effects of therapeutic hypothermia have been capitalised upon in fields such as cardiac surgery for several decades. Hypothermia not only slows metabolism and consumption of metabolic substrates, but also confers cellular protection against ischaemia and reperfusion. Hypothermia has historically been considered as something to avoid in trauma casualties, with coagulopathy being the main concern. There is now increasing evidence for the role of controlled therapeutic hypothermia in trauma, particularly improved functional outcomes following brain injury and the utility of ‘suspended animation’ or ‘emergency preservation’ in the resuscitation of severe haemorrhagic shock. With the ongoing ‘Eurotherm’ trial of hypothermia in the treatment of traumatic brain injury, and the imminent launch of the ‘Emergency Preservation and Resuscitation (EPR) for Cardiac Arrest From Trauma’ clinical trial in the USA, this presentation will provide a timely overview of the developments of therapeutic hypothermia in trauma management

Aim. Which patients is bone-defect-reconstruction with the Masquelet-technique suitable and which problems did we see?. Method. From 11/2011 to 4/2016 we treated 49 Patients (12f/37m) with bone-defects up to 150mm after septic complications with the Masquelet-technique. We had infected-non-unions of upper and lower extremity, chronic osteomyelitis, infected knee-arthrodesis and upper-ancle-empyema. On average the patients were 48 (8–74) years old. The mean bone-defect-size was 60 mm (25–150). From other hospitals came 47 of the 49 patient, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 40 patients receaved flaps because of soft tissue-defects (12 free flaps, 28 local flaps). 21 patients suffered a polytrauma. In 8 cases the femur, in 4 cases a knee-arthrodesis, in 34 cases tibia, in 2 cases humerus and in 1 case the ulna were infected resulting in bone defects. Indication for the Masquelet-technique was low-/incompliance in 35 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 9 times problems with segment-transport and in 5 cases as dead space management. Positive microbial detection succeeded in 32 patients at the first operation. Mainly we found difficult to treat bacteria. After treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with antibiotic loaded cement spacer and external fixation we removed the spacer6–8 weeks later and filled the defect with bone graft. In 23 cases we stabilized the defect then with an internal angle stable plate. All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department until full weight bearing, later every 3 months. Results. In 41 of 49 cases the infection was clinically treated successfully. 21 patients are allowed for full weight bearing (all with secondary internal plates). There were 8 recurrences of infection, 22 instabilities needing internal stabilization and further bone graft. We saw “Plate-breaks” in 4 cases. 2 patients underwent amputation. Conclusions. For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal bone graft and to the segment transport. The stiffness of the new Masquelet bone like a rod is a problem. Internal fixation is often necessary

Objective: To assess the efficacy of split Tibialis Posterior tendon transfers for the treatment of spastic equino-varus feet. Materials and Methods: Fourteen patients with 14 spastic equino-varus feet underwent split Tibialis Posterior tendon transfers. The spasticity was due to cerebral palsy, ataxia telangiectasia and traumatic brain injury. All the patients had Ashworth 1–3 spasticity, and the forefoot was correctible in equinus. Evaluation of the results was by grading of the shape of the feet, ambulation, pain and brace tolerance. Results: One patient was lost to follow-up after an excellent primary result. Twelve patients had good or excellent results, and one patient had a fair result due to partial recurrence of the deformity. No complications were encountered. Conclusions: Split Tibialis Posterior tendon transfer is a safe and efficacious procedure for the treatment of spastic equino-varus feet. Good alignment of the treated feet allows comfortable brace and shoe wear. Patient selection is important in order to avoid over-correction or recurrence of the deformity

The aim of present study was to evaluate the clinical evolution of a series of 60 pelvic fractures with uncontrolled hypotension treated with combined ex fix/angio algorithm based on fracture pattern. Materials and Methods: Retrospective study. We analysed 60 patients admitted between 2000 and 2008 with pelvic fracture and haemodinamic instability, treated by the same treatment algorithm. Decision-making (angio vs external fixation) was based on fracture type and hypotensive pattern. Key points were: immediate pelvic sheeting, early CT scan if possible and early arteriogram if contrast blushing in CT. Patients with rotationally unstable fractures were treated by external fixation and those with vertically unstable or stable pattern were transferred to angio suite. Patients with hemoperitoneum detected by fast were transferred to OR for laparotomy and external fixation. Inclusion criteria: pelvic fracture, SAP< 90mmHg, ISS> 16, RBT > 800cc in first 24 hours. Exclusion criteria: Traumatic brain injury with AIS> 3. Results: Mean ISS: 31.2, mean RBT: 4859 cc. Most fractures were C1 Tile. External fixation was used in 38 patients (63%) and 51 (85%) patients were treated initially by angio. We found active arterial bleeding in 48 cases. Successful embolization was achieved in 85%. Both treatments was used in 23 patients. Laparotomy was performed in 21 patients. Incidence of systemic complications was high. Mortality was 21 %. Conclusions:. Arterial lesions demonstrated by arteriogram were high in our study. External fixation for control hemodynamics it’s useful mainly in open book fra

For which patients is bone-defect-reconstruction with the Masquelet-technique suitable?. Between 11/2011 and 1/2015 we treated 27 Patients (4 female/ 23 male) with bone-defects up to 150mm after septic complications with the Masquelet-technique. Reason of the bone defects were infected-non-unions of lower extremity, chronic osteomyelitis, infected knee-arthrodesis, chronic upper-ancle-empyema and infect-defect-non-union of the humerus. On average the patients were 47,5 (18–74) years old. The mean bone-defect-size was 62,6 mm (25–150). 26 of the 27 patients came from other hospitals, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 25 patients receaved flaps because of soft tissue-defects (7 free flaps, 18 local flaps). 13 patients suffered a polytrauma. In 5 cases the femur, in 3 cases a knee-arthrodesis, in 18 cases the tibia and in 1 case the humerus was affected by infection resulting in bone defects. Indication for the Masquelet-technique was low-/incompliance in 10 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 6 times after problems with segment-transport and in 1 case as dead space management. Positiv microbial detection succeeded in 19 patients at the first operation although most of the patients underwent long term antibiotic therapy. Mainly we found problematic bacteria. At the time of defect reconstruction with spongious graft we found persistant bacteria in 4 cases. The first operation aimed treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with an antibiotic loaded cementspacer as well as external fixation. 6–8 weeks later we removed the spacer and filled the defect with autologous bonegraft. In 2 cases we needed 2 bone grafts to fill the defect. In 9 cases we removed the fixateur and stabilized the defect with an internal anglestable plate. All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department for osteitis until full weight bearing and later every 3months. In 22 of 27 cases the infection was clinically treated successfully. 5 patients are allowed for full weight bearing (all with secondary internal plates). No patient underwent amputation. There were 4 recurrences of infection, 9 instabilities needing internal stabilization and further bonegraft. For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal autologious spongegraft and to the segmenttransport. Internal fixation seems necessary

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aims

Adenosine, lidocaine, and Mg²⁺ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

Aims

To assess the impact of the declaration of the state of emergency due to the COVID-19 pandemic on the number of visits to a traumatology emergency department (ED), and on their severity.

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics.

Cite this article: Bone Joint J 2021;103-B(2):234–244.

Aims

Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings.

In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications.

The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.