Midshaft clavicle fractures can be classified into simple or complex/comminuted. The hardest fracture to treat is the severely comminuted and displaced fracture. We retrospectively compared 286 consecutive operatively treated simple (2 and 3 part) fractures with the more complex comminuted (>=4 part) midshaft clavicle fractures, looking at outcome, complication rate and union rate. Between 2008 and 2010 the senior author operated on 286 displaced midshaft clavicle fractures using a plate and screws. In this cohort there were 173 simple (2 and 3 part) fractures and 99 complex (>=4 part) fractures. The operation was performed through a limited incision technique and was standardized. All fractures were fixed with at least 3 screws on either side of the comminution. All patients were up until radiological and clinical union. A standardized questionnaire was used to assess patient satisfaction, return to work, sport and outcome at each postoperative visit. All complications were documented. All fractures eventually went onto union. There were 242 males and 44 females with the average age being 33. The complex fractures had a larger scar, took longer to return to normal motion, work and sport, and took on average 10 weeks to unite compared to 6 weeks in the simple fractures. The infection rate in the simple fractures was 1% and in the complex fractures was 2%. The big difference was the incidence of non union in the complex fractures of 10% compared to 1%; the other main difference was postoperative shoulder stiffness of 3% at 3 months in the complex fractures compared to 1 % in the simple fractures. Plate elevation/irritation was also more prevalent in the complex fractures of 10% compared to 3%. This study clearly shows there is a higher complication rate in complex fractures. Particular attention must be placed on surgical technique and anatomical reduction of these difficult fractures followed closely by postoperative rehabilitation. Future studies of clavicle fractures should specify the type of fracture being treated to give a better understanding of the potential outcome

Introduction. Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions. Materials & Methods. This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements. Results. 104 patients were identified, 23 patients were treated by internal fixation and 81 with circular frames. Patients required a median of 190 minutes of total operative time and 6 days of hospital stay at a median cost of £16,233 each, median reimbursement was £10,625. The total cost of treatment for all 104 patients was £2,205,611 and total reimbursement was £1,391463, the median deficit per patient being £5825. The overall deficit over the 2 years was £814,148. Conclusions. This study reveals a considerable economic burden associated with treating complex tibial fractures. It should be emphasised that these do not include patients referred for fracture-related infection or non-union, who may also incur similar deficits in recovered costs. These findings emphasise the importance of understanding and addressing the financial implications of managing tertiary referral orthopaedic trauma patients to ensure efficient and sustainable resource allocation

Introduction

Rolando type base of thumb metacarpal fractures are potentially debilitating injuries, which can be difficult to manage because of their inherent instability. Malunion is associated with stiffness, pain and weakness of pinch grip. We aimed to assess the outcome of a simple technique for the treatment of this fracture using the principle of ligamentotaxis, with a static, 2-pin external fixator spanning the trapeziometacarpal joint. We present the results and functional outcomes of this technique.

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures. The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations. 150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity. Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Introduction. External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb. Materials & Methods. A comprehensive search of AMED, CINAHL, MEDLINE and COCHRANE databases was conducted to identify relevant articles for inclusion, using a search strategy developed in collaboration with a research librarian. Inclusion criteria consisted of adults aged 18 years and over who have experienced leg trauma (open fracture, soft tissue damage), elective leg deformity corrective surgery, bone infection or fracture non-union who have been treated with the use of an external fixator for fixation. Specific exclusion criteria were patients below the age of 18 years old, patients with cancer, treatment of the injury with internal nail, patients who underwent amputation, the use of external fixators for soft tissue contracture management, editorials, comment papers, review papers, conference proceedings and non-English papers. Titles, abstracts, and full texts were screened for suitability by pairs of reviewers according to the inclusion and exclusion criteria using Rayyan QCRI online software. Any conflicts were resolved through discussion with three independent specialist senior reviewers. Following full text screening, references lists of included articles were manually searched to ensure that all relevant studies were identified. Due to lack of evidence, forward searching was also completed for studies included in the review. Data quality was assessed using the mixed methods appraisal tool and the CERT assessment tool was utilised to look at completeness of reporting of exercise interventions. Results. A total number of 832 articles were initially retrieved from our search once duplicate articles removed. After title and abstract screening, 45 articles remained for full text screening. Of these, 11 articles met our inclusion criteria and included for data extraction. Conclusions. We expect high variability of results due to our inclusion criteria and therefore plan to conduct a narrative synthesis to summarise the findings whilst measing against the mixed methods appraisal tool and CERT assessment scores to assess the data quality. We anticipate lower assessment scores within the fewer articles found and therefore poorer-quality data. We currently are in the process of finalising this data extraction. This will be completed ready for submission and potential presentation at the BLRS conference in March 2023

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

This study aimed to determine if multiple failed closed reductions (CRs) prior to fixation of distal radius fracture is associated with the odds of complication-related reoperation up to two years post fracture. We identified all distal radius fracture patients aged 18 or older between the years of 2003-2016 in Ontario, Canada from linked administrative databases. We used procedural and fee codes to identify patients who underwent primary outpatient surgical fixation between 8 and 14 days post fracture, and grouped patients by the number of CRs they underwent prior to definitive fixation. We excluded patients who underwent fixation within 7 days of their fracture to exclude more complex fracture types and/or patients who required more immediate surgery. We grouped patients according to the number of CRs they underwent prior to definitive fixation. We used intervention and diagnostic codes to identify reoperations within two years of fixation. We used multi-level multivariable logistic regression to compare the association between the number of CRs and reoperation while accounting for clustering at the surgeon level and adjusting for other relevant covariables. We performed an age-stratified analysis to determine if the association between the number of CRs and reoperation differed by patient age. We identified 5,464 patients with distal radius fractures managed with outpatient fixation between 8 and 14 days of their fracture. A total of 1,422 patients (26.0%) underwent primary surgical fixation (mean time to fixation 10.6±2.0 days), while 3,573 (65.4%) underwent secondary fixation following one failed CR (mean time to fixation 10.1±2.2 days, time to CR 0.3±1.2 days), and 469 (8.6%) underwent fixation following two failed CRs (mean time to fixation 10.8±2.2 days, time to first CR 0.0±0.1 days, time to second CR 4.7±3.0 days). The CR groups had higher proportions of female patients compared to the primary group, and patients who underwent two failed CRs were more likely to be fixed with a plate (vs. wires or pins). The unadjusted proportion of reoperations was significantly higher in the group who underwent two failed CRs (7.5%) compared to those who underwent primary fixation (4.4%), and fixation following one failed CR (4.9%). Following covariable adjustment, patients who underwent two failed CRs had a significantly higher odds of reoperation (odds ratio [OR] 1.72 [1.12-2.65]) compared to those who underwent primary fixation. This association appeared to worsen for patients over the age of 60 (OR 3.93 [1.76-8.77]). We found no significant difference between the odds of reoperation between patients who underwent primary fixation vs. secondary fixation following one failed CR. We found that patients with distal radius fractures who undergo multiple CRs prior to definitive fixation have a significantly higher odds of reoperation compared to those who undergo primary fixation, or fixation following a single CR. This suggests that surgeons should offer fixation if indicated following a single failed CR rather than attempt multiple closed reductions. Prospective studies are required to confirm these findings

Introduction. Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach. Materials & Methods. We compared clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, fracture classification, post-treatment alignment and presence of an open fracture. Results. The mean time in frame was 168 days for the 2-ring group and 200 days for the 3+ rings group (p=0.003). No significant difference was found in the rate of malunion (p=0.428) or the requirement for secondary surgical intervention to achieve union (p=0.363). No significant difference in time in frame was found between individual surgeons. Conclusions. This study finds that 2-ring frame constructs are a reliable option associated with significantly shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations. Although this study cannot identify the underlying cause of the difference in treatment time between frame designs, it is possible that differences in mechanical stability lead to a more favourable strain environment for fracture healing in the 2-ring group

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Surgeries for reverse total shoulder arthroplasty (RTSA) significantly increased in the last ten years. Initially developed to treat patients with cuff tear arthropathy (CTA) and pseudoparalysis, wider indications for RTSA were described, especially complex proximal humerus fractures. We previously demonstrated in patients with CTA a different sequence of muscular activation than in normal shoulder, with a decrease in deltoid activation, a significant increase of upper trapezius activation and slight utility of the latissimus dorsi. There is no biomechanical study describing the muscular activity in patients with RTSA for fractures. The aim of this work is to describe the in vivo action of RTSA in patients with complex fractures of the proximal humerus. We conducted an observational prospective cohort study comparing 9 patients with RTSA for complex humerus fracture (surgery more than 6 months, healed tuberosities and rehabilitation process achieved) and 10 controls with normal shoulder function. Assessment consisted in a synchronized analysis of range of motion (ROM) and muscular activity on electromyography (EMG) with the use of 7 bipolar cutaneous electrodes, 38 reflective markers and 8 motion-recording cameras. Electromyographic results were standardized and presented in muscular activity (RMS) adjusted with maximal isometric contractions according to the direction tested. Five basic movements were evaluated (flexion, abduction, neutral external rotation, external rotation in 90° of abduction and internal rotation in 90° of abduction). Student t-test were used for comparative descriptive analysis (p < 0,05). The overall range of motion with RTSA is very good, but lower than the control group: flexion 155.6 ± 10 vs 172.2 ± 13.9, p<0.05, external rotation at 90° 55.6 ± 25 vs 85.6 ± 8.8, p<0,05, internal rotation at 90° 37.8 ± 15.6 vs 52.2 ± 12, p<0,05. The three heads of the deltoid are more stressed during flexion and abduction in the RTSA group (p. The increased use of the 3 deltoid chiefs does not support the hypothesis proposed by Grammont when the RTSA is performed for a complex proximal humerus fracture. This can be explained by the reduced dispalcement of the rotation center of the shoulder in these patients compared to those with CTA. These patients also didn't present shoulder stiffness before the fracture. The maximal muscle activity of the trapezius in flexion and of the latissimus dorsi in flexion and abduction had not been described to date. These new findings will help develop better targeted rehabilitation programs. In addition, the significant role of the latissimus dorsi must question the risks of its transfer (L'Episcopo procedure) to compensate for external rotation deficits

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Introduction. Cerament, a bioresorbable hydroxyapatite and calcium sulfate cement, is known to be used as a bone-graft substitute in traumatic bone defect cases. However, its use in open fractures has not previously been studied. Materials and Methods. Retrospective, single-centre review of cases between November 2016 and February 2021. Open fractures were categorised according to the Orthopaedic Trauma Society classification (OTS). Cases were assessed for union, time to union, and associated post-operative complications. Results. Twenty-four patients were identified. Fifteen cases were classified as OTS simple open fractures, and nine cases were complex open fractures requiring soft tissue reconstruction. Four cases were lost to follow-up. Four cases had limited follow-up beyond 6 months but showed evidence of progressive radiographic union. Of the remaining 16 cases, eight cases (50%) went on to union with a mean time to union of 6.7 months (5 to 12 months). Persistent non-union remained in six cases (38%). Two cases required return to theatre due to an infected skin graft and wound dehiscence respectively. One case had the complication of persistent weeping of Cerament from the wound. This self-resolved within two weeks. Limitations of this case series include the lack of complete follow-up in eight patients (33%) and the lack of patient reported outcome measures. Conclusions. Cerament can be a useful adjunct in managing open fractures. However, it should be noted there is a high rate of non-union which may be reflective of the significant morbidity associated with open fractures with structural bone defects

Distal radius fractures have an incidence rate of 17.5% among all fractures. Their treatment in case of comminution, commonly managed by volar locking plates, is still challenging. Variable-angle screw technology could counteract these challenges. Additionally, combined volar and dorsal plate fixation is valuable for treatment of complex fractures at the distal radius. Currently, biomechanical investigation of the competency of supplemental dorsal plating is scant. The aim of this study was to investigate the biomechanical competency of double-plated distal radius fractures in comparison to volar locking plate fixation. Complex intra-articular distal radius fractures AO/OTA 23-C 2.1 and C 3.1 were created by means of osteotomies, simulating dorsal defect with comminution of the lunate facet in 30 artificial radii, assigned to 3 study groups with 10 specimens in each. The styloid process of each radius was separated from the shaft and the other articular fragments. In group 1, the lunate facet was divided to 3 equally-sized fragments. In contrast, the lunate in group 2 was split in a smaller dorsal and a larger volar fragment, whereas in group 3 was divided in 2 equal fragments. Following fracture reduction, each specimen was first instrumented with a volar locking plate and non-destructive quasi-static biomechanical testing under axial loading was performed in specimen's inclination of 40° flexion, 40° extension and 0° neutral position. Mediolateral radiographs were taken under 100 N loads in flexion and extension, as well as under 150 N loads in neutral position. Subsequently, all biomechanical tests were repeated after supplemental dorsal locking plate fixation of all specimens. Based on machine and radiographic data, stiffness and angular displacement between the shaft and lunate facet were determined. Stiffness in neutral position (N/mm) without/with dorsal plating was on average 164.3/166, 158.5/222.5 and 181.5/207.6 in groups 1–3. It increased significantly after supplementary dorsal plating in groups 2 and 3. Predominantly, from biomechanical perspective supplemental dorsal locked plating increases fixation stability of unstable distal radius fractures after volar locked plating. However, its effect depends on the fracture pattern at the distal radius

Aims

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

Background. Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomical monopolar press-fit radial head system commonly used for the treatment of radial head fractures. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with RHA between November 2007 and April 2014. Patients with a minimum of 12-month follow-up were included. Most recent radiographs were evaluated for loosening, stress shielding, and instability. Post-operative motion and outcomes were reported at most-recent follow-up. Results. At an average follow-up of 30 months, 7 of the 17 patients (41%) demonstrated radiographic loosening. Six of the 10 patients (60%) without loosening demonstrated stress shielding (average 6mm). Functional outcome scores included a mean ASES of 74, MEPS of 87, VAS Pain of 1, VAS Function of 8 and SANE of 79. Average flexion-extension arc was 13°–138°, and average pronation-supination was 77°–76° (Figure 1). Of the patients with radiographic loosening, 86% had undergone RHA with an associated ligamentous injury of the elbow. Satisfaction among patients was high, as no patient reported an unsatisfactory outcome. Conclusions. The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation due to a high rate of implant loosening observed

This paper describes how advances in three-dimensional printing may benefit the military trauma patient, both deployed on operations and in the firm base. Use of rapid prototype manufacturing to produce a 3D representation of complex fractures that can be held and rotated will aid surgical planning within multidisciplinary teams. Patient-clinician interaction can also be aided using these graspable models. The education of military surgeons could improve with the subsequent accurate, inexpensive models for anatomy and surgical technique instruction. The developing sphere of additive manufacturing (3D printing functional end-use components) lends itself to further advantages for the military orthopaedic surgeon. Military trauma patients could benefit from advances in direct metal laser sintering which enable the manufacture of complex surfaces and porous structures on bio-metallic implants not possible using conventional manufacturing. “Bio-printing” of tissues mimicking anatomical structures has potential for military trauma patients with bone defects. Deployed surgeons operating on less familiar fracture sites could benefit from three-dimensionally printing patient-specific medical devices. These can make operating technically easier, reducing radiation exposure and operating time. Further ahead, it may be possible to contemporaneously 3D print medical devices unavailable from the logistics chain whilst operating in the deployed environment

Aim. The optimal treatment of displaced intra-articular calcaneal fractures (DIACF) remains controversial. The operative treatment group has better anatomical recovery, functional outcome scores and less pain than non operative treatment patients, but it may lead to a higher incidence of complications, such as delayed wound healing and surgical site infections. The aim of this study was to analyze the prophylactic effect using a biphasic bone substitute (BS) eluting antibiotic on calcaneal implant-related infections. Methods. We conducted a retrospective non-randomized review of all patients with DIACF (type Sanders 2, 3, 4) from 2009 to 2017; 103 calcaneal fractures of 90 patients (13 bilaterally) were treated with plates. All cases received the same systemic antibiotic prophylaxis; BS was used on more complex cases with large bone defect and BS was added with antibiotic on higher risk patients. We collected data including complications: major (deep infections, osteomyelitis) and minor complications (wound dehiscence, superficial infection). We considered the absence of deep infections after 6 months. We compared statistically the outcomes of 3 operative groups: the first was treated with plates only (A), the second with plates and BS (B) and the third with plates added with BS eluting antibiotic (vancomicine or gentamicine) (C). Results. We examined 99 cases (group A: n33, B: n52, C: n14), 4 patients were lost; the mean age was 47,8 years (range 18–83 years). Minimal follow up was 6 months (range: 6 – 42 months). We have observed 8 (8,1%) implant-related infection (A:4, 12,1%; B:4, 7,7%), 2 (2%) superficial infection (B:2, 3,8%), 20 (20,2%) wound healing defects (A:11, 33,3%; B:7, 13,5%; C:2, 14,2%). We found a relevant reduction of the rates in the group C regarding the major complications without a statistic evidence. Conclusion. The three groups are uneven; particularly the group C has a high concentration of more severe risk patients. The low number of cases in the group C, which limited the statistic evidence, represents a second limit. The absence of major infection on group C found in this study, needs larger data to confirm this result. The open surgery has an intrinsic rate of skin complications but the use of BS eluting local antibiotic is an additional tool to manage difficult complex fractures and to prevent implanted-related infection, inhibiting bacterial colonization and biofilm protection, particularly in those patients that have suffered from a minor complication, which could lead to a deep infection