Aims

To investigate if preoperative CT improves detection of unstable trochanteric hip fractures.

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

Introduction. The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy. Methods. A survey was devised to investigate orthopaedic surgeons' knowledge of the law of consent and risk disclosure and distributed by Survey Monkey. Results. 194 respondents from a total of 365 consultant orthopaedic surgeons contacted (53%). 85% of respondents were aware that Montgomery is primarily an obstetric case, 14.5% thought it was a spinal surgery case, and 1 respondent (0.5%) thought it was a paediatric surgery case. 99% correctly defined the Bolam test, but 57% erroneously believed that Bolam was still applicable in consent cases. 7% of respondents believed that it was not necessary to disclose a risk of surgery if the risk was less than 1%, and 4% of respondents if the risk was less than 10%. The legal test of materiality was correctly identified by 86% of respondents where a reasonable person in the patient's position would be likely to attach significance to the risk. 5% erroneously believed that provision of a standardised, printed information booklet provides sufficient risk disclosure for the individual patient to give their informed consent. 97% were aware that the surgeon must discuss reasonable alternative treatments including ‘no treatment’. Only 28% were aware that when a surgeon refers a patient for an interventional radiology procedure, it is the referring doctor who should formally hold and document the initial consent discussion. Discussion. General awareness of Montgomery was satisfactory, including the need to discuss alternative treatments including ‘no treatment’, and the qualitative concept of material risk. There was less understanding that material risk is independent of any quantitative rate of occurrence. Over half of consultants erroneously believed that the Bolam test was still applicable in consent cases. Small numbers of respondents erroneously thought that an information booklet constituted sufficient information disclosure. There was widespread misunderstanding that if a consultant surgeon refers an individual for an interventional radiology investigation it is in fact for the referring doctor to hold the initial consent discussion. Further training is required in respect of several issues raised by Montgomery

Our study was undertaken to assess the inter- and intra-observer variability of the classification system of Sanders for calcaneal fractures. Five consultant orthopaedic surgeons with different subspecialty interests classified CT scans of 28 calcaneal fractures using this classification system. After six months, they reclassified the scans. Kappa statistics were used to analyse the two groups. The interobserver variability of the classification system was 0.32 (95% confidence interval (CI) 0.26 to 0.38). The subclasses were then combined and assessment of agreement between the general classes as a whole gave a kappa value of 0.33 (95% CI 0.25 to 0.41). The mean kappa value for intra-observer variability of the classification system was 0.42 (95% CI 0.22 to 0.62). When the subclasses were combined, it was 0.45 (95% CI 0.21 to 0.65). Our results show that, despite its popularity, the classification system of Sanders has only fair agreement among users

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants. This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively. There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921). This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively

Objective. Delayed radiographs are routinely done to help in diagnosis of occult scaphoid fractures. Our aim was to determine the diagnostic value of these late x-rays. Methods. This is a radio-diagnostic study. We prospectively reviewed radiographs of 67 patients with injury to their wrists who presented with anatomical snuff box to the accident and emergency department.5 patients showed up a fracture of the scaphoid on trauma x-rays and they were excluded from the study. All patients had a radiograph on day of presentation as well as a delayed radiograph at a later date. The radiographs were standardized to include 4 scaphoid views. All the radiographs were reported independently by a consultant radiologist (JN) and a consultant orthopaedic surgeon (ML). Results. 62 radiographs of 42 males and 20 females with an average age of 25.91 were examined. The two sequential radiographs were taken at an average delay of 10.23 days. There was no difference of opinion between the radiologist and the orthopaedic surgeon with regards to reporting. Only one of the late radiographs showed up a fracture of the proximal pole. Rest of the x-rays failed to detect any bony injury. Conclusion. If a fracture is not visible on first day it is difficult to visualize the fracture in delayed x-rays and a strong clinical suspicion should be supplemented with a more specific investigation like a bone scan or MRI scan. We present our data with an up to date review of literature

Introduction. In the orthogeriatric model of care, orthopaedic surgeons, geriatricians, anesthesiologists, physiotherapists and the nursing staff work together with the aim to optimize the outcomes of vulnerable older patients undergoing orthopaedic surgery. It is recommended that the orthogeriatric care of hip fracture patients should be based on systematic treatment guidelines. We describe here how operative and perioperative management of hip fracture patients changed between the first and the second year after initiation of orthogeriatric collaboration. Method. Data on all patients aged 65 years or over and experiencing a hip fracture between September 1st 2007 and August 31st 2009 were prospectively collected in a Finnish hospital district with a total of 200,000 inhabitants. The patients were evaluated 4–6 months postoperatively at the geriatric outpatient clinic. Starting from the second year, geriatrician's rounds 2–3 times a week at the orthopaedic ward were provided. In addition, a systematic treatment protocol agreed by orthopaedic surgeons, geriatricians and anesthesiologists was introduced to the hospital staff responsible for the care of hip fracture patients. Results. Data were available on 177 patients in the first and 232 patients in the second year (87 % and 95 % of eligible patients, respectively). There were no significant differences in the patient characteristics in regard with age, sex distribution, prefracture mobility level, living arrangements, number of medication used, body mass index, anesthesiological risk score or the type of the fracture between the two years. Compared to the first year, the patients were more likely to be operated by a consultant orthopaedic surgeon (74 % vs. 49 %, p<0.001) and to undergo hemiarthroplasty (64 % vs. 53 %, p=0.013) during the second year. Urinary catheters were also removed before discharge from the orthopaedic ward more frequently (28 % vs. 14 %, p=0.001). There was a trend towards shorter delay to operation (<24 hours in 40 % vs. 32 %, p=0.140) and more frequent use of blood transfusions (39 % vs. 32 %, p=0.128). There was no difference in the mean length of stay at the orthopaedic ward between the two years (6 days in the first vs. 7 days in the second year, p=0.081). The 4-month mortality was 20 % in the first and 17 % in the second year (p=0.436). Conclusions. The treatment practices showed changes towards guideline recommendations after initiation of orthogeriatric collaboration in the care of hip fracture patients without increasing the length of stay at the orthopaedic ward. Further follow-up is required to show how these improvements translate into longer-term outcomes and mortality

Aims

We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function.

Aims

The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

Aims

The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures.

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Aims

Distal radial fractures are the most common fracture sustained by the adult population. Most can be treated using cast immobilization without the need for surgery. The aim of this study was to assess the feasibility of a definitive trial comparing the commonly used fibreglass cast immobilization with an alternative product called Woodcast. Woodcast is a biodegradable casting material with theoretical benefits in terms of patient comfort as well as benefits to the environment.

Objectives

Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.

Aims

The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.

Background

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis.

Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55).

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer.

The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis.

Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score.

Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437).

Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable.

Cite this article: Bone Joint J 2015;97-B:532–8.

A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died.

There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws.

There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws.

It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies.

Cite this article: Bone Joint J 2013;95-B:1402–5.

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).

The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D_indexscore) was significant in both groups compared with that before the fracture (p < 0.005).

Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.

The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.