This study compares outcomes of fixation of subtrochanteric femoral fractures using a single lag screw (Gamma3 nail, GN) with a dual lag screw device (InterTAN nail, IN). The primary outcome was mechanical failure, defined as lag screw cut-out, back-out, nail breakage or peri-implant fracture. Technical factors associated with mechanical failure were also identified. All adult patients (>18yrs) with a subtrochanteric femoral fracture treated in a single centre were retrospectively identified using electronic records. Included patients underwent surgical fixation using either a long GN (2010–2017) or IN (2017–2022). Cox regression analysis was used to determine the risk of mechanical failure and technical predictors of failure. The study included 587 patients, 336 in the GN group (median age 82yrs, 73% female) and 251 in the IN group (median age 82yrs, 71% female). The IN group exhibited a higher prevalence of osteoporosis (p=0.002) and CKD□3 (p=0.007). There were no other baseline differences between groups. The risk of any mechanical failure was increased two-fold in the GN group (HR 2.51, p=0.020). Mechanical failure comprising screw cut-out (p=0.040), back-out (p=0.040) and nail breakage (p=0.51) was only observed in the GN group. The risk of peri-implant fracture was similar between the groups (HR 1.10, p=0.84). Technical predictors of mechanical included varus >5° for cut-out (HR 15.61, p=0.016), TAD>25mm for back-out (HR 9.41, p=0.020) and shortening >1cm for peri-implant fracture (HR 6.50, p=<0.001). Dual lag screw designs may reduce the risk of mechanical complications for patients with subtrochanteric femoral fractures

Background. Hip fractures affect annually over 350,000 people in the USA and over 1.6 million worldwide. About 50% of these numbers are intertrochanteric fractures,. The surgeon should be able to minimize the morbidity associated with the fracture by: recognizing the fracture pattern, choosing the appropriate fixation device, performing accurate reductions with ideal implant placement and being conscious of implant costs. In this study we assessed the ability of the orthopaedic surgeons to recognize fractures pattern, and choosing the ideal implant for the recognized fracture. Methods. We assessed 134 orthopaedic surgeons with questionnaires that assessed 14 different intertrochanteric femoral fractures. We evaluated the fractures as stable or unstable. We chose for each fracture the appropriate fixation device: either a Dynamic Hip Screw (for stable fractures) or an Intra Medullary Nail (for unstable ones), taking into consideration fracture's stability and implants’ costs. We compared the answers of the assessed surgeons to ours. Results. 134 orthopaedic surgeons fulfilled our questionnaires. The average agreement among the assessed surgeons and the authors for fractures’ stability distributed as follows: 78.2% agreement for the stable fractures, 86.2% for the unstable fractures. The agreement for the appropriate fixator between both groups (authors and surgeons) distributed as follows: in choosing the dynamic hip screws for the stable fractures 79.6% agreed with our choice. When choosing the Intra Medullary Nail for the unstable fractures 72.4% of the surgeons agreed with our choice. Interestingly, surgeons that their subspecialty is orthopaedic trauma tended to use more the Intra Medullary Nails in the stable fractures compared to the other surgeons. Conclusions. The majority of the assessed surgeons know to recognise inertrochanteric fractures’ stability and to choose the appropriate fixation device. 20% of surgeons did not agree with our choices. Choosing an Intra Medullary Nail for the stable fracture is not a mistake, but the wrong fixation device for the unstable fracture may cause non-union, mal-union or hardware failure, and might complicate patients’ rehabilitation and cure. We believe that a team discussion should take place for each and any case before operation, and whenever there is a doubt about fractures stability, the Iintra Medullary Nail should be chosen

Fractures of the lateral clavicle with complete displacement have a high non-union rate and are associated with poor functional outcomes following non-operative treatment. Various operative techniques are available but preliminary studies of open reduction and tunnelled suspensory device (ORTSD) fixation report good early functional outcomes with a low rate of complications. This study assesses the functional outcomes in a large series of patients treated using ORTSD. After surgical reconstruction in 67 patients, outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Oxford score at six weeks, and three, six and twelve months post-operatively. 55 of 64 surviving patients were contacted at a mean of 69 (27–120) months to complete DASH and Oxford scores, evaluate overall satisfaction, and document any complications. At one year post-operatively, the mean Oxford score was 46.4 and mean DASH score was 2.4 points (59/67 patients assessed). At a mean of 69 months after surgery, the mean Oxford score was 46.5 and mean DASH score was 2.2 (55 surviving and contactable patients). There were no significant differences between the one-year functional scores and those at the latest follow-up. Two patients developed symptomatic non-union requiring re-operation, and two developed an asymptomatic fibrous union not requiring surgery. The five-year survival when considering only obligate revision for implant-related complications was 97.0%. ORTSD fixation for isolated displaced lateral-end clavicle fractures in medically-fit patients is associated with good functional outcomes, and a low rate of medium-term complications. Routine removal of the implant was not necessary

This prospective, randomized, controlled trial compares patient outcome after non-operative care versus open reduction and tunneled suspension device fixation (ORTSD) for grade III or IV acromioclavicular joint disruptions. Sixty patients aged between sixteen and thirty-five years with an acute grade III or IV AC joint disruption were randomized to receive ORTSD fixation or non-operative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year using the Disabilities of the Arm, Shoulder and Hands (DASH), Oxford Shoulder Scores (OSS) and Short Form (SF-12). Reduction was evaluated using radiographs. Complications were recorded, and an economic evaluation performed. There was no significant difference in DASH or OSS at one year between non-operative and ORTSD groups (DASH score, 4.67 versus 5.63; OSS, 45.72 versus 45.63). Patients undergoing surgery had inferior DASH scores at 6 weeks (p<0.01). Five patients who failed non-operative management subsequently received surgery. Overall cost of treatment was significantly greater after ORTSD fixation (£796.22 vs £3359.73 (p<0.01)). ORTSD fixation confers no functional benefit over non-operative treatment at one year. While patients managed non-operatively generally recover faster, a significant group remain dissatisfied following non-operative treatment requiring delayed surgical reconstruction

Introduction. Locking nail have considerably improved the treatment of long weight bearing bones. However, distal locking needs experience and may expose to radiations. Many methods have been proposed to facilitate distal locking and improve safety. Recently, an external distal targeting device adapted to the ancillary of the Long Gamma Nail has been proposed. We report our experience with this device through a comparative series of distal lockings. Aim of this work was to assess feasibility and advantages brought about with this targeting device when considering time or dose of irradiation. Material and methods. Two prospective series of 50 distal locking performed by an experienced surgeon have been compared. Two methods were compared: the classical freehand technique using a Steinmann rod with the image of rounded holes, and the external distal targeting device. The following datas were collected: technical difficulties with either technique, locking mistakes and duration of exposure to radiations. Results. Two locking errors were observed using the targeting device, in pathological fractures with the use of a titanium nail. These cases belonged to the five earliest cases. External targeting device requires a learning curve that is reasonnably short with little difficulties encountered. Ther is a fundamental difference between the two series concerning exposure to radiations. In the freehand technique mean exposure was 25,8s (6–38) and it was 8,6s (6–18) with the dital targeting device. Discussion. A short learning curve confirms the ease of use of the distal targerting device. Diminution of exposure to radiation is effectively obtained. Some factors may increase the risk of error: the use of very long nails and the use of titanium nails as this may increase motion at distal end. Conclusion. The external visor is an efficient device as it facilitates distal locking and alllows for a diminution of irradiation time

Objectives. The additive use of an external modular device may improve dorsal compression forces in pelvic external fixation. This would improve the efficiency of indirect reduction and stabilization with an anterior pelvic external fixator. The purpose of this study was to determine the forces of the posterior pelvis achieved by a new device improving the application of a supraacetabular anterior external fixator compared with other constructs. Material and Method. Synthetic pelvic models were used. Complete pelvic ring instability was created by symphyseal and unilateral sacroiliac joint disruption. Four different constructs of fixation were tested. A pressure-sensitive film was placed in the sacroiliac joint. The constructs were applied in a standardized way. The maximum sacroiliacal compression loads (N) of each trial was recorded. Statistics was performed with the student t-test. Results. Standard supraacetabular two-pin external fixator achieved a dorsal compression load of 13.84 (SD 8.13). The new dorsal pelvic compression device delivered 177.05N (SD 32.32) of load across the sacroiliac joint when the pins were inserted half way and 183.58N (SD 46.64) with full pin insertion. Both the half- and full-pin construct demonstrated a significant dorsal load improvement with the pelvic compressor (p<0.05) compared with the standard supraacetabular fixator group. The C-clamp revealed compression forces of 384.88N (SD 22.95), which was significantly greater than all the other groups (p<0.05). Conclusion. We tested a simple and new modular device for improved application of pelvic external fixation. The centres of rotation of supra-acetabular pins were determined and used to achieve greater dorsal compression forces in disrupted pelvic ring injuries. The compression load is less than with a C-Clamp, but significantly greater than the familiar technique of standard external supra-acetabular fixation. This improves the initial stability in acute management of unstable, disrupted and life threatening pelvic ring fractures

Aims. Dual SC Screw (DSCS) is a novel fixation device for the femoral neck fracture. DSCS is comprised of screw and barrel allowing sliding of the screw and preventing protrusion of the screw end. Two types of the barrels are available, threaded barrel (TB) and plate barrel (PB). Ordinarily, both barrels are implanted. Concept of the design is that the PB contributes stability to the screw against the varus force of the femoral head while the additional screw with TB prevents rotational deformity. The aim of this study was to represent clinical results after DSCS operation in patients with femoral neck fracture. Method. Fifty-one patients with femoral neck fractures treated using DSCS and at least 3 months follow up are included and their clinical was evaluated. Result. Most fractures healed uneventfully. Cut out was occurred in two patients, perforation of the femoral head in one, femoral head necrosis in two, subtrochanteric fracture in one and 1backout of screw in one. The cases except that are excellent postoperative results. Discussion and Conclusion. Most complication was associated with some technical problems and all but one patients without that showed excellent results even for displaced fracture. Furthermore, secondary subtrochanteric fracture was rare compared other devices. The plate augmentation for screw fixation contributes to these excellent results

The management of pelvic fractures remains a challenging problem for orthopaedic surgeons. The prompt recognition of unstable fracture patterns is important in reducing mortality and morbidity. It is perceived wisdom that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. There is a paucity of evidence in the literature to support this belief. The aim of our study was to determine if a fracture of the transverse process of L5 was a predictor of pelvic fracture instability.

The Hospital Trauma database was reviewed. Between 2006 and 2009, 65 pelvic fractures were identified. They were classified according to the Burgess and Young classification. There were 37 stable and 28 unstable fractures. 14 patients had an associated fracture of the transverse process of L5; 9 were associated with an unstable fracture pattern. The odds ratio was 3; the relative risk 1.7.

A fracture of the transverse process of L5 is associated with an increased risk of pelvic fracture instability. Its presence should alert the attending physicians to the possibility of an unstable injury.

Aims. The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI). Methods. This is a retrospective cohort study of operatively managed orthopaedic trauma patients from 1 January 2007 to 31 December 2016, performed in Queensland, Australia. Record linkage was used to develop a person-centric, population-based dataset incorporating routinely collected administrative, clinical, and health economic information. The FRI group consisted of patients with International Classification of Disease 10th Revision diagnosis codes for deep infection associated with an implanted device within two years following surgery, while all others were deemed not infected. Demographic and clinical variables, as well as healthcare utilization costs, were compared. Results. There were 111,402 patients operatively managed for orthopaedic trauma, with 2,775 of these (2.5%) complicated by FRI. The development of FRI had a statistically significant association with older age, male sex, residing in rural/remote areas, Aboriginal or Torres Strait Islander background, lower socioeconomic status, road traffic accident, work-related injuries, open fractures, anatomical region (lower limb, spine, pelvis), high injury severity, requiring soft-tissue coverage, and medical comorbidities (univariate analysis). Patients with FRI had an eight-times longer median inpatient length of stay (24 days vs 3 days), and a 2.8-times higher mean estimated inpatient hospitalization cost (AU$56,565 vs AU$19,773) compared with uninfected patients. The total estimated inpatient cost of the FRI cohort to the healthcare system was AU$156.9 million over the ten-year period. Conclusion. The results of this study advocate for improvements in trauma care and infection management, address social determinants of health, and highlight the upside potential to improve prevention and treatment strategies. Cite this article: Bone Joint J 2024;106-B(1):77–85

Introduction. Anterior cruciate ligament reconstruction (ACLr) is the most widely published operation in the orthopaedic literature. Over recent years there has been increased interest in the surgical technique and role of concomitant procedures performed during ACLr. The National Ligament Registry (NLR) collects robust data on ACLr performed in the UK. In this registry analysis we explore trends in ACLr surgery and how they relate to published literature and the growing industry portfolio available to surgeons. Methods. Using data from the NLR, 14,352 ACLr performed between 2013–2021 were analysed. High impact papers on ACLr were then cross referenced against this data to see if surgical practice was influenced by literature or whether surgical practice dictated publication. Common trends were also compared to key surgical industry portfolios (Arthrex, Smith and Nephew) to see how new technology influenced surgical practice. Results. The number of ACLr performed in isolation is decreasing. The number of ACL reconstructions involving meniscal surgery shows an increasing trend since 2013, with 57% of ACLr in 2021 now involving meniscus surgery. The number of ACLr with lateral extra-articular tenodesis (LET) has increased sharply since 2018, preceding the stability trial publication in 2020. Graft preference and size has remained static despite the introduction of new graft harvest and fixation devices. Additional procedures such as other ligament reconstruction and additional cartilage surgery have also remained static over time. Conclusion. In this analysis we looked at surgical trends in ACLr and their relation to literature and industry. Meniscal intervention is increasing, in keeping with the growing level of literature in this area. In the setting of LET, a high impact level 1 study appears to have significantly changed the practice of UK surgeons with a sharp increase in the number of LET procedures being performed. Industry appears to have little influence on the change in surgical trends, suggesting high quality evidence is what drives innovation in ACLr while industry supports rather than influences innovation. It will be interesting to see the impact of the stability 2 study, recent work on the medial structures of the knee and the commissioning of cartilage centres on future trends

Periprosthetic femur fracture (PPF) are heterogeneous, complex, and thought to be increasingly prevalent. The aims were to evaluate PPF prevalence, casemix, management, and outcomes. This nationwide study included all PPF patients aged >50 years from 16 Scottish hospitals in 2019. Variables included: demographics; implant and fracture factors; management factors, and outcomes. There were 332 patients, mean age 79.5 years, and 220/332 (66.3%) were female. One-third (37.3%) were ASA1-2 and two-thirds (62.3%) were ASA3+, 91.0% were from home/sheltered housing, and median Clinical Frailty Score was 4.0 (IQR 3.0). Acute medical issues featured in 87/332 (26.2%) and 19/332 (5.7%) had associated injuries. There were 251/332 (75.6%) associated with a proximal femoral implant, of which 232/251 (92.4%) were arthroplasty devices (194/251 [77.3%] total hip, 35/251 [13.9%] hemiarthroplasty, 3/251 [1.2%] resurfacing). There were 81/332 (24.4%) associated with a distal femoral implant (76/81 [93.8%] were total knee arthroplasties). In 38/332 (11.4%) there were implants proximally and distally. Most patients (268/332; 80.7%) were treated surgically, with 174/268 (64.9%) requiring fixation only and 104/268 (38.8%) requiring an arthroplasty or combined solution. Median time to theatre was longer for arthroplasty versus fixation procedures (120 vs 46 hours), and those requiring inter-hospital transfer waited longer (94 vs 48 hours). Barriers to investigating PPF include varied classification, coding challenges, and limitations of existing registries. This is the first study to examine a national PPF cohort and presents important data to guide service design and research. Additional findings relating to fracture patterns, implant types, surgeon skill-mix, and outcomes are reported herein

MOXIMED KineSpring® Knee Implant System is an Orthopaedic device designed for younger or highly active patients with osteoarthritis. The device is placed under the skin, is attached to the tibia and femur, and contains springs which help limit some of the forces that are transmitted through the knee during activities such as walking or running and thereby relieve pain that may be experienced by patients with early arthritis of the knee. The aim of this study is to determine the long term safety and efficacy of the KineSpring knee implant system. This is a prospective case series involving two centres in Glasgow. 29 patients (mean age of 45.1 years and range 18-65 years) were recruited into the study between 2011 and 2016. The Primary outcome measure was Oxford knee score (OKS) at 2, 5 and 10 years post-operatively. Secondary outcome measures include device related complications and survival, patient reported functional outcome measures, patient satisfaction, pain levels and change in radiographic classification of osteoarthritis. At 2-year follow-up, 7 implants were removed (74.1% survival). Complications include deep infection, requiring removal in 1 patient, 2 implant failures requiring removal and one spring breakage. In comparison to pre-operative measures there was an improvement in the pain (3.58 vs. 5.20, p=0.02), stiffness (4.16 vs. 4.47, p=0.6) and OKS (32.4 vs. 36.9, p=0.03). The KineSpring improves overall pain, stiffness and functional outcome at 2 years following surgery, however there was a high rate of removal and further long-term follow up analysis is required regarding its effectiveness

Aims. Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants. Methods. All hip fracture patients aged 18 to 60 years admitted to a single centre over a 15-year period were used to identify the study group. Fracture pattern (undisplaced intracapsular, displaced intracapsular, and extracapsular) and type of operation (multiple cannulated hip screws, angular stable fixation, hemiarthroplasty, and total hip replacement) were recorded. The primary outcome measures were the Oxford Hip Score (OHS), the EuroQol five-dimension questionnaire (EQ-5D-3L), and EQ-visual analogue scale (VAS) scores. Preinjury scores were recorded by patient recall and postinjury scores were collected at a mean of 57 months (9 to 118) postinjury. Ethics approval was obtained prior to study commencement. Results. A total of 72 patients were included. There was a significant difference in pre- and post-injury OHS (mean 9.8 point reduction (38 to -20; p < 0.001)), EQ-5D (mean 0.208 reduction in index (0.897 to -0.630; p < 0.001)), and VAS , and VAS (mean 11.6 point reduction (70 to -55; p < 0.001)) Fracture pattern had a significant influence on OHS (p < 0.001) with extracapsular fractures showing the least favourable long-term outcome. Fixation type also impacted significantly on OHS (p = 0.011) with the worst outcomes in patients treated by hemiarthroplasty or angular stable fixation. Conclusion. There is a significant reduction in function and quality of life following injury, with all three patient-reported outcome measures used, indicating that this is a substantial injury in younger patients. Treatment with hemiarthroplasty or angular stable devices in this cohort were associated with a less favourable hip score outcome. Cite this article: Bone Joint J 2020;102-B(6):766–771

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

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Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

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The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

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To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

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Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.