Aims. There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results. A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion. MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients. Cite this article: Bone Joint J 2024;106-B(4):387–393

Aims. Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes. Methods. In total, 140 patients were retrospectively identified from data obtained from a database of hospitals participating in a trauma research group. We divided them into two groups according to coronal plane malalignment of more than 5°: 108 had satisfactory fracture alignment (< 5°, group S), and 32 had unsatisfactory alignment (> 5°, group U). Patient characteristics and injury-related factors were recorded. We compared the rates of nonunion, implant failure, and reoperation as healing outcomes and Knee Society Score (KSS) at three, six, and 12 months as functional outcomes. We also performed a sub-analysis to assess the effect of fracture malalignment by plates and nails on postoperative outcomes. Results. The rates of nonunion and reoperation in group U were worse than those in group S (25.0% vs 14.3%; 15.6% vs 5.6%), but the differences were not significant (p = 0.180 and p = 0.126, respectively). Mean KSS in group U at all follow-up periods was significantly worse that in group S (75.7 (SD 18.8) vs 86.0 (SD 8.7); p < 0.001; 78.9 (SD 17.2) vs 89.1 (SD 9.8); p < 0.001; 85.0 (SD 11.9) vs 91.1 (SD 7.2); p = 0.002, respectively). In the sub-analysis of plates, mean KSS was significantly worse in group U at three and six months. In the sub-analysis of nails, the rate of reoperation was significantly higher in group U (28.6% vs 5.8%; p = 0.025), and mean KSS at six and 12 months was significantly worse in Group U. Conclusion. To obtain good postoperative functional results, intraoperative alignment of the coronal plane should be accurately restored to less than 5°. Cite this article: Bone Jt Open 2022;3(2):165–172

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

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. Methods. Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the “after weightbearing” images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft. Results. Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found. Conclusion. The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis. Cite this article: Bone Jt Open 2024;5(1):37–45

Aims

The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock. A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery. Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing. The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm. The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation

The collective orthopaedic literature appears to highlight the Jones fracture of the fifth metatarsal, as being slow to heal, and having a high incidence of non-union. There remains a lot of confusion, throughout the orthopaedic literature, about the exact nature of this fracture. . The authors present the largest case series currently published of 117 patients who sustained a Jones fracture, demonstrating patient outcomes with different modalities of care. All Medical notes from the Emergency Department are recorded on a database. A computer program was use to search the Emergency department database of the Edinburgh Royal infirmary notes data base for the terms 5. th. metatarsal combined with a coding for referral to fracture clinic over a 6 years period from 2004–2010. The researchers went through the X-ray archive, identified and classified all 5. th. metatarsal fractures. There were 117 patients in our series, refracture rate 7/117 6%. Average time to discharge 13 weeks (4–24). 18% of patients took longer than 18 weeks for their fracture to clinically heal. 34% were clinically healed at less than six weeks, with only 7% radiologically healed at six weeks. There was no significant difference in outcome between cast, moonboot, tubigrip or hard shoe in terms of outcome. A large proportion of Jones fractures have delayed healing, patients who are clinically asymptomatic may not have radiological healing. Currently in our practice there is no uniform management of Jones fractures. We discuss the difference in healing rates for different management techniques

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It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT.

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery

Objective. Ankle fractures are frequent and seem to be easy to handle in most cases. Of course, also these easy fractures can cause infections that must be carefully managed. What risk factors do we find? What options do we have in treating these complications? What are the consequences and what will the result for the patient be like, compared to non-infected cases?. In a retrospective study we included 82 patients treated with an osteosynthesis in ankle fractures (AO 44 B or C fractures). Average age was 52.4 years (range 20–84 years, median 51.0). Results. In 9 (10.9%) patients there were septic complications. Concerning risk factors, we found 4 (44.4%) patients with nicotine abuse, 2 (22.2%) with additional alcohol abuse. Average stay in hospital was 39.6 days (range 9–95 days). In 4 (44.4%) cases local infection was treated with antibiotics and rest alone. 5 (55.5%) of the patients had additional operations due to infection, in average 5.4 per patient (range 1–10). Early implant removal was done in 3 (33.3%) cases, in average after 3 months. We found 2 (22.2%) infections due to Staphylococcus aureus, 1 (11.1%) due to MRSA and one infection with MRSA and Proteus mirabilis. In one case vacuum dressing had been applied for 44 days. In another case infection could only be healed with an intramedullary vancomycin augmented spacer and finally a screw arthodesis of the ankle, this was a patient with proven arteriosclerosis of the lower extremities. All other fractures finally showed bony healing in xrays. No plastic surgery (e.g. flaps) was needed to close a wound definitely. In follow up (in average after 33 months, range 17–42), the average AOFAS of these patients was 76.5 (range 35–100, median 81.5), compared to an average AOFAS of 89.4 (range 35–100, median 98.0) of all patients. No patient developed a septic syndrom, no ICU stay occurred because of the infection. Conclusions. In spite of most cases of ankle fractures having good outcomes without complications, once infected an ankle osteosynthesis can be a serious problem for both surgeon and patient. Consequent surgical therapy at the right time including early hardware removal, spacers or vacuum dressing if necessary as well as an antibiotic regime addressing problematic pathogens like MRSA are needed to control infections. Problems remaining are functional outcome and wound closure in this sensitive area. Plastic surgery might be needed

Goal. The goal of this prospective, non-randomized study is to compare functional and life-quality changes in primary total hip replacement (THR) with minimally invasive anterior (MIA) and direct lateral (DL) approach in six months follow-up. Materials and Methods. Sixty (30 MIA and 30 DL) consecutive patients underwent primary THR were operated by the same senior surgeon. Patients completed functional and life-quality scores (Oxford Hip Score, Harris Hip Score, EQ-5D) before operation and four times (2 and 6 weeks, 3 and 6 months) after THR. Physical examination was taken all times. 15–15 patients underwent MRI examination to adjudge status of abductor muscles. The average patient age was approximately equal in both group. Results. The average OHS values were 13,4; 27,5; 40,9; 45,3; 47,5 in MIA and 15,3; 25,3; 39,7; 43,8; 45 in DL, the average HHS values 43,1; 68,7; 85,3; 91,9; 96,7 in MIA and 43; 58,2; 81,5; 90,2; 93,9 in DL, the average EQ-VAS 41,1; 72,5; 85,9; 87,8; 92,4 in MIA and 55,6; 67,8; 80,6; 84; 91,3 in DL consecutively. In MIA group both functional and life-quality scores showed better results, but for the 3rd postoperative month increases were approximately equal. Abductor muscle strength was significantly greater in MIA group in this period. In the 6th postoperative week Trendelenburg-sign was detected in 24 cases (80%) in DL and in 2 cases (6,7%) in MIA group, but in MIA patients were greater trochanter fractures, which had gone healing and limping was not detected 3 months after surgery. 3 months after surgery Trendelenburg-sign was detected in 2 cases in DL group. In follow-up period residual trochanteric pain was detected in 3 cases in DL but none in MIA group. Two weeks after THR climbing a flight of stairs was normal and public transport could be used by 80% of patients in MIA group. Distance walk was unlimited, support had not needed, daily activities were easy. There were 7 operative complications in MIA group, including 2 greater trochanter fracture, 1 haematoma and 4 transient lateral femoral cutaneous nerve palsy, which showed change for the better after 6 months. Postoperative hip dislocation was not detected. In DL group MRI represented fatty infiltration and atrophy of abductor muscles in most cases. Conclusions. Besides the fact that our learning curve may influence the results. It seems that earlier mobilisation and faster postoperative recovery can be achieved by MIA approach, which have many financial and social benefits. It preserves muscles and tendons, which probably can influence the long-term results. By preventing abductor muscles can assure better gait pattern. Of course additional long-term studies are needed

Aims

The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Current dogma is that a programme of anatomic repositioning with rigid internal fixation of fractures will lead to successful healing. Failures are attributed to failures in technique, not in instruments, implants, or concepts. Current basic science research shows that in the osteoporotic skeleton, bone trabeculae, once lost, are not replaced. This is true in fractures. In a series of cases, the author will show that lost bone is indeed not replaced, and the unsuccessful clinical outcome is caused by adherence to concepts that do not solve the problem of fracture repair in the elderly. Five specific case examples will be shown to demonstrate this problem. Despite an abundance of bone graft substitutes, bone morphogenic protein preparations, and cancellous bone autografting, the problem of dependable fracture repair in the elderly skeleton still needs to be solved

Aims

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

Introduction. Neonatal fractures are often quite distressing to parents and medical teams involved. Their management can be daunting due to the small size of the patient, the concern of the new parents and the fear of the obstetric staff about litigation and deformity or long term disability of the neonate. Aim. This study assesses the radiological and functional outcome of neonatal fractures up to two years post injury. Methods. We reviewed the notes of neonates at our hospital who sustained fractures spanning a 4 year period. Clavicle and humeral fractures were treated in a swaddling bandage for 3 weeks. Femoral fractures were treated in a gallows traction for 2–3 weeks. Xrays were taken once weekly. Patients were examined two years following their injury and function of the affected limb was assessed and compared with the unaffected side. Radiographs of the previously fractured bones were also taken at the 2 years follow up. Results. Eighteen (18) neonates sustained fractures predominantly due to birth trauma. There were four clavicle fractures, one fracture of a humerus, three femoral and 10 skull fractures. All seven (7) patients extremity fractures healed satisfactorily clinically and radiologically, with no residual deformity, limb length discrepancy or functional impairment at 2 years follow up. All parents were very satisfied with the outcome. Discussion and Conclusion. Neonatal fractures occur in <1% of births. Causes include birth trauma and congenital bone disease. Neonates with fractures are referred for Orthopaedic management which can be intimidating due to the infrequency of management of this cohort of patients. In our study all of our neonates with long bone fractures had good radiological results and no functional deficit when reviewed after 2 year. Clinicians can be reassured that neonatal fractures have a propensity to heal rapidly without residual functional or radiological abnormality as long as alignment is grossly maintained initially

A multicenter retrospective analysis of patients treated for tibial fracture was conducted to develop a score that correlates with fracture healing time and, ultimately, to identify the risk gradient of delayed healing. The clinical records of 93 patients treated for tibial fracture at three orthopaedic centers were evaluated. Patients were considered healed when full weight bearing was allowed and no further controls were scheduled. For the purpose of our analysis, we separated patients healed within or after 180 days. Patient's risk factors known to be associated to delay healing, as well as fracture morphology and orthopaedic treatment were recorded in an electronic Case Report Form (e-CRF). Information available in the literature was used to weight the relative risk (RR) associated to each risk factor; values were combined to calculate a score to be correlated to the fracture healing time: L-ARRCO (Literature-Algoritmo Rischio Ritardo Consolidazione Ossea). Among all information collected in e-CRFs, we identified other risk factors, associated to delayed healing, that were used to calculate a new score: ARRCO. Univariate logistic analysis was used to determine a correlation between the score and healing time. Analysis by receiver operating characteristic (ROC) and calculation of the area under the curve (AUC) were used for sensitivity and specificity. Complete information was available for 53 patients. The mean value of the L-ARRCO score among patients healed within 180 days was 5.78 ± 1.59 and 7.05 ± 2.46 among those healed afterwards, p=0.044. The mean value of the ARRCO score of patients healed within 180 days was 5.92 ± 1.78 and 9.03 ± 2.79 among those healed afterwards, p<0.0001. The ROC curve shows an AUC of 0.62±0.09 for L-ARRCO and an AUC of 0.82±0.07 for ARRCO, (p<0.0001). We have shown that the ARRCO score value is significantly correlated to fracture healing time. The score may be used to identify fractures at risk of delayed healing, thus allowing surgeon's early intervention to stimulate osteogenesis

OBJECTIVES. In elderly patients the temporary loss of function of the upper extremity due to immobilization for treatment of unstable proximal humeral fractures is a very disabling condition. Stable fixation of such fractures allowing immediate functional aftercare may contribute to early social reintegration in this group of patients. Aim of this study is to present the surgical technique of humeral blade plate fixation and the clinical and radiographic results after fixation of unstable surgical neck fractures with this implant followed by immediate functional treatment in patients older than 60 years. PATIENTS. 20 patients (4 male, 16 female) with a mean age of 74 years (59y–93y) were included in this study and treated consecutively for an unstable/displaced surgical neck fracture with a humeral blade plate. Postoperatively functional treatment was allowed. All but one patient had a clinical and radiographic follow-up 6 weeks po. At an average final follow-up of 18,8 months (12–24 months) 4 patients had died from causes unrelated to surgery. RESULTS. Surgery was performed in all patients without local or general complications despite comorbidities. In all patients anatomic reduction and stable fixation could be achieved. 6 weeks po all patients (N=20) were free of pain at rest, 7 patients had low pain (VAS < 4) when actively moving the arm. All patients used their operated arm for ADL and were back home or in the institution they came from at the time of trauma. All fractures were deamed to be healed without implant failure. In two cases a clinically asymptomatic 1–2mm protrusion of the blade through the subchondral bone was observed, but did not required further surgery. At final follow-up (N=8) the average absolute Constant/Murley Score was 68,6 points (contralateral 71,4). Radiographically all fractures had healed without complications. Implant removal was not required. CONCLUSION. Humeral blade plate fixation combined with suture tension-banding of the rotator cuff allows indirect reduction, dynamic and stable osteosynthesis of unstable surgical neck fractures even in osteoporotic bone. In our small series, this technique has shown to be a safe and reliable therapeutic option allowing immediate functional treatment and thus early social reintegration in elderly patients

We reviewed 27 diabetic patients who sustained a tibial fracture treated with a reamed intramedullary nail and compared them with a control group who did not have diabetes. There were 23 closed fractures and four were open. Union was delayed until after six months in 12 of the 23 (52%) diabetic patients with closed fractures and ten of the 23 (43%) control patients (p = 0.768). In two patients with diabetes (9%), closed tibial fractures failed to unite and required exchange nailing, whereas all closed fractures in the control group healed without further surgery (p = 0.489). In both the diabetic and control groups with closed fractures two patients (9%) developed superficial infections. There were two (9%) deep infections in diabetic patients with closed fractures, but none in the control group (p = 0.489). Overall, there was no significant difference in the rate of complications between the diabetic patients and the control group, but there was a tendency for more severe infections in patients with diabetes