Classification systems for the reporting of surgical complications have been developed and adapted for many surgical subspecialties. The purpose of this systematic review was to examine the variability and frequency of reporting terms used to describe complications in ankle fracture fixation. We hypothesized that the terminology used would be highly variable and inconsistent, corroborating previous results that have suggested a need for standardized reporting terminology in orthopaedics. Ankle fracture outcome studies meeting predetermined inclusion and exclusion criteria were selected for analysis by two independent observers. Terms used to define adverse events were identified and recorded. If a difference occurred between the two observers, a third observer was enlisted. Results of both observers were compared. All terms were then compiled and assessed for variability and frequency of use throughout the studies involved. Reporting terminology was subsequently grouped into 10 categories. In the 48 studies analyzed, 301 unique terms were utilized to describe adverse events. Of these terms, 74.4% (224/301) were found in a single study each. Only one term, “infection”, was present in 50% of studies, and only 19 of 301 terms (6.3%) were used in at least 10% of papers. The category that was most frequently reported was infection, with 89.6% of studies reporting on this type of adverse event using 25 distinct terms. Other categories were “wound healing complications” (72.9% of papers, 38 terms), “bone/joint complications” (66.7% of papers, 35 terms), “hardware/implant complications” (56.3% of papers, 47 terms), “revision” (56.3% of papers, 35 terms), “cartilage/soft tissue injuries” (45.8% of papers, 31 terms), “reduction/alignment issues” (45.8% of papers, 29 terms),“medical complications” (43.8% of papers, 32 terms), “pain” (29.2% of papers, 16 terms) and “other complications” (20.8% of papers, 13 terms). There was a 78.6% interobserver agreement in the identification of adverse terms across the 48 studies included. The reporting terminology utilized to describe adverse events in ankle fracture fixation was found to be highly variable and inconsistent. This variability prevents accurate reporting of adverse events and makes the analysis of potential outcomes difficult. The development of standardized reporting terminology in orthopaedics would be instrumental in addressing these challenges and allow for more accurate and consistent outcomes reporting

High energy chest trauma resulting in flail chest injury is associated with increased rates of patient morbidity. Operative fixation of acute rib fractures is thought to reduce morbidity by reducing pain and improving chest mechanics enabling earlier ventilator weaning. A variety of operative techniques have been described and we report on our unit's experience of acute rib fracture fixation. Over 18 months, 10 patients have undergone acute rib fracture fixation. Outcome measures included; patient demographics, time ventilated pre-operatively, time ventilated post-operatively and time spent on ITU/HDU post operatively. The mean time from presentation to surgery was 5 days (range 2–12 days). The mean time ventilated post operatively was 2 days (range 1–4 days) and the mean number of days spent on ITU/HDU post-operatively was 6 days (range 2–11 days). Our results appear positive in terms of time spent ventilated post-operatively but no conclusion can be drawn as we have no comparable non-operative group. We have however shown, that rib fracture fixation can be carried out successfully and safely in a trauma centre. Further evidence on rib fracture fixation is required from a large, multi-centre randomised controlled trial

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

Aim. The objective of this study was to define hospital-related healthcare costs associated with infection after fracture fixation (IFF) of the tibia and identify the subset of clinical variables relevant in driving these costs within the Belgium's healthcare system. Method. Between January 1. st. 2009 and January 1. st. 2014, a total of 358 patients treated operatively for AO type 41, 42 and 43 tibial fractures, were included in this study. The calculated costs were related to the Belgium's healthcare financing context and limited to costs induced by hospital related care. Five main hospital-related cost categories were studied: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. In addition, a total of 19 clinical and process variables were defined. Results. The median total treatment cost for all tibial fractures was €6.962 euro (IQR €4932 – €10.972), with AO type 42 being the most expensive fracture type. In 12 (3.4%) patients the treatment was complicated by deep (implant-related) infection. Subsequently, the treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients (€44.680 vs. €6.855 p<0.001) with hospitalization, length of stay (LOS), accounting for 50% of the total amount of the cost. The bivariate correlation between total treatment costs and LOS was close to 1. Multivariate analyses showed deep (implant-related) infection, non-union, age and ASA-3 as most important drivers (p<0.001) for both the total treatment costs and LOS. Moreover, the LOS was also driven by a delayed staged surgery protocol. Conclusions. One of the most challenging complications in trauma surgery is the development of IFF. Infections associated with fracture fixation devices result in significant patient morbidity and a prolonged treatment period. Currently, there is a lack of data regarding the definition, functional outcome and health care burden of this musculoskeletal complication. This study shows that treatment costs for deep (implant-related) infection were almost 7-times higher compared to non-infected patients. Furthermore, LOS accounted for 50% of the total amount of the cost. This study shows that future research needs to focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact

Surgical training has been greatly affected by the challenges of reduced training opportunities, shortened working hours, and financial pressures. There is an increased need for the use of training system in developing psychomotor skills of the surgical trainee for fracture fixation. The training system was developed to simulate dynamic hip screw fixation. 12 orthopaedic senior house officers performed dynamic hip screw fixation before and after the training on training system. The results were assessed based on the scoring system that included the amount of time taken, accuracy of guide wire placement and the number of exposures requested to complete the procedure. The result shows a significant improvement in amount of time taken, accuracy of fixation and the number of exposures after the training on simulator system. This was statistically significant using paired student t-test (p-value <0.05). Computer navigated training system appears to be a good training tool for young orthopaedic trainees The system has the potential to be used in various other orthopaedic procedures for learning of technical skills aimed at ensuring a smooth escalation in task complexity leading to the better performance of procedures in the operating theatre

Background. Bioresorbable materials offer the potential of developing fracture fixation plates with similar mechanical properties to bone thereby minimizing stress shielding and obviating the need for implant removal. Aim. To determine the in vivo degradation profile of a novel phosphate glass fibre composite bioresorbable plate and effects on the underlying bone. Methods. Twenty five NZW rabbits underwent application of the plate to the intact right tibia. They were divided into 5 groups corresponding to the time points from surgery to sacrifice −2, 6, 12, 26 and 52 weeks. Outcomes included radiographs, nanoCT imaging, scanning electron microscopy (SEM) and mechanical testing of the plated bone and the opposite unplated tibia at each time point. Results. At sacrifice, plate integrity was retained up to 12 weeks with no evidence of macroscopic inflammation. The mean load to failure of the plated bones expressed as a percentage of the opposite unplated bones was 179, 174, 172 and 115% after implantation for 2, 6, 12 and 26 weeks respectively. The flexural stiffness of the plated bones expressed as a percentage of the opposite bones revealed a mean increase of 245, 317, 205 and 110% at 2, 6, 12 and 26 weeks respectively. Although radiographs did not reveal any evidence of structural changes in the bones, NanoCT and SEM analysis revealed early porosity and progressive thinning of the cortex beneath the implant. However, bone formation around the plate progressed up to 26 weeks with improved cross sectional area characteristics of the plated bone compared to the control bone. Discussion. Cortical changes beneath the plate would indicate that stress shielding may occur even in plates with similar mechanical characteristics to bone. However, this is only one part of the adaptive response of the bone which overall maintains the mechanical properties of the plated bone

Intra-operative Tip-Apex Distance (TAD) estimation optimises dynamic hip screw (DHS) placement during hip fracture fixation, reducing risk of cut-out. Thread-width of a standard DHS screw measures approximately 12.5 millimetres. We assessed the effect of introducing screw thread-width as an intra-operative distance reference to surgeons. The null hypothesis was that there were no differences between hip fracture fixation before and after this intervention. Primary outcome measure was TAD. Secondary outcome measures included position of the screw in the femoral head, quality of reduction, cut-out and surgeon accuracy of estimating TAD. 150 intra-operative DHS radiographs were assessed before and after introducing screw thread-width distance reference to surgeons. Mean TAD reduced from 19.37mm in the control group to 16.49mm in the prospective group (p=<0.001). The number of DHS with a TAD > 25mm reduced from 14% to 6%. Screw position on lateral radiographs was significantly improved (p=0.004). There were no significant differences in screw position on antero-posterior radiographs, quality of reduction, or rate of cut-out. Significant improvement in accuracy (p=0.05) and precision (p=0.005) of TAD estimation was demonstrated. Awareness and use of screw-thread width improves estimation and positioning of a DHS screw in the femoral head during fixation of hip fractures

Background. The aim of our study was to assess the ability of orthopaedic surgical trainees to adequately assess ankle radiographs following operative fixation of unstable ankle fracture. Methods and results. We identified 26 Supination-External rotation (SER) stage IV fractures, and 4 Pronation-External rotation (PER) stage III fractures treated surgically in our institution. Radiographs were evaluated for shortening of the fibula, widening of the joint space, malrotation of the fibula and widening of the medial clear space. Trainees were shown these radiographs and asked to comment on the adequacy of reduction. They were then given a simple tutorial on assessing adequacy of reduction and asked to reassess these radiographs. The parameters discussed included assessment of medial clear space, drawing of the tibiofibular line, use of the “circle sign” and measurement of the talocrural angle. There was a statistically significant improvement from 64% to 71.4% (P< 0.05) in the radiographs correctly assessed by orthopaedic trainees following a short tutorial on radiographical assessment. Conclusions. Despite the frequency with which junior surgical trainees deal with ankle fractures, there is a lack of awareness on the objective means of adequately assessing ankle fracture fixation. We highlight this deficiency and demonstrate that a short tutorial on radiographic parameters results in improved assessment and better critical analysis of adequacy of reduction following ankle fracture fixation. As with fractures about the wrist, careful assessment of radiographic parameters should be considered standard practice in assessment of adequacy of reduction in fractures about the ankle

Introduction. The distal radius is the most frequently fractured bone in the forearm with an annual fracture incidence in the UK of about 9–37 in 10,000. Restoration of normal anatomy is an important factor that dictates the final functional outcome. A number of operative options are available, including Kirschner wiring, bridging or non-bridging external fixation and open reduction and internal fixation by means of dorsal, radial or volar plates. We designed this study to analyse the clinical and radiological outcome of distal radial fracture fixation using volar plating. Materials/Methods. Thirty-seven patients with distal radius fractures undergoing open reduction and internal fixation using volar plates were included. Tilt of the fractured distal radial fragment was recorded from the initial radiograph and classification of fractures was done using the Orthopaedic Trauma Association system. The QuickDASH questionnaire was used for evaluation of symptomatic and functional outcome six months to one year after surgery. The radiological outcome was assessed using measurements of radial inclination, ulnar variance and volar tilt. Of the thirty-seven patients, 13 were male and 24 were female. The mean age was 55.6 years (range 18–87 years). According to the AO classification, there were 8 cases each of C2 and C3 fractures, 6 cases of C1 fractures and 3 cases each of class A2, A3, B1 and B3 fractures. There were 2 patients with class B2 fracture. Results. Post-operatively, the average restoration of volar tilt was 6.47 degrees (range −12.4 to 20.3 degrees). Mean restoration of radial inclination was 23 degrees (range 12.5 to 30.0 degrees). Ulnar variance on average was 0.09 mm (range −5.0–6.7mm). The mean QuickDASH score was 9.8. Conclusion. The results of this study indicate that fixation of displaced intra- and extra-articular distal radial fractures is achieved satisfactorily with restoration of both normal anatomy and function using volar plates

Introduction. Surgical fixation of greater tuberosity fractures in the shoulder is the choice of treatment even if the fragment is minimally displaced. This helps to reduce the incidence of impingement secondary to a malunited tuberosity fragment especially in younger patients. We evaluated the functional outcome of our patients treated with open reduction and internal fixation of these fractures using cancellous screws. Materials and Methods. 19 patients with a mean age of 57.1 years (range 27–84) with 19 isolated greater tuberosity fractures treated with cancellous screws were included. These patients were evaluated after an average follow up period of nearly four years (range 66–444 weeks) using the DASH score and the Constant and Murley score. They were also clinically assessed to check for signs of impingement. Results. The median age in our study was 59. The mean Constant and Murley score was 75 (range 35–98) and the mean DASH score was 15.7 (0.8–45.0) which is a good result. Most patients had trouble in performing overhead activities (as per the DASH scoresheet) inspite of surgery. Impingement signs were also positive in nearly half of our patients (9 patients). Conclusions. Greater tuberosity fracture fixation using cancellous screws is a simple procedure associated with good results. However comparision needs to be made with the outcomes following fixation using suture anchors which is also a popular technique

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review.

A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information.

30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1.

Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve.

Socially deprived patients face significant barriers that reduce their access to care, presenting unique challenges for orthopaedic surgeons. Few studies have investigated the outcomes of surgical fracture care among those socially deprived, despite the increased incidence of fractures, and the inequality of care received in this group. The purpose of this study was to evaluate whether social deprivation impacted the complications and subsequent management of marginalized/homeless patients following ankle fracture surgery.

In this retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, we evaluated 45,444 patients who underwent open reduction internal fixation for an ankle fracture performed by 710 different surgeons between January 1, 1994, and December 31, 2011. Socioeconomic deprivation was measured for each patient according to their residential location by using the “deprivation” component of the Ontario Marginalization Index (ON-MARG). Multivariable logistic regression models were used to assess the relationship between deprivation and shorter-term outcomes within 1 year (implant removal, repeat ORIF, irrigation and debridement due to infection, and amputation). Multivariable cox proportional hazards (CPH) models were used to assess longer-term outcomes up to 20 years (ankle fusion and ankle arthroplasty).

A higher level of deprivation was associated with an increased risk of I&D (quintile 5 vs. quintile 1: odds ratio (OR) 2.14, 95% confidence interval (CI), 1.25–3.67, p = 0.0054) and amputation (quintile 4 vs. quintile 1: OR 3.56, 95% CI 1.01–12.4, p = 0.0466). It was more common for less deprived patients to have their hardware removed compared to more deprived patients (quintile 5 vs. quintile 1: OR 0.822, 95% CI 0.76–0.888, p < 0.0001). There was no correlation between marginalization and subsequent revision ORIF, ankle fusion, or ankle arthroplasty.

Marginalized patients are at a significantly increased risk of infection and amputation following operatively treated ankle fractures. However, these complications are still extremely rare among this group. Thus, socioeconomic deprivation should not prohibit marginalized patients from receiving operative management for unstable ankle fractures.

Introduction. Internal fixation of pertrochanteric fractures is evolving as newer implants are being developed. Proximal Femoral Nail Antirotation (PFNA) is a recently introduced implant from AO/ASIF designed to compact the cancellous bone and may be particularly useful in unstable and osteoporotic hip fractures. This study is a single and independent centre experience of this implant used in management of acute hip fractures. Methods. 68 patients involving 68 PFNA nailing procedures done over a period of 2 years (2007–09) were included in the study. Average follow-up period of patients was 1 year. AO classification for trochanteric fractures was used to classify all the fractures. Radiological parameters including tip-apex distance and neck shaft angle measurement were assessed. Results. Average age of patients included in the study was 80 years. 18 patients died during the follow up period due to non-procedure related causes. Average tip-apex distance was 12.7 mm and radiological fracture union time was 5 months. Revision of short to a long PFNA was needed for periprosthetic fracture of shaft of femur in two patients. Two patients needed a complex total hip replacement eventually and further two patients had removal of the implant due to PFNA blade penetration through the femoral head. Discussion. PFNA is a technically demanding procedure and has a learning curve. Our experience shows that it is a useful implant in unstable pertrochanteric fracture fixation. A close radiological and clinical follow up is recommended due to the risk of late fracture and implant related complications

Aims

Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement.

Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates.

Radial head fractures with fragment displacement should be reduced and fixed, when classified as Mason II type injuries. We describe a method of arthroscopic fixation which is performed as a day case trauma surgery, and compare the results with a more traditional fixation approach, in a case controlled manner.

We prospectively reviewed six Mason II radial head fractures which were treated using an arthroscopic reduction and fixation technique. The technique allows the fracture to be mobilised, reduced, and anatomically fixed using headless screws. All arthroscopic surgeries were conducted as day-cases. We retrospectively collected age and sex matched cases of open reduction and fixation of Mason II fractures using headless screws.

The arthroscopic cases required less analgesia, shorter hospital admissions, and had fewer complications. The averaged final range of follow-up, at 1 year post-operation was 15 to 140 degrees in the arthroscopic group and 35 to 120 degrees in the open group. The Mayo Elbow Performance Score was 95/100 and 90/100 respectively. No acute complications were noted in the arthroscopic group, and a radial nerve neuropraxia [n=1], superficial wound infection [n=1], and loose screw [n=1]. Two patients of the arthroscopic group required secondary motion gaining operations [n=1 arthroscopic anterior capsulectomy for a fixed flexion contracture of 35 degrees, and n=1 loss of supination requiring and arthroscopic radial scar excision]. Three patients in the open group required secondary surgery [n=2 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic anterior capsulectomy for fixed flexion deformities, and n=1 arthroscopic radial head excision for prominent screws, loss of forearm rotation, and radiocapitellar arthrosis pain].

The technique of arthroscopic fixation of Mason II radial head fractures appears to be valid, with respect to anatomical restoration of the fracture, minimal hospital admission, reduction in analgesia requirement, fewer complications, and a decreased need for secondary surgery.

Hypothesis

This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial shear fractures.

Postero-medial shear fractures are under-appreciated and their clinical relevance have recently been characterised. Less invasive surgery and indirect reduction techniques are inadequate for treating these postero-medial coronal plane fractures.

Introduction

The primary goal of treatment of an ankle fracture is to obtain a stable anatomic fixation to facilitate early mobilisation and good functional recovery. However, the need for open reduction and internal fixation must be weighed against poor bone quality, compromised soft tissues, patient co-morbidities and potential wound-healing complications.

Aim

The aim of this study was to define the role of implant material and surface topography on infection susceptibility in a preclinical in vivo model incorporating appropriate fracture biomechanics and bone healing.

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling.

Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9.

Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome

There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction.

Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients.

Follow up: clinical review and postal outcomes for 1 year

Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively.

Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction

Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18.

Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon).

Background

Angular stable volar locking plates have become increasingly popular for more comminuted fractures of the distal radius. Newer designs of plates have been thicker in profile and incorporate more options for distal fragment fixation. Although they have been shown to be successful at maintaining reduction to allow early mobilisation the main drawback is from screw cut-out. In our practice we have noticed that the newer style of plates that offer more rigid fixation has lead to more instances of screw cut-out. We aimed to quantify the minimum number of locking pegs and or screws need to maintain the operative reduction.