Aims. In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries. Patients and Methods. Between January 2014 and April 2016, all patients with an isolated, nonoperatively treated one-part proximal humerus fracture were prospectively followed up. Clinical and radiological evaluation took place at less than two, six, 12, and 52 weeks. Fracture configuration, bone quality, and comminution were determined on the initial radiographs. Fracture healing, secondary displacement, and treatment changes were recorded during follow-up. Results. In 100 patients (59 female, 41 male; mean age 57 years), 91 of the fractures (91%) remained stable. In five of nine patients (55%) with secondary displacement, surgery was recommended. Comminution, present in 23 patients (23%), was identified as a predictor of secondary displacement (p < 0.001). Patients’ age, sex, fracture configuration, and bone quality were not associated with secondary displacement (p ≥ 0.438). Nonoperative treatment resulted in a mean absolute Constant score (CS) of 80 (49 to 98), relative CS of 101% (63% to 138%), median subjective shoulder value of 95% (interquartile range (IQR) 90% to 100%), and median EuroQol five-dimensional questionnaire score of 0.89 (IQR 0.80 to 1.00) with bone union in all cases at one-year follow-up. Conclusion. Radiological re-evaluation was only necessary in patients presenting with comminution and may be redundant for 77% of patients with one-part proximal humerus fractures. Nonoperative treatment of one-part proximal humerus fractures remains the mainstay of treatment with a low rate of secondary surgery, a high union rate, and good clinical results. Cite this article: Bone Joint J 2019;101-B:1307–1312

We have examined the accuracy of reduction and the functional outcomes in elderly patients with surgically treated acetabular fractures, based on assessment of plain radiographs and CT scans. There were 45 patients with such a fracture with a mean age of 67 years (59 to 82) at the time of surgery. All patients completed SF-36 questionnaires to determine the functional outcome at a mean follow-up of 72.4 months (24 to 188). All had radiographs and a CT scan within one week of surgery. The reduction was categorised as ‘anatomical’, ‘imperfect’, or ‘poor’.

Radiographs classified 26 patients (58%) as anatomical,13 (29%) as imperfect and six (13%) as poor. The maximum displacement on CT showed none as anatomical, 23 (51%) as imperfect and 22 (49%) as poor, but this was not always at the weight-bearing dome. SF-36 scores showed functional outcomes comparable with those of the general elderly population, with no correlation with the radiological reduction.

Perfect anatomical reduction is not necessary to attain a good functional outcome in acetabular fractures in the elderly.

Aims. To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups. Methods. Based on specific eligibility criteria, 120 adults (median age 37.5 years (interquartile range (18 to 61)) and 84% males (n = 101)) diagnosed with an acute displaced mid-shaft fracture were recruited, and randomized to either the operative (n = 60) or nonoperative (n = 60) treatment group. This randomized controlled, partially blinded trial followed patients for 12 months following initial treatment. Functionality was assessed by the Constant score (CS) (assessor blinded to treatment) and Disability of the Arm, Shoulder and Hand (DASH) score. Clinical and radiological evaluation, and review of patient files for complications and reoperations, were added as secondary outcomes. Results. At 12 months, 87.5% of patients (n = 105) were available for analysis. The two groups were well balanced based on demographic and fracture-related characteristics. At six weeks of follow-up a significant difference in DASH score (p < 0.001) was found in favour of operative treatment. The functionality at 12 months of follow-up based on CS and DASH was excellent in both groups (CS > 90 points and DASH < 10 points) with no significant difference (p = 0.277 for DASH and p = 0.184 for CS) between the two groups. The risk of symptomatic nonunion was significantly higher in the nonoperative group (p = 0.014), with a relative risk of 9.47 (95% confidence interval (CI) 1.26 to 71.53) in this group compared to the operative group. The number-needed-to-treat to avoid one symptomatic nonunion was 6.2. Initial treatment and age were factors significantly associated with nonunion in a logistic analysis. There were 26% in both groups (n = 14 in operative group and n = 15 in nonoperative group) who required secondary surgery, with most indications in the nonoperative group mandatory due to nonunion compared to most relative indications in the operative group requiring intervention due to implant irritation. Conclusion. Superiority was not identified with either an all-operative or all-nonoperative approach. The functionality at short term (within six weeks) seems igreater following operative treatment but was not found at one year. The risk of nonunion is significantly higher with nonoperative treatment. However, an all-operative approach to lower the nonunion risk may result in unnecessary surgery and is not recommended. Cite this article: Bone Joint J 2021;103-B(4):762–768

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Aims

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Aims

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

Aims

The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years.

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.

Aims

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

Introduction. Sacral fractures were previously treated with transiliac bars, sacroiliac screws or posterior plates. Sacroiliac screws are not as invasive, but the risk of intra-operative neurovascular damage must be considered. Posterior plate fixation is slightly invasive. In 2006, we conceived a new fixation method with spinal instrumentation system, and I will introduce it. Procedure. We make 5cm skin incisions just above each side of post. sup. spine of ilium and make a tunnel under the soft tissue. Then, we insert 4 screws to ilium, pass two rods through the tunnel and fix them. If needed we make reduction or compression. Finally, set the transvers connecting device on both sides. Material and Method. We indicate this method for type C1 and C2 sacral fracture on AO classification. We treated 17 cases, C1 for 6 and C2 for 11 cases. We evaluated clinically and radiologically. Result. Mean operating time was 105 minutes, and mean hemorrhage was 125ml. We had 2 miss-directional insertions of screws out of 68 screws. We had 3 cases that complained of irritation pain around screw heads. No surgical site infection and no soft tissue necrosis. On radiological evaluation, we had no cases of correction loss, nonunion or implant failure. Conclusion. The advantages of our method are (1)easy and safety procedure, (2) high compatibility, (3)soft tissue protection, (4)stiffness of fixation, and (5)intraoperative manipulation, such as reduction or compression

Aim. In the last years, many short hip stem variants were developed, almost always sharing the principle of metaphyseal and proximal diaphyseal anchorage. In this study, we analyzed the midterm results after implanting short cementless hip stem of ESKA. Methods. A total of 380 total hip replacements using the ESKA-short cementless stems were performed in a series of 340 patients between November 2002 till May 2008. The clinical and radiological evaluation of the patients was done in September 2008. The mean follow up was 37 months (3–54 months). Results. The mean age of the patients was 65 years (35–85 years). The indications varied between osteoarthritis (n=342), avascular necrosis (n=23) and aseptic loosening of stem (n=15). Good clinical and radiological outcome without complications was observed in 361 cases. However, complications were recorded in 19 cases. Aseptic loosening was noted in 4 cases and was treated with stem exchange. Deep infection occurred in 5 cases, 3 of which had direct exchange and 2 had two-stage delayed reconstruction. Dislocation was noted in 2 cases, which were revisions after aseptic loosening. 8 patients suffered intraoperative femur fissures, 7 of which healed completely after prolonged partial weight bearing postoperatively (n=4 without osteosynthesis, n=3 needed adjunctive cerclage around the proximal femur). Only 1 spiral fracture was recorded and needed a periprosthetic NCB-plate. Conclusion. Our own experience with cementless short hip stems is, in accordance with other studies, also encouraging. Based on the metaphyseal and proximal diaphyseal anchorage, short stems established themselves as a surgical option in the hip replacement surgery. There was no increase in the postoperative complication rate compared with standard total hip arthoplasty. It is also an option for elderly population. However, long-term outcome is still to be investigated

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

Introduction. Distal radius fractures are one of the most common injuries attended in hospitals. Throughout the years the treatment has change from simple cast to ORIF. Objectives. To compare the functional and radiographic results in the treatment of the distal intrarticular radial fractures treated by volar buttress plate (T plate AO® Synthes, Oberdorf, Suiza) and fixed volar angle locking plate (DVR® Depuy, Warsaw, Indiana, USA). Material and Methods. We performed a comparative retrospective study between two series of patients treated by fixed volar angle locking plate (40 patients) or volar buttress plate (36 patients). Distal radius fractures were classified by the AO/ASIF Müller classification after X-ray study in two views (Anteroposterios and lateral views), surgical treatment was indicated by the type of fracture (unstable fractures) and open fractures. Demographic information was gathered, injury mechanism and postoperatory complications. The minimal follow-up was 10 months. We performed clinical and radiographic evaluations before surgery, postoperatory, to 3 months and at the end of the follow-up (Palmar tilt, radial inclination, radial height and the radioulnar index were measured). Lidström's and Quick Dash scale, by means of telephonic survey, were used for the functional evaluation. Results. The time from fracture to surgery was on average 3.74 days in the group of DVR ® plates and 1.69 days for the group treated with T buttress plates. Henry's approach was realized in every case and the average time spent in surgery was 74 minutes for patients treated with T buttress plate and 80 minutes for patients treated with plate DVR®. In some cases K wires had to be used in 9 cases in the DVR® group and 7 in the other group. DVR® group obtained better results in radiological evaluation except in the radial inclination. In the Quick Dash scale, conducted a telephone survey, the average for the DVR® group was 26.40 (CI: 13.6 to 81.8) and 33.37 (CI: 10.2–90) for the group of T buttress plate (p=0.055). Conclusion. The potential advantages of ORIF in the distal radius fractures are low complication rate, stable subchondral fixation and early active movement of the wrist in the postoperative period. The disadvantages are a high cost, greater complexity and surgical exposure. Locking plates were designed to prevent postoperative collapse of the fracture also allows a better fix system in osteoporotic bone. Both types of plates obtained good results radiological and functional at the end of follow-up but we have obtained better results in the patients treated with locking plates

Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. Methods and material. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. Results. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening). Discussion. Clinically, the three bearing types perform equally well at seven years, and there are few signs of impending failure for the stem. However, there are an alarmingly high proportion of cups showing signs of loosening. Two hips have been revised in the MOM group for aseptic loosening as opposed to none in the two other groups, which adds to the concern. The MOM articulation used in this study should be monitored closely for signs of aseptic loosening

The purpose of the study is to evaluate the retrospective results of 92 surgically treated spastic hips. Twenty-one patients were able to walk in the community with aids, 19 were able to walk about the house, and 13 were wheelchair bound. The mean age at the time of the operation was 7 yrs (3–18) and the average follow-up was 5. The cohort of the study included 45 tetraplegic patients, 6 diplegic, and 2 hemiplegic. The dislocated hips were 25 and the subluxated ones 67. The surgical treatment included soft tissue and bone procedures. The 53 patients were divided into two age groups: those less than 7yrs old and those older than 7yrs. The cohort was also divided into 39 patients operated in one setting, and 14 operated in more than one. Clinical evaluation was based on the joint range of motion, the ambulatory status and the pain. The radiological evaluation criteria were based on Reimer's migration index, the center-edge angle, Sharp's angle, and neck-femoral angle. We used the interclass correlation coefficient to measure our interobserver reliability for MI 0,93, for CE angle 0,95 and for Sharp's angle 0,81, as the interobserver difference for MI averaged 9% for CE angle 7and for Sharp's angle 3. Statistical analysis of continuous variables was done by Student's t-test or the Wilcoxon rank sum test. Categorical variables were evaluated by Fisher's test. Concerning the walking ability, from the 13 severe quadriplegic patients, none improved his functional level but they achieved better sitting balance. The walking ability of the rest of the patients improved one level in 78% of the cases. The mean preoperative abduction was improved from 24,7 to 33,5, the mean flexion was slightly reduced from 123 preoperatively to 114 postoperatively and the mean extension reduced from −20 preoperatively to −8 postoperatively. Reimer's index reduced from 67,2 to 21,7 postoperatively, the CE angle increased from −10,6 to 20,5, the Sharp's angle increased from 36,9 to 40,5 and the neck-shaft angle increased from 119,7 to 157,5post-operatively. Of greater significance were MI and CE at p<0.05. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year post-operatively. 46 hips were evaluated as good, 30 as satisfactory, and 16 as poor. The severe tetraplegic with small-negative CE angle and Reimer's migration index > 50%, as well as the small age of the patients (<7 yrs) were negative prognostic factors. Better results were observed when patients were operated at age <7yrs by soft tissue procedures and MI<30%, while patients >7yrs had satisfactory results only after combined bony and soft tissue procedures and MI <50%. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year postoperatively

Aims

Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone.

Aims

The aim of this study was to evaluate the clinical and radiological outcomes of locking plate fixation, with and without an associated fibular strut allograft, for the treatment of displaced proximal humeral fractures in elderly osteoporotic patients.

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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.

Aims

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis.

The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.