Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

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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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Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients.

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To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial.

Paget's disease of bone (PDB) is the second most common metabolic bone disease. Osteoarthritis (OA) affects one-third of patients with PDB. The incidence of THR (total hip replacement) and TKR (total knee replacement) is 3.1- and 1.7-fold higher in PDB patients compared to non-affected age-matched controls. No large studies or joint registry reports exist describing the outcomes following THR or TKR in patients with PDB. The objectives of this study were to investigate the outcomes following THR and TKR in patients with PDB using national joint registry data. 144 THR and 43 TKR were identified using the Scottish Arthroplasty Project from 1996–2013. For THR, the most common early post-operative surgical complications were haematoma formation (1.4%), and surgical site infection (1.4%). The absolute incidence during follow-up of dislocation was 2.8%, and revision hip arthroplasty was performed in 2.8% of cases. Implant survival of the primary prosthesis was 96.3% (CI: 92.8 – 99.8) at 10-years, and patient survival was 50.0% (39.6 – 60.4) at 10-years. For TKR, the most common early post-operative surgical complication was surgical site infection (2.3%). The absolute incidence during follow-up of revision knee arthroplasty was 4.7%. On survival analysis, implant survival of the primary prosthesis was 94.5% (CI: 87.1 – 100) at 10-years, and patient survival was 38.3% (16.7 – 59.9) at 10-years. This is the largest reported series of outcomes following primary THR and TKR in patients with PDB. PDB patients are not at increased risk of surgical complications following primary THR or TKR compared to non-PDB patients

Background:. Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential. Methods:. Clinical and radiological outcomes in 49 patients with AO type 43B and 43C fractures were evaluated retrospectively. Definitive management depended on patient factors, soft tissue injury and fracture pattern. Results:. The majority of fractures (n=26, 53%) were C3 type. 9 fractures were open (18%), grade 3A or 3B. 34 patients (69%) were definitively managed with open reduction and internal fixation (ORIF) predominantly through an anterior approach. 15 (31%) had mini-open or percutaneous plafond reduction and external fixation. No medial plates were used. There were no deep infections. Complications occurred in 5 (10%) patients, all relating to metaphyseal delayed or non-union. At last review, 18 patients (36%) had radiographic evidence of post-traumatic arthritis. Discussion:. Surgeons treating pilon fractures should be familiar with external and internal fixation techniques in order to minimise surgical complications. An algorithm for treatment planning is suggested. Conclusion:. It is possible to achieve low surgical complication rates through careful management according to the nature of the fracture and patient characteristics. For plating, the antero-lateral distal tibial Peri-Loc plate is an effective and safe implant

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The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

Background:. The aim of this study was to review the surgical complications and clinical outcomes of patients with Pilon fractures treated with Ilizarov frames. Methods:. Data collected included surgical complications, grade of initial injury using the Ruedi-Allgower classification and quality of reduction according to the Teeny and Wiss criteria. Outcome scores were collected retrospectively using the Foot and Ankle Disability Index (FADI). Results:. A total of 97 consecutive patients were identified. All patients were treated with indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov external fixator. The mean time to union was 6 months. Data was available for 70 patients. 35 patients developed a pin site infection. There were no cases of osteomyelitis. 4 patients developed a DVT and 1 patient a PE, 4 patients required ankle fusions. Quality of reduction according to the criteria of Teeny and Wiss was anatomic in 40 patients, good in 23 patients, fair in 6 patients, poor in 3 patients. Conclusion:. This is one of the larger series of Pilon factures on literature review. Ilizarov frame fixation achieves stable reduction of the fractured fragments without additional trauma to soft tissues with minimal complications and good functional results

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Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Purpose. Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI. Methods and results. Retrospective analysis was carried out for consecutive humeral roddings for severe OI in last 3 years. Surgical technique for all humeri included retrograde telescopic nailing (female or both of FD or TST rods) with entry from olecranon fossa, exploration of radial nerve followed by osteotomies. Deformities were quantified and sub-classified as per level of deformity). Variables such as number of osteotomies, radiological union, intraoperative and postoperative complications, improvement in ROM and subjective patient satisfaction were recorded. Total 18 humeri in 12 patients with type III OI (except 1) with mean age of 8.9 years underwent nailing. All patients achieved radiological union at 6–10 weeks. Total 8 complications (44.4 %) were reported within mean 8.4 months follow up. Four segments (22.2 %) had intraoperative fractures at distal third of the humerus while negotiating the nail. Significantly higher intraoperative complications were encountered in humeri fixed with both components combined and upper third level deformities, deformities > 900 and more than 2 osteotomies. Other complications were prominent implant at upper end (2) with growth and one each of contralateral fracture and distal humeral varus. All patients reported improvement in ROM and functional status. Conclusion. Significant complications are associated with humeral nailing for severe OI. Quantification of the deformity with meticulous surgical planning and execution is advised. Despite these complications outcomes show benefits of the surgical treatment. Level of evidence. Therapeutic III

Proximal femoral fractures remain the most common reason for admission to hospital following orthopaedic injury, with an annual cost of £1.7 billion to the National Health Service and social care services. Fragility fractures of the hip in the elderly are a substantial cause of mortality and morbidity. Revision surgery for any cause carries a higher morbidity, mortality, healthcare- and social economic burden. Which patients suffer failed surgery and the reasons for failure have not been established. The aim of this study was to determine which patients are at risk of failed proximal femoral fracture surgery, the mechanism and cause fo failed surgery and modifiable patient factors associated with failure of hip fracture surgery. From prospectively collected data of 795 consecutive proximal femoral fractures admitted between July 2007 and July 2008, all peri-operative and post-operative complications were identified. 55 (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age (p=0.01), smoking (p=0.01) and cannulated screw fixation (p<0.01). Cannulated screw fixation was associated with a 30.9% complication rate. Mechanical cause was the most common reason for cannulated screw failure. Hip hemiarthroplasty most commonly failed by infective causes. Inter-trochanteric and subtrochanteric fracture fixation had very low failure rates. Surgical complication was not found to be associated with an increased mortality but a post-operative medical complication (21.8%) was associated with higher rate of mortality at 4-years (78.5%) and shorter time to mortality. (Median time 0.16 years (95% CI 0.00–0.33)

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Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

Aims. A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection. Patients and Methods. A quasi-randomised study of 848 patients with an intracapsular fracture of the hip was conducted in one large teaching hospital on two sites. All were treated with a hemiarthroplasty. A total of 448 patients received low dose single-antibiotic impregnated cement (control group) and 400 patients received high dose dual-antibiotic impregnated cement (intervention group). The primary outcome measure was deep SSI at one year after surgery. Results. The rate of deep SSI was 3.5% in the control group and 1.1% in the intervention group (p = 0.041; logistic regression adjusting for age and gender). The overall rate of non-infective surgical complications did not differ between the two groups (unadjusted chi-squared test; p > 0.999). Conclusion. The use of high dose dual-antibiotic impregnated cement in these patients significantly reduces the rate of SSI compared with standard low dose single antibiotic loaded bone cement. Cite this article: Bone Joint J 2016;98-B:1534–1541

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The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

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Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms.

Introduction. Managing open tibial fractures according to national guidelines is a primary focus for major trauma centres, however pressures of capacity and expertise limit the capability to achieve all of these standards for every patient. Debate remains over the impact of particular aspects of guidance, especially in relation to the timing of surgical interventions. Evaluation of these tenants of care predominantly hinge on trends derived from low level scientific evidence, mainly due to the difficulty in completing high level studies. The aim of this study is to assess the complication rates and the associations with difficulties in achieving the national guidance standards. Methods. Retrospective analysis of the 2015/2016 cohort of 3B open tibial fractures treated at the Queen Elizabeth Hospital Birmingham. Data collected, through the use of the patient electronic records, cross referenced against hospital coding and trauma injury database, included patient demographics, injury details, clinical interventions, surgical management, complications and time to bony union. Results. During the studied period, 40 patients were identified with 3B open tibial fractures. 2 patients died during the period of management, 3 patients were lost to follow up. Median time to definitive soft tissue coverage was achieved at 5 days post injury, definitive fixation at 6 days post injury. 25% of the cohort breached the 7 day maximum recommended limit. Overall complication rate was greater than 50%, with deep infection rate of 11% and non-union rate of 9%. Median time to union was 9 months. Conclusions. Missed opportunities to provide optimal patient care for severe lower limb open fractures are contributing to the high complication rates for these injuries. In order to aim for improvements in clinical outcomes, considered multispecialty clinical decision making needs to be coupled with institutional support and resources to adequately provide care for this injury cohort

Distal clavicle fractures have a significant non-union rate, and are often managed operatively. Many of the fixation devices used have a high complication rate or require removal. An arthroscopic technique using the Tightrope device (Arthrex) has been used in our institution. We aimed to describe our initial results. Eighteen cases were identified retrospectively, and the notes and radiographs reviewed. Twelve patients were male, six female, with mean age 33 years. All fractures were displaced, lateral to the coraco-clavicular ligament complex: six showed marked comminution. Mean follow-up was thirteen weeks. Fifteen fractures united, with a mean radiological time to union of 8 weeks (range 6-13 weeks). There were three surgical complications. In one, the clavicular button was not seated correctly on bone, and early failure required revision surgery. In another, there was inadequate reduction, radiographic non-union at five months and subsequent device failure. In the last, there was radiographic non-union, but the patient was asymptomatic. The arthroscopic tightrope device provides minimally invasive stabilisation and reliable union. The complications seen were related to incorrect technique, and anticipate the complication rate to diminish as the technique is developed. We recommend the use of this technique for the stabilisation of distal clavicle fractures

Introduction. The treatment of clavicle fractures remains controversial. Although most clavicle fractures can be treated successfully nonoperatively, no consensus exists for the complete range of lesions. A systematic literature review was performed to summarize and compare the results of different treatments. Material and Methods. A Pubmed search on ‘clavicle’ and ‘fracture’ was performed and relevant papers collected. Predefined inclusion/exclusion criteria had to be met and parameters were extracted. The articles were regrouped according to fracture location: midshaft; lateral; or location not specified. Main parameters were: Edinburgh classification; treatment type; complications; pseudarthrosis; cosmetic satisfaction and pain. Results. From 105 papers retrieved, 41 were included representing 4959 patiens with a median follow-up of 33 months. Patients lost to follow-up was 20.2%. The rate of displacement was higher in the lateral fracture group (63.5% versus 50.5% for the midshaft group and 33.5% for location not specified. Of all patients, 75.9% were treated nonoperatively. The lateral fracture group was operated on most (48.4%). Nonoperative treatment led to pseudarthrosis in 3.1% of midshaft fractures compared to 12.6% for lateral fractures. Operative treatment led to 7% and 2.7% of pseudarthrosis for the midshaft and lateral fractures respectively. Cosmetic dissatisfaction was frequent (13.6% for the nonoperatively treated fractures and 7.9% for surgically treated fractures). Surgical complications occurred frequently, especially wound infections (5.8%). Operatively treated patients had better pain scores at final follow-up. Conclusions. A considerable number of patients treated nonsurgically have suboptimal outcome at follow-up. In selected cases, especially displaced lateral fractures, surgery may be warranted

Introduction. Direct lateral approaches to the hip require detachment and repair of the anterior part of the gluteus medius and minimus tendon attachments. Limping may occur postoperatively due to nerve injury or failure of muscle re-attachment. The aim of this study was to assess the integrity of abductor muscle repairs using a braided wire suture marker. Methods. Total hip arthroplasties were inserted using a modified Freeman approach. After repair of the abductor tendons using a 1 PDS suture with interlocking Kessler stitches, a 3–0 braided wire suture marker was stitched into the lower end of the flap. The suture was easily visible on postoperative radiographs and its movement could be measured. Patients were assessed using radiographs and Oxford hip scores collected prospectively. Results. 56 joint replacements were performed in 51 patients with no major surgical complications. Mean age was 65 yr and 80% (n=41) were female. It proved possible to reproducibly classify repairs based on radiographic measurements as: no wire movement (43%); repair stretched, moving cephalad a short distance (46%); repair detached, moving cephalad a significant distance (11%). Risk of failure of the repair had no relationship with age, preoperative Oxford hip score, or postoperative Oxford hip score. The mean Oxford hip score drop in the no movement group was 36%, the stretched group 37%, and the detached group 33%. These differences were not significant. Discussion/Conclusion. The wire marker proved to be a revealing method of auditing abductor repair following hip arthroplasty. No difference was demonstrated in outcome in relation to wire movement, therefore this study did not show any advantage from a careful repair technique. Due to the small number of failed repairs there may be a type II error. This method may also be useful in assessing the integrity of other large tendon repairs, such as quadriceps tendons splits in total knee replacements

BACKGROUND. From 1995 the cost of litigation to the National Health Service (NHS) from surgical procedures has been over 1.3 billion GBP. Spinal patients can present diagnostic challenges and the consequences of delayed diagnosis and surgical complications can be devastating. As a consequence these patients represent a high risk when surgeons seek to indemnify themselves. We therefore, aim to highlight the litigation patterns for these injuries within the United Kingdom. METHOD. Data was obtained from the NHS Litigation Authority from 2002 to 2010 which was analysed. RESULTS. Of the 236 claims, 144 were related to trauma or acute diagnostic issues and 92 from elective surgery. The total financial burden to the NHS came to 60.5 million GBP/72.5 million Euros. Of this sum 42.8 million GBP/51.3 million Euros were paid in damages, and the remaining 29% in legal costs. The financial costs were on average similar for trauma and elective cases. The most frequent cause of successful litigation for trauma were, missed fractures (41.7%), missed cauda equina (23.6%) and spinal infection (11.8%). The emergency department (43.8%), orthopaedic surgery (28.5%) and Medicine (13.9) bore the brunt of the claims. For elective surgery, Spinal Damage(19.8%), failure in Post-Operative Care (15.4%), Infection (11%) and Wrong Level Surgery, Cauda Equina and Surgical Failure at 9.9%. were likely to result in a successful claim, and the litigation burden was felt by the orthopaedic(60.4%), Neurosurgery(18.7%) and other surgical disciplines (11%). CONCLUSION. Acute spinal fractures, cord compression and infection should be considered in patients in the emergency department setting, with appropriate examination and investigations for uncertainty. A lack of awareness of at risk cases increases the likelihood of a pay-out and sums involved. For elective spinal surgery, a failure in the consenting process and the technical skill of the surgeon are likely to result in a pay-out. A failure to identify post-operative complications such as infection and thromboembolism are also indefensible. Protecting patients intra-operatively and maintaining high technical expertise and vigilance post-operative in an adequately consented patient may decrease litigation rates