Aims. To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on
Aims. Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods. Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results. Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion. Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where
Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures. A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages.Aims
Methods
National guidelines encourage the use of total hip arthroplasty (THA) to treat intracapsular neck of femur fractures. There have been no population based studies appraising the
We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture. Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis.Aims
Methods
Hip fractures in young adults are rare but represent an important cohort of patients, of which relatively limited data exists. The aim of this study was to evaluate this distinct subgroup of hip fractures from an epidemiological perspective and assess their subsequent outcomes. Patients aged 18–50 were identified across an 8 year period from a total of 5326 hip fractures. 46 hip fractures met the inclusion criteria and a retrospective case series analysis was conducted. 25/46 (54%) of fractures were intracapsular and 21/46 (46%) were extracapsular. Only 15/46 (33%) of fractures were sustained from a high energy mechanism and 31/46 (67%) low energy. The low energy cohort was significantly more comorbid with a mean Elixhauser comorbidity score of 1.5 compared to the high energy cohort 0.3 (p<0.0005, unpaired t-test). Alcohol excess was the most prevalent comorbidity present in 24% of patients and was a positive predictor in complication (p=0.006, binary regression). Failure of fixation (non-union/avascular necrosis) in displaced intracapsular fractures sustained following low energy trauma managed by internal fixation 5/11 (45%) was markedly higher than the high energy cohort 0/6 (0%). 5 year mortality was 9% for all hip fractures, six times higher than an aged matched cohort of non-hip fractures (p=0.007, Wilcoxon test). Representing only 0.86% of all hip fractures in the study period, hip fractures in young adults are rare. A clear sub-division of patients is observed between patients with a low and high energy mechanism, both in terms of level of comorbidity and
Arthritis of the mid-foot is a common presentation to the foot and ankle clinic, resulting from primary (idiopathic), post-traumatic, or inflammatory joint degeneration. Treatment in the initial stages is conservative, with midfoot fusion regarded as the operative treatment of choice; however there is a paucity of comparative and patient reported data regarding outcomes. Patient reported outcome measures (PROMS), were prospectively collected from October-2015 to March-2018. Diagnoses were confirmed with image guided injection and initial management was conservative. In total, 66 patients were managed conservatively and 40 treated with mid-foot fusion. MOxFQ (Manchester Oxford Foot Questionnaire) and EQ-5D-3L (Euroqual) PROMS were collected pre-operatively, at 26 weeks and at 52 weeks. In the operatively managed group, the female:male ratio was 5.7:1, with a mean age of 61 (range 24–80), while in the conservatively managed group, the ratio was 2.1:1 with mean age 63 (range 29–86). In the surgically managed group, 88.2% of patients reported improvement in symptoms at 26 weeks and 88.9% at 52 weeks. This was greater than the conservatively managed group, in which 40.6% reported improvement at 26 weeks and 33.3% at 52 weeks. Mean MOxFQ improvement in the surgically managed group was +30.7 and +33.9 at 26 and 52 weeks respectively, and in the conservative group, +9.4 and +4.3, at 26 and 52 weeks. Similarly, favourable
Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout.Aims
Methods
A multicentre retrospective study of 879 total hip replacements (THR) was undertaken to investigate any differences in outcome between trainee surgeons and consultants. The effect of trainee supervision was also assessed. The primary outcome measures were survivorship and the Harris Hip Score (HHS). Length of stay was a secondary outcome. Patients were evaluated pre-operatively and at 1, 3, 5, 7 and 10 years post-operatively.
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. From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors.Aims
Methods
Introduction. Fractures of the distal tibia can be challenging to manage. Numerous surgical techniques have been utilised in managing these however there remains debate as to the optimum method of fixation. This study aims to assess the
Patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma have been recently established. However, little is known regarding what patient factors affect these outcomes. This is the first and largest prospective study to determine which patient factors influence
Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA.Aims
Methods
The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT. A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures.Aims
Methods
Objectives. Because of the contradictory body of evidence related to the
potential benefits of helical blades in trochanteric fracture fixation,
we studied the effect of bone compaction resulting from the insertion
of a proximal femoral nail anti-rotation (PFNA). . Methods. We developed a subject-specific computational model of a trochanteric
fracture (31-A2 in the AO classification) with lack of medial support
and varied the bone density to account for variability in bone properties
among hip fracture patients. Results. We show that for a bone density corresponding to 100% of the
bone density of the cadaveric femur, there does not seem to be any
advantage in using a PFNA with respect to the risk of blade cut-out.
On the other hand, in a more osteoporotic femoral head characterised
by a density corresponding to 75% of the initial bone density, local
bone compaction around the helical blade provides additional bone
purchase, thereby decreasing the risk of cut-out, as quantified
by the volume of bone susceptible to yielding. Conclusions. Our findings indicate benefits of using a PFNA over an intramedullary
nail with a conventional lag screw and suggest that any clinical
trial reporting
A series of 76 distal tibial pilon fractures treated with surgical fixation were retrospectively reviewed from case notes, plain radiographs and CT imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30). Definitive fixation was most commonly performed through an open technique (71 cases) with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. Single or double incision techniques were used to access the tibia, with fixation of the fibular performed when necessary. Superficial infection occurred in 5 cases (6.9%) and deep infection in 2 (2.8%). Aseptic wound breakdown occurred in 5 cases (6.9%). The rate of wound breakdown after three-incision technique was 37.5%. There were 10 cases of non-union (13.9%) and 8 of mal-union (10.5%). Post-traumatic arthritis was present on the most recent x ray in 17 cases (23.4%). Further surgery was required in 20 cases (27.8%), most commonly for metalwork related problems and also for treatment of non-union, post-traumatic arthritis and infection. This review gives comprehensive injury specific and
Introduction. Transscaphoid perilunate dislocation is a rare injury and therefore it is easily missed at the initial treatment. Once ignored, an alternative treatment such as proximal row carpectomy is indicated, but
Introduction. Correction and arthrodesis for cervical kyphosis associated with atetoid cerebral palsy has been considered to be difficult because of their involuntary neck movements and severe deformity. The aim of this study is to evaluate the
Introduction. Malalignment of some designs of stem is associated with an increased risk of aseptic loosening and revision. We investigated whether the alignment of the cemented polished, double-taper design adversely affected outcome, in a multicentre prospective study. Methods. A multicentre prospective study of 1189 total hip replacements was undertaken to investigate whether there is an association between
The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the
