We describe the routine imaging practices of
Level 1 trauma centres for patients with severe pelvic ring fractures, and
the interobserver reliability of the classification systems of these
fractures using plain radiographs and three-dimensional (3D) CT
reconstructions. Clinical and imaging data for 187 adult patients
(139 men and 48 women, mean age 43 years (15 to 101)) with a severe
pelvic ring fracture managed at two Level 1 trauma centres between July
2007 and June 2010 were extracted. Three experienced orthopaedic
surgeons classified the plain radiographs and
This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the
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. All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT.Aims
Methods
Aims. To evaluate whether an ultra-low-dose CT protocol can diagnose
selected limb fractures as well as conventional CT (C-CT). Patients and Methods. We prospectively studied 40 consecutive patients with a limb
fracture in whom a CT scan was indicated. These were scanned using
an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography
In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected
cases were compared with 16 C-CT scans matched for age, gender and
type of fracture. Studies were assessed for diagnosis and image
quality. Descriptive and reliability statistics were calculated.
The total effective radiation dose for each scanned site was compared. Results. The mean estimated effective dose (ED) for the REDUCTION protocol
was 0.03 milliSieverts (mSv) and 0.43 mSv (p <
0.005) for C-CT.
The sensitivity (Sn), specificity (Sp), positive predictive value
(PPV) and negative predictive value (NPV) of the REDUCTION protocol
to detect fractures were 0.98, 0.89, 0.98 and 0.89 respectively
when two occult fractures were excluded. Inter- and intra-observer
reliability for diagnosis using the REDUCTION protocol (κ = 0.75, κ =
0.71) were similar to those of C-CT (κ = 0.85, κ = 0.82). Using
the REDUCTION protocol,
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. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively.Aims
Methods
The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up.Aims
Methods
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 surgical outcomes. A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups.Aims
Methods
Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature.Aims
Methods
In this randomized study, we aimed to compare quality of regenerate in monolateral Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study.Aims
Patients and Methods
In the time since Letournel popularised the surgical
treatment of acetabular fractures, more than 25 years ago, there
have been many changes within the field, related to patients, surgical
technique, implants and post-operative care. However, the long-term
outcomes appear largely unchanged. Does this represent stasis or
have the advances been mitigated by other negative factors? In this
article we have attempted to document the recent changes within
the surgery of patients with a fracture involving the acetabulum,
outline contemporary management, and identify the major problem
areas where further research is most needed. Cite this article:
The aim of this study was to evaluate near-infrared spectroscopy
(NIRS) as a continuous, non-invasive monitor for acute compartment
syndrome (ACS). NIRS sensors were placed on 86 patients with, and 23 without
(controls), severe leg injury. NIRS values were recorded for up
to 48 hours. Longitudinal data were analyzed using summary and graphical
methods, bivariate comparisons, and multivariable multilevel modelling.Aims
Patients and Methods
We compared the accuracy, operating time and radiation exposure
of the introduction of iliosacral screws using O-arm/Stealth Navigation
and standard fluoroscopy. Iliosacral screws were introduced percutaneously into the first
sacral body (S1) of ten human cadavers, four men and six women.
The mean age was 77 years (58 to 85). Screws were introduced using
a standard technique into the left side of S1 using C-Arm fluoroscopy
and then into the right side using O-Arm/Stealth Navigation. The
radiation was measured on the surgeon by dosimeters placed under
a lead thyroid shield and apron, on a finger, a hat and on the cadavers.Aims
Materials and Methods
Fractures of the distal femur can be challenging to manage and
are on the increase in the elderly osteoporotic population. Management
with casting or bracing can unacceptably limit a patient’s ability
to bear weight, but historically, operative fixation has been associated
with a high rate of re-operation. In this study, we describe the outcomes
of fixation using modern implants within a strategy of early return
to function. All patients treated at our centre with lateral distal femoral
locking plates (LDFLP) between 2009 and 2014 were identified. Fracture
classification and operative information including weight-bearing
status, rates of union, re-operation, failure of implants and mortality
rate, were recorded.Aims
Patients and Methods
This article presents a unified clinical theory
that links established facts about the physiology of bone and homeostasis,
with those involved in the healing of fractures and the development
of nonunion. The key to this theory is the concept that the tissue
that forms in and around a fracture should be considered a specific
functional entity. This ‘bone-healing unit’ produces a physiological
response to its biological and mechanical environment, which leads
to the normal healing of bone. This tissue responds to mechanical
forces and functions according to Wolff’s law, Perren’s strain theory
and Frost’s concept of the “mechanostat”. In response to the local
mechanical environment, the bone-healing unit normally changes with
time, producing different tissues that can tolerate various levels
of strain. The normal result is the formation of bone that bridges
the fracture – healing by callus. Nonunion occurs when the bone-healing
unit fails either due to mechanical or biological problems or a
combination of both. In clinical practice, the majority of nonunions
are due to mechanical problems with instability, resulting in too
much strain at the fracture site. In most nonunions, there is an
intact bone-healing unit. We suggest that this maintains its biological
potential to heal, but fails to function due to the mechanical conditions.
The theory predicts the healing pattern of multifragmentary fractures
and the observed morphological characteristics of different nonunions.
It suggests that the majority of nonunions will heal if the correct
mechanical environment is produced by surgery, without the need
for biological adjuncts such as autologous bone graft. Cite this article:
The most widely used classification system for
acetabular fractures was developed by Judet, Judet and Letournel over
50 years ago primarily to aid surgical planning. As population demographics
and injury mechanisms have altered over time, the fracture patterns
also appear to be changing. We conducted a retrospective review
of the imaging of 100 patients with a mean age of 54.9 years (19
to 94) and a male to female ratio of 69:31 seen between 2010 and
2013 with acetabular fractures in order to determine whether the
current spectrum of injury patterns can be reliably classified using
the original system. Three consultant pelvic and acetabular surgeons and one senior
fellow analysed anonymous imaging. Inter-observer agreement for
the classification of fractures that fitted into defined categories
was substantial, (κ = 0.65, 95% confidence interval (CI) 0.51 to
0.76) with improvement to near perfect on inclusion of CT imaging
(κ = 0.80, 95% CI 0.69 to 0.91). However, a high proportion of injuries
(46%) were felt to be unclassifiable by more than one surgeon; there
was moderate agreement on which these were (κ = 0.42 95% CI 0.31
to 0.54). Further review of the unclassifiable fractures in this cohort
of 100 patients showed that they tended to occur in an older population
(mean age 59.1 years; 22 to 94 Cite this article:
The aim of this study was to quantify the stability
of fracture-implant complex in fractures after fixation. A total
of 15 patients with an undisplaced fracture of the femoral neck,
treated with either a dynamic hip screw or three cannulated hip
screws, and 16 patients with an AO31-A2 trochanteric fracture treated
with a dynamic hip screw or a Gamma Nail, were included. Radiostereometric
analysis was used at six weeks, four months and 12 months post-operatively
to evaluate shortening and rotation. Migration could be assessed in ten patients with a fracture of
the femoral neck and seven with a trochanteric fracture. By four
months post-operatively, a mean shortening of 5.4 mm (-0.04 to 16.1)
had occurred in the fracture of the femoral neck group and 5.0 mm
(-0.13 to 12.9) in the trochanteric fracture group. A wide range
of rotation occurred in both types of fracture. Right-sided trochanteric
fractures seem more rotationally stable than left-sided fractures. This prospective study shows that migration at the fracture site
occurs continuously during the first four post-operative months,
after which stabilisation occurs. This information may allow the
early recognition of patients at risk of failure of fixation. Cite this article:
We evaluated the effect of low-intensity pulsed ultrasound stimulation (LIPUS) on the remodelling of callus in a rabbit gap-healing model by bone morphometric analyses using three-dimensional quantitative micro-CT. A tibial osteotomy with a 2 mm gap was immobilised by rigid external fixation and LIPUS was applied using active translucent devices. A control group had sham inactive transducers applied. A region of interest of micro-CT was set at the centre of the osteotomy gap with a width of 1 mm. The morphometric parameters used for evaluation were the volume of mineralised callus (BV) and the volumetric bone mineral density of mineralised tissue (mBMD). The whole region of interest was measured and subdivided into three zones as follows: the periosteal callus zone (external), the medullary callus zone (endosteal) and the cortical gap zone (intercortical). The BV and mBMD were measured for each zone. In the endosteal area, there was a significant increase in the density of newly formed callus which was subsequently diminished by bone resorption that overwhelmed bone formation in this area as the intramedullary canal was restored. In the intercortical area, LIPUS was considered to enhance bone formation throughout the period of observation. These findings indicate that LIPUS could shorten the time required for remodelling and enhance the mineralisation of callus.
We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification. These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus.
It is becoming increasingly common for a patient
to have ipsilateral hip and knee replacements. The inter-prosthetic (IP)
distance, the distance between the tips of hip and knee prostheses,
has been thought to be associated with an increased risk of IP fracture.
Small gap distances are generally assumed to act as stress risers,
although there is no real biomechanical evidence to support this. The purpose of this study was to evaluate the influence of IP
distance, cortical thickness and bone mineral density on the likelihood
of an IP femoral fracture. A total of 18 human femur specimens were randomised into three
groups by bone density and cortical thickness. For each group, a
defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing
the appropriate lengths of component. The maximum fracture strength
was determined using a four-point bending test. The fracture force of all three groups was similar (p = 0.498).
There was a highly significant correlation between the cortical
area and the fracture strength (r = 0.804, p <
0.001), whereas
bone density showed no influence. This study suggests that the IP distance has little influence
on fracture strength in IP femoral fractures: the thickness of the
cortex seems to be the decisive factor. Cite this article:
In this study, we describe a morphological classification
for greater tuberosity fractures of the proximal humerus. We divided
these fractures into three types: avulsion, split and depression.
We retrospectively reviewed all shoulder radiographs showing isolated
greater tuberosity fractures in a Level I trauma centre between
July 2007 and July 2012. We identified 199 cases where records and
radiographs were reviewed and included 79 men and 120 women with
a mean age of 58 years (23 to 96). The morphological classification
was applied to the first 139 cases by three reviewers on two occasions
using the Kappa statistic and compared with the AO and Neer classifications.
The inter- and intra-observer reliability of the morphological classification
was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior
to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59
to 0.65) classifications. The distribution of avulsion, split and
depression type fractures was 39%, 41%, and 20%, respectively. This
classification of greater tuberosity fractures is more reliable
than the Neer or AO classifications. These distinct fracture morphologies
are likely to have implications in terms of pathophysiology and
surgical technique. Cite this article:
