To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1).Aims
Methods
Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery. A prospective feasibility study was performed in which consecutive tibial plateau fracture patients were treated with 3D surgical planning, including patient-specific drilling guides applied to standard off-the-shelf plates. A postoperative CT scan was obtained to assess whether the screw directions, screw lengths, and plate position were performed according the preoperative planning. Quality of the fracture reduction was assessed by measuring residual intra-articular incongruence (maximum gap and step-off) and compared to a historical matched control group.Aims
Methods
The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty. The mean age of the patients was 85 years (58 to 102) and 273 (68%) were female. Follow-up was undertaken by a nurse who was blinded to the hemiarthroplasty that was used, at intervals for up to three years from surgery. The short-term follow-up of these patients at a mean of one year has previously been reported.Aims
Methods
The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression.Aims
Methods
There is no consensus on the treatment of proximal humeral fractures. Hemiarthroplasty has been widely used in patients when non-surgical treatment is not possible. There is, despite extensive use, limited information about the long-term outcome. Our primary aim was to report ten-year patient-reported outcome after hemiarthroplasty for acute proximal humeral fractures. The secondary aims were to report the cumulative revision rate and risk factors for an inferior patient-reported outcome. We obtained data on 1,371 hemiarthroplasties for acute proximal humeral fractures from the Danish Shoulder Arthroplasty Registry between 2006 and 2010. Of these, 549 patients (40%) were alive and available for follow-up. The Western Ontario Osteoarthritis of the Shoulder (WOOS) questionnaire was sent to all patients at nine to 14 years after primary surgery. Revision rates were calculated using the Kaplan-Meier method. Risk factors for an inferior WOOS score were analyzed using the linear regression model.Aims
Methods
Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles. Three observers reviewed 213 bilateral lower limb CT scans of uninjured ankles. Multiple measurements were recorded on the axial CT 1 cm above the plafond: anterior syndesmotic distance; posterior syndesmotic distance; central syndesmotic distance; fibular rotation; and sagittal fibular translation. Previously studied malreduction standards were evaluated on bilateral CT, including differences in: anterior, central and posterior syndesmotic distance; mean syndesmotic distance; fibular rotation; sagittal translational distance; and syndesmotic area. Unilateral CT was used to compare the anterior to posterior syndesmotic distances.Aims
Methods
Aims. The primary aim of this study was to address the hypothesis that fracture
It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples Aims
Methods
Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation. In a multicentre, parallel randomized controlled trial, 146 adult patients with an acute displaced fracture of the midthird of the clavicle were randomized to either nonoperative treatment with a sling (71, 55 men and 16 women with a mean age of 39 years, 18 to 60) or fixation with a pre-contoured plate and locking screws (75, 64 men and 11 women with a mean age of 40 years, 18 to 60). Outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, the Constant Score, and radiographical evidence of union. Patients were followed for one year.Aims
Patients and Methods
The Intraosseous Transcutaneous Amputation Prosthesis (ITAP)
may improve quality of life for amputees by avoiding soft-tissue
complications associated with socket prostheses and by improving
sensory feedback and function. It relies on the formation of a seal
between the soft tissues and the implant and currently has a flange
with drilled holes to promote dermal attachment. Despite this, infection
remains a significant risk. This study explored alternative strategies
to enhance soft-tissue integration. The effect of ITAP pins with a fully porous titanium alloy flange
with interconnected pores on soft-tissue integration was investigated.
The flanges were coated with fibronectin-functionalised hydroxyapatite
and silver coatings, which have been shown to have an antibacterial
effect, while also promoting viable fibroblast growth Aims
Materials and Methods
Periprosthetic femoral fractures (PFF) following total hip arthroplasty
(THA) are devastating complications that are associated with functional
limitations and increased overall mortality. Although cementless
implants have been associated with an increased risk of PFF, the
precise contribution of implant geometry and design on the risk
of both intra-operative and post-operative PFF remains poorly investigated.
A systematic review was performed to aggregate all of the PFF literature
with specific attention to the femoral implant used. A systematic search strategy of several journal databases and
recent proceedings from the American Academy of Orthopaedic Surgeons
was performed. Clinical articles were included for analysis if sufficient
implant description was provided. All articles were reviewed by
two reviewers. A review of fundamental investigations of implant
load-to-failure was performed, with the intent of identifying similar
conclusions from the clinical and fundamental literature.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
Objectives. The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane
This study compared the quality of reduction
and complication rate when using a standard ilioinguinal approach and
the new pararectus approach when treating acetabular fractures surgically.
All acetabular fractures that underwent fixation using either approach
between February 2005 and September 2014 were retrospectively reviewed
and the demographics of the patients, the surgical details and complications
were recorded. A total of 100 patients (69 men, 31 women; mean age 57 years,
18 to 93) who were consecutively treated were included for analysis.
The quality of reduction was assessed using standardised measurement
of the gaps and steps in the articular surface on pre- and post-operative
CT-scans. There were no significant differences in the demographics of
the patients, the surgical details or the complications between
the two approaches. A significantly better reduction of the gap,
however, was achieved with the pararectus approach (axial: p = 0.025,
coronal: p = 0.013, sagittal: p = 0.001). These data suggest that the pararectus approach is at least equal
to, or in the case of reduction of the articular gap, superior to
the ilioinguinal approach. This approach allows direct buttressing of the dome of the acetabulum
and the quadrilateral plate, which is particularly favourable in
geriatric fracture patterns. 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:
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
Antegrade nailing of proximal humeral fractures
using a straight nail can damage the bony insertion of the supraspinatus
tendon and may lead to varus failure of the construct. In order
to establish the ideal anatomical landmarks for insertion of the
nail and their clinical relevance we analysed CT scans of bilateral
proximal humeri in 200 patients (mean age 45.1 years (. sd. 19.6;
18 to 97) without humeral fractures. The entry point of the nail
was defined by the point of intersection of the anteroposterior
and lateral vertical axes with the cortex of the humeral head. The
critical point was defined as the intersection of the sagittal axis
with the medial limit of the insertion of the supraspinatus tendon
on the greater tuberosity. The region of interest, i.e. the biggest
entry hole that would not encroach on the insertion of the supraspinatus
tendon, was calculated setting a 3 mm minimal distance from the critical
point. This identified that 38.5% of the humeral heads were categorised
as ‘critical types’, due to
Bicondylar tibial plateau fractures result from
high-energy injuries. Fractures of the tibial plateau can involve
the tibial tubercle, which represents a disruption to the extensor
mechanism and logically must be stabilised. The purpose of this
study was to identify the incidence of an independent tibial tubercle
fracture in bicondylar tibial plateau fractures, and to report management
strategies and potential complications. We retrospectively reviewed
a prospectively collected orthopaedic trauma database for the period
January 2003 to December 2008, and identified 392 bicondylar fractures
of the tibial plateau, in which 85 tibial tubercle fractures (21.6%)
were identified in 84 patients. There were 60 men and 24 women in
our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures
open reduction and internal fixation was undertaken, either with
screws alone (23 patients) or with a plate and screws (61 patients).
The remaining patient was treated non-operatively. In all, 52 fractures
were available for clinical and radiological assessment at a mean
follow-up of 58.5 weeks (24 to 94). All fractures of the tibial
tubercle united, but 24 of 54 fractures (46%) required a secondary
procedure for their tibial plateau fracture. Four patients reported
pain arising from prominent tubercle plates and screws, which in
one patient required removal. Tibial tubercle fractures occurred
in over one-fifth of the bicondylar tibial plateau fractures in
our series. Fixation is necessary and can be reliably performed
with screws alone or with a screw and plate, which restores the
extensor mechanism and facilitates early knee flexion. Cite this article:
We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator
(RIA) system retain substantial osteogenic potential and are at
least equivalent to graft harvested from the iliac crest. Graft
was harvested using the RIA in 25 patients (mean age 37.6 years
(18 to 68)) and from the iliac crest in 21 patients (mean age 44.6
years (24 to 78)), after which ≥ 1 g of bony particulate graft material
was processed from each. Initial cell viability was assessed using Trypan
blue exclusion, and initial fluorescence-activated cell sorting
(FACS) analysis for cell lineage was performed. After culturing
the cells, repeat FACS analysis for cell lineage was performed and
enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin
red staining to determine osteogenic potential. Cells obtained via
RIA or from the iliac crest were viable and matured into mesenchymal
stem cells, as shown by staining for the specific mesenchymal antigens
CD90 and CD105. For samples from both RIA and the iliac crest there
was a statistically significant increase in bone production (both
p <
0.001), as demonstrated by osteocalcin production after induction. Medullary autograft cells harvested using RIA are viable and
osteogenic. Cell viability and osteogenic potential were similar
between bone grafts obtained from both the RIA system and the iliac
crest. Cite this article: