Aims

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.

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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.

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The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures.

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It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

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Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS).

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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).

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The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

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Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

Aims. This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent. Patients and Methods. The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014. Results. A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p < 0.001) had a fracture of a TP. Patients with a fracture of a TP of L4 and/or L5 had a 5.5-fold risk (odds ratio (OR)) of having a biomechanically unstable pelvic injury. TP fractures (OR 1.6, p = 0.2) could not be confirmed as an independent predictor of haemodynamic instability. Conclusion. This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214–19

Aims. The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods. The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results. Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion. Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973–83

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The aim of this study was to record the incidence of post-traumatic osteoarthritis (OA), the need for total hip arthroplasty (THA), and patient-reported outcome measures (PROMS) after surgery for a fracture of the acetabulum, in our centre.

Aim. There is not adequate evidence to establish whether external fixation (EF) of pelvic fractures leads to a reduced mortality. We used the Japan Trauma Data Bank database to identify isolated unstable pelvic ring fractures to exclude the possibility of blood loss from other injuries, and analyzed the effectiveness of EF on mortality in this group of patients. Patients and Methods. This was a registry-based comparison of 1163 patients who had been treated for an isolated unstable pelvic ring fracture with (386 patients) or without (777 patients) EF. An isolated pelvic ring fracture was defined by an Abbreviated Injury Score (AIS) for other injuries of < 3. An unstable pelvic ring fracture was defined as having an AIS ≥ 4. The primary outcome of this study was mortality. A subgroup analysis was carried out for patients who required blood transfusion within 24 hours of arrival in the Emergency Department and those who had massive blood loss (AIS code: 852610.5). Propensity-score matching was used to identify a cohort like the EF and non-EF groups. Results. With the use of propensity-score matching using the completed data, 346 patients were matched. When the propensity-score matching was adjusted, EF was associated with a significantly lower risk of death (p = 0.047). In the subgroup analysis of patients who needed blood transfusion within 24 hours and those who had massive blood loss, EF was associated with a significantly lower risk of death in patients who needed blood transfusion within 24 hours (p = 0.014) and in those with massive blood loss (p = 0.016). Conclusion. The use of EF to treat unstable pelvic ring fractures was associated with a significantly lower risk of death, especially in patients with severe fractures. Cite this article: Bone Joint J 2018;100-B:233–41

Aims. To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries. Patients and Methods. The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients. Results. Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures. . Conclusion. Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. . Cite this article: Bone Joint J 2017;99-B:1677–80

Aims. Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome. Patients and Methods. A total of 285 patients underwent surgery for a displaced acetabular fracture between 1993 and 2005. For the survival analysis 253 were included, there were 197 men and 56 women with a mean age of 42 years (12 to 78). The mean follow-up of 11 years (1 to 20) was identified from our pelvic fracture registry. There were 99 elementary and 154 associated fracture types. For the long-term clinical follow-up, 192 patients with complete data were included. Their mean age was 40 years (13 to 78) with a mean follow-up of 12 years (5 to 20). Injury to the femoral head and acetabular impaction were assessed with CT scans and patients with an ipsilateral fracture of the femoral head were excluded. Results. A total of 36 patients underwent total hip arthroplasty (THA). The overall ten-year survival of the hip joint was 86% (95% confidence interval (CI) 81% to 90%) and the 20-year survival was 82% (95% CI 76% to 87%). Injury to the femoral head and acetabular impaction were the strongest predictors of failure, with the long-term survival rate falling towards 50% in these patients. The survival fell to 0% at three years when both these risk factors were present in patients aged > 60 years. Conclusion. The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. These patients may be better treated with a combination of open reduction and internal fixation and primary arthroplasty. Cite this article: Bone Joint J 2017;99-B:834–40

Aims

We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy.

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

The aims of this study were to identify the early in-hospital mortality rate after hip fracture, identify factors associated with this mortality, and identify the cause of death in these patients. A retrospective cohort study was performed on 4426 patients admitted to our institution between the 1 January 2006 and 31 December 2013 with a hip fracture (1128 male (26%), mean age 82.0 years (60 to 105)).

Admissions increased annually, but despite this 30-day mortality decreased from 12.1% to 6.5%; 77% of these were in-hospital deaths. Male gender (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.3 to 3.0), increasing age (age ≥ 91; OR 4.1, 95% CI 1.4 to 12.2) and comorbidity (American Society of Anesthesiologists grades 3 to 5; OR 4.2, 95% CI 2.0 to 8.7) were independently and significantly associated with increased odds of in-hospital mortality. From 220 post-mortem reports, the most common causes of death were respiratory infections (35%), ischaemic heart disease (21%), and cardiac failure (13%). A sub-group of hip fracture patients at highest risk of early death can be identified with these risk factors, and the knowledge of the causes of death can be used to inform service improvements and the development of a more didactic care pathway, so that multidisciplinary intervention can be focused for this sub-group in order to improve their outcome.

Cite this article: Bone Joint J 2015;97-B:246–51.

The purpose of this study was to describe the radiological characteristics of a previously unreported finding: posterior iliac offset at the sacroiliac joint and to assess its association with pelvic instability as measured by initial displacement and early implant loosening or failure. Radiographs from 42 consecutive patients with a mean age of 42 years (18 to 77; 38 men, four women) and mean follow-up of 38 months (3 to 96) with Anteroposterior Compression II injuries, were retrospectively reviewed. Standardised measurements were recorded for the extent of any diastasis of the pubic symphysis, widening of the sacroiliac joint, static vertical ramus offset and a novel measurement (posterior offset of the ilium at the sacroiliac joint identified on axial CT scan). Pelvic fractures with posterior iliac offset exhibited greater levels of initial displacement of the anterior pelvis (anterior sacroiliac widening, pubic symphysis diastasis and static vertical ramus offset, p < 0.001,0.034 and 0.028, respectively). Pelvic fractures with posterior ilium offset also demonstrated higher rates of implant loosening regardless of fixation method (p = 0.05). Posterior offset of the ilium was found to be a reliable and reproducible measurement with substantial inter-observer agreement (kappa = 0.70). Posterior offset of the ilium on axial CT scan is associated with greater levels of initial pelvic displacement and early implant loosening. Cite this article: Bone Joint J 2014;96-B:1535–9

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. . This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation. Cite this article: Bone Joint J 2014; 96-B:1143–54

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients. Cite this article: Bone Joint J 2014;96-B:1090–7