Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30).Aims
Methods
The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN). The study involved a retrospective analysis of 23 patients. All had a previous, operatively managed, femoral shaft fracture with malunion due to hardware failure. They were treated with a clamshell osteotomy between May 2015 and March 2020. The mean age was 42.6 years (26 to 62) and 15 (65.2%) were male. The mean follow-up was 2.3 years (1 to 5). Details from their medical records were analyzed. Clinical outcomes were assessed using the quality of correction of the deformity, functional recovery, the healing time of the fracture, and complications.Aims
Methods
Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days).Aims
Methods
The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day.Aims
Methods
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. A population-based, matched cohort study of all hip fracture patients (aged over 45 years) in Ontario, Canada between 2009 and 2014 was conducted. The primary exposure was preoperative echocardiography (occurring between hospital admission and surgery). Mortality rates, surgical wait times, postoperative LOS, and medical costs (expressed as 2013$ CAN) up to one year postoperatively were assessed after propensity-score matching.Aims
Methods
No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction.Aims
Methods
Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery.Aims
Methods
Aims. 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. Methods. 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. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral
The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk.Aims
Patients and Methods
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. 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.Aims
Patients and Methods
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. 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.Aim
Patients and Methods
To evaluate interobserver reliability of the Orthopaedic Trauma
Association’s open fracture classification system (OTA-OFC). Patients of any age with a first presentation of an open long
bone fracture were included. Standard radiographs, wound photographs,
and a short clinical description were given to eight orthopaedic
surgeons, who independently evaluated the injury using both the
Gustilo and Anderson (GA) and OTA-OFC classifications. The responses
were compared for variability using Cohen’s kappa.Aims
Patients and Methods
Compartment syndrome results from increased intra-compartmental
pressure (ICP) causing local tissue ischaemia and cell death, but
the systemic effects are not well described. We hypothesised that
compartment syndrome would have a profound effect not only on the affected
limb, but also on remote organs. Using a rat model of compartment syndrome, its systemic effects
on the viability of hepatocytes and on inflammation and circulation
were directly visualised using intravital video microscopy.Aims
Methods
In this study we quantified and characterised
the return of functional mobility following open tibial fracture
using the Hamlyn Mobility Score. A total of 20 patients who had
undergone reconstruction following this fracture were reviewed at
three-month intervals for one year. An ear-worn movement sensor
was used to assess their mobility and gait. The Hamlyn Mobility
Score and its constituent kinematic features were calculated longitudinally,
allowing analysis of mobility during recovery and between patients
with varying grades of fracture. The mean score improved throughout
the study period. Patients with more severe fractures recovered
at a slower rate; those with a grade I Gustilo-Anderson fracture
completing most of their recovery within three months, those with
a grade II fracture within six months and those with a grade III
fracture within nine months. Analysis of gait showed that the quality of walking continued
to improve up to 12 months post-operatively, whereas the capacity
to walk, as measured by the six-minute walking test, plateaued after
six months. Late complications occurred in two patients, in whom the trajectory
of recovery deviated by >
0.5 standard deviations below that of
the remaining patients. This is the first objective, longitudinal
assessment of functional recovery in patients with an open tibial
fracture, providing some clarification of the differences in prognosis
and recovery associated with different grades of fracture. Cite this article:
We evaluated the outcome of treatment of nonunion
of an intracapsular fracture of the femoral neck in young patients
using two cannulated screws and a vascularised bone graft. A total
of 32 patients (15 women and 17 men, with a mean age of 36.5 years;
20 to 50) with failed internal fixation of an intracapsular fracture
were included in the study. Following removal of the primary fixation,
two cannulated compression screws were inserted with a vascularised
iliac crest bone graft based on the ascending branch of the lateral
femoral circumflex
Compartment syndrome, a devastating consequence
of limb trauma, is characterised by severe tissue injury and microvascular
perfusion deficits. We hypothesised that leucopenia might provide
significant protection against microvascular dysfunction and preserve
tissue viability. Using our clinically relevant rat model of compartment syndrome,
microvascular perfusion and tissue injury were directly visualised
by intravital video microscopy in leucopenic animals. We found that
while the tissue perfusion was similar in both groups (38.8% (standard
error of the mean ( Cite this article:
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:
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:
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:
Coronal plane fractures of the posterior femoral
condyle, also known as Hoffa fractures, are rare. Lateral fractures are
three times more common than medial fractures, although the reason
for this is not clear. The exact mechanism of injury is likely to
be a vertical shear force on the posterior femoral condyle with
varying degrees of knee flexion. These fractures are commonly associated
with high-energy trauma and are a diagnostic and surgical challenge. Hoffa
fractures are often associated with inter- or supracondylar distal
femoral fractures and CT scans are useful in delineating the coronal
shear component, which can easily be missed. There are few recommendations
in the literature regarding the surgical approach and methods of
fixation that may be used for this injury. Non-operative treatment
has been associated with poor outcomes. The goals of treatment are
anatomical reduction of the articular surface with rigid, stable
fixation to allow early mobilisation in order to restore function.
A surgical approach that allows access to the posterior aspect of
the femoral condyle is described and the use of postero-anterior
lag screws with or without an additional buttress plate for fixation
of these difficult fractures. Cite this article: