A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.Objectives
Methods
The spiral blade modification of the Dynamic
Hip Screw (DHS) was designed for superior biomechanical fixation
in the osteoporotic femoral head. Our objective was to compare clinical
outcomes and in particular the incidence of loss of fixation. In a series of 197 consecutive patients over the age of 50 years
treated with DHS-blades (blades) and 242 patients treated with conventional
DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were
identified from a prospectively compiled database in a level 1 trauma
centre. Using propensity score matching, two groups comprising 177
matched patients were compiled and radiological and clinical outcomes
compared. In each group there were 66 males and 111 females. Mean
age was 83.6 (54 to 100) for the conventional DHS group and 83.8
(52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of
the blades had observable migration while nine DHSs had gross migration
within the femoral head before the fracture healed. There were two
versus four implant cut-outs respectively and one side plate pull-out
in the DHS group. There was no significant difference in mortality
and eventual walking ability between the groups. Multiple logistic
regression suggested that poor reduction (odds ratio (OR) 11.49,
95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation
by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent
predictors of loss of fixation. The spiral blade design may decrease the risk of implant migration
in the femoral head but does not reduce the incidence of cut-out
and reoperation. Reduction of the fracture is of paramount importance
since poor reduction was an independent predictor for loss of fixation
regardless of the implant being used. Cite this article:
Injuries to the foot in athletes are often subtle
and can lead to a substantial loss of function if not diagnosed
and treated appropriately. For these injuries in general, even after
a diagnosis is made, treatment options are controversial and become
even more so in high level athletes where limiting the time away
from training and competition is a significant consideration. In this review, we cover some of the common and important sporting
injuries affecting the foot including updates on their management
and outcomes. Cite this article:
This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury.
Clinical studies evaluating the effects of vitamin D alone or in combination with calcium on physical function, falls and fractures have been inconsistent. Vitamin D has, however, been the focus of much orthopaedic, trauma and endocrine research. Playing a central role in muscle and bone metabolism, some studies on Vitamin D therapies offer the tantalising suggestion of a reduction in falls and fractures simply with vitamin D supplementation. We review the background and evidence behind vitamin D.
There remains conflicting evidence regarding cortical bone strength
following bisphosphonate therapy. As part of a study to assess the
effects of bisphosphonate treatment on the healing of rat tibial
fractures, the mechanical properties and radiological density of
the uninjured contralateral tibia was assessed. Skeletally mature aged rats were used. A total of 14 rats received
1µg/kg ibandronate (iban) daily and 17 rats received 1 ml 0.9% sodium
chloride (control) daily. Stress at failure and toughness of the
tibial diaphysis were calculated following four-point bending tests.Objectives
Methods
The Unified Classification System (UCS) was introduced
because of a growing need to have a standardised universal classification
system of periprosthetic fractures. It combines and simplifies many
existing classification systems, and can be applied to any fracture
around any partial or total joint replacement occurring during or
after operation. Our goal was to assess the inter- and intra-observer
reliability of the UCS in association with knee replacement when
classifying fractures affecting one or more of the femur, tibia
or patella. We used an international panel of ten orthopaedic surgeons with
subspecialty fellowship training and expertise in adult hip and
knee reconstruction (‘experts’) and ten residents of orthopaedic
surgery in the last two years of training (‘pre-experts’). They
each received 15 radiographs for evaluation. After six weeks they
evaluated the same radiographs again but in a different order. The reliability was assessed using the Kappa and weighted Kappa
values. The Kappa values for inter-observer reliability for the experts
and the pre-experts were 0.741 (95% confidence interval (CI) 0.707
to 0.774) and 0.765 (95% CI 0.733 to 0.797), respectively. The weighted
Kappa values for intra-observer reliability for the experts and
pre-experts were 0.898 (95% CI 0.846 to 0.950) and 0.878 (95% CI
0.815 to 0.942) respectively. The UCS has substantial inter-observer reliability and ‘near
perfect’ intra-observer reliability when used for periprosthetic
fractures in association with knee replacement in the hands of experienced
and inexperienced users. Cite this article:
The aim of this study was to investigate the
epidemiology of fractures of the distal radius in the Swedish population and
to review the methods used to treat them between 2005 and 2010. The study population consisted of every patient in Sweden who
was diagnosed with a fracture of the wrist between 1 January 2005
and 31 December 2010. There were 177 893 fractures of the distal
radius. The incidence rate in the total population was 32 per 10
000 person-years. The mean age of the patients was 44 years (0 to
104). The proportion of fractures treated operatively increased
from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation
in the adult population increased 3.61 fold. The incidence rate
for external fixation decreased by 67%. The change was greatest
in the 50 years to 74 years age group. In Sweden, there is an increasing tendency to operate on fractures
of the distal radius. The previously reported increase in the use
of plating is confirmed: it has increased more than threefold over
a five-year period. Cite this article:
The June 2014 Trauma Roundup360 looks at: BMP use increasing wound complication rates in trauma surgery; can we predict re-admission in trauma?; humeral bundle nailing; how best to treat high-angle femoral neck fractures?; hyperglycaemia and infection; simultaneous soft-tissue and bony repair in terrible triad injuries; metaphyseal malunion in the forearm leading to function restrictions; delayed fixation of the distal radius: not a bad option; and fasciotomies better with shoelaces
Forearm fractures in children have a tendency
to displace in a cast leading to malunion with reduced functional
and cosmetic results. In order to identify risk factors for displacement,
a total of 247 conservatively treated fractures of the forearm in
246 children with a mean age of 7.3 years ( Fractures of both forearm bones in children have a strong tendency
to displace even in an above-elbow cast. Severe fractures of the
non-dominant arm are at highest risk for displacement. Radiographs
at set times during treatment might identify early displacement,
which should be treated before malunion occurs, especially in older children
with less potential for remodelling. Cite this article:
Most hip fractures treated with modern internal
fixation techniques will heal. However, failures occasionally occur and
require revision procedures. Salvage strategies employed during
revision are based on whether the fixation failure occurs in the
femoral neck, or in the intertrochanteric region. Patient age and
remaining bone stock also influence decision making. For fractures
in young patients, efforts are generally focused on preserving the
native femoral head via osteotomies and repeat internal fixation.
For failures in older patients, some kind of hip replacement is
usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers
from previous internal fixation devices all pose technical challenges
to successful reconstruction. Attention to detail is important in
order to minimise complications. In the majority of cases, good
outcomes have been reported for the various salvage strategies. Cite this article:
The October 2013 Children’s orthopaedics Roundup360 looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.
Small animal models of fracture repair primarily investigate
indirect fracture healing via external callus formation. We present
the first described rat model of direct fracture healing. A rat tibial osteotomy was created and fixed with compression
plating similar to that used in patients. The procedure was evaluated
in 15 cadaver rats and then Objectives
Methods
Although the importance of lateral femoral wall
integrity is increasingly being recognised in the treatment of intertrochanteric
fracture, little attention has been put on the development of a
secondary post-operative fracture of the lateral wall. Patients
with post-operative fractures of the lateral wall were reported
to have high rates of re-operation and complication. To date, no
predictors of post-operative lateral wall fracture have been reported.
In this study, we investigated the reliability of lateral wall thickness
as a predictor of lateral wall fracture after dynamic hip screw
(DHS) implantation. A total of 208 patients with AO/OTA 31-A1 and -A2 classified
intertrochanteric fractures who received internal fixation with
a DHS between January 2003 and May 2012 were reviewed. There were
103 men and 150 women with a mean age at operation of
78 years (33 to 94). The mean follow-up was 23 months (6 to 83).
The right side was affected in 97 patients and the left side in
111. Clinical information including age, gender, side, fracture
classification, tip–apex distance, follow-up time, lateral wall
thickness and outcome were recorded and used in the statistical
analysis. Fracture classification and lateral wall thickness significantly
contributed to post-operative lateral wall fracture (both p <
0.001). The lateral wall thickness threshold value for risk of developing
a secondary lateral wall fracture was found to be 20.5 mm. To our knowledge, this is the first study to investigate the
risk factors of post-operative lateral wall fracture in intertrochanteric
fracture. We found that lateral wall thickness was a reliable predictor
of post-operative lateral wall fracture and conclude that intertrochanteric
fractures with a lateral wall thickness <
20.5 mm should not
be treated with DHS alone. Cite this article:
Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.
This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.