Several studies have reported the rate of post-operative
mortality after the surgical treatment of a fracture of the hip,
but few data are available regarding the delayed morbidity. In this
prospective study, we identified 568 patients who underwent surgery
for a fracture of the hip and who were followed for one year. Multivariate
analysis was carried out to identify possible predictors of mortality
and morbidity. The 30-day, four-month and one-year rates of mortality
were 4.3%, 11.4%, and 18.8%, respectively. General complications
and pre-operative comorbidities represented the basic predictors
of mortality at any time interval (p <
0.01). In-hospital, four-month
and one-year general complications occurred in 29.4%, 18.6% and
6.7% of patients, respectively. After adjusting for confounding variables,
comorbidities and poor cognitive status determined the likelihood
of early and delayed general complications, respectively (p <
0.001). Operative delay was the main predictor of the length of
hospital stay (p <
0.001) and was directly related to in-hospital
(p = 0.017) and four-month complications (p = 0.008). 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
The best method of managing a fracture of the
distal humerus in a frail low-demand patient with osteoporotic bone remains
controversial. Total elbow arthroplasty (TEA) has been recommended
for patients in whom open reduction and internal fixation (ORIF)
is not possible. Conservative methods of treatment, including the
‘bag of bones’ technique (acceptance of displacement of the bony
fragments and early mobilisation), are now rarely considered as
they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93
years, 72% women) with a fracture of the distal humerus who had
been treated conservatively at our hospital between March 2008 and
December 2013, and assessed their short- and medium-term functional
outcome. In the short-term, the mean Broberg and Morrey score improved
from 42 points (poor; 23 to 80) at six weeks after injury to 67
points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford
elbow score of 30 points (7 to 48) at four years and a mean Disabilities
of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95%
reported a functional range of elbow flexion. The cumulative rate
of fracture union at one year was 53%. The mortality at five years approached
40%. Conservative management of a fracture of the distal humerus in
a low-demand patient only gives a modest functional result, but
avoids the substantial surgical risks associated with primary ORIF
or TEA. Cite this article:
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:
The December 2015 Trauma Roundup360 looks at: Delay to surgery in hip fracture; Hexapod fixators in the management of hypertrophic tibial nonunions; Thromboembolism after nailing pathological fractures; Tibial plateau fracture patterns under the spotlight; The health economic effects of long bone nonunion; Adverse outcomes in trauma; The sacral screw in children; Treating the contralateral SUFE
The Gamma nail is frequently used in unstable
peri-trochanteric hip fractures. We hypothesised that mechanical failure
of the Gamma nail was associated with inadequate proximal three-point
fixation. We identified a consecutive series of 299 Gamma nails
implanted in 299 patients over a five-year period, 223 of whom fulfilled
our inclusion criteria for investigation. The series included 61
men and 162 women with a mean age of 81 years (20 to 101). Their fractures
were classified according to the Modified Evans’ classification
and the quality of fracture reduction was graded. The technical
adequacy of three points of proximal fixation was recorded from
intra-operative fluoroscopic images, and technical inadequacy for
each point was defined. All patients were followed to final follow-up
and mechanical failures were identified. A multivariate statistical
analysis was performed, adjusting for confounders. A total of 16
failures (7.2%) were identified. The position of the lag screw relative
to the lateral cortex was the most important point of proximal fixation,
and when inadequate the failure rate was 25.8% (eight of 31: odds
ratio 7.5 (95% confidence interval 2.5 to 22.7), p <
0.001). Mechanical failure of the Gamma nail in peri-trochanteric femoral
fractures is rare (<
1%) when three-point proximal fixation is
achieved. However, when proximal fixation is inadequate, failure
rates increase. The strongest predictor of failure is positioning
the lateral end of the lag screw short of the lateral cortex. Adherence
to simple technical points minimises the risk of fixation failure
in this vulnerable patient group. Cite this article:
The Unified Classification System (UCS) emphasises
the key principles in the assessment and management of peri-prosthetic
fractures complicating partial or total joint replacement. We tested the inter- and intra-observer agreement for the UCS
as applied to the pelvis and femur using 20 examples of peri-prosthetic
fracture in 17 patients. Each subtype of the UCS was represented
by at least one case. Specialist orthopaedic surgeons (experts)
and orthopaedic residents (pre-experts) assessed reliability on
two separate occasions. For the pelvis, the UCS showed inter-observer agreement of 0.837
(95% confidence intervals (CI) 0.798 to 0.876) for the experts and
0.728 (95% CI 0.689 to 0.767) for the pre-experts. The intra-observer
agreement for the experts was 0.861 (95% CI 0.760 to 0.963) and
0.803 (95% 0.688 to 0.918) for the pre-experts. For the femur, the
UCS showed an inter-observer kappa value of 0.805 (95% CI 0.765
to 0.845) for the experts and a value of 0.732 (95% CI 0.690 to 0.773)
for the pre-experts. The intra-observer agreement was 0.920 (95%
CI 0.867 to 0.973) for the experts, and 0.772 (95% CI 0.652 to 0.892)
for the pre-experts. This corresponds to a substantial and ‘almost
perfect’ inter- and intra-observer agreement for the UCS for peri-prosthetic
fractures of the pelvis and femur. We hope that unifying the terminology of these injuries will
assist in their assessment, treatment and outcome. Cite this article:
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 3D CT reconstruction
images of 100 patients using the Tile/AO and Young–Burgess systems.
Reliability was compared using kappa statistics. A total of
115 patients (62%) had plain radiographs as well as two-dimensional
(2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films
only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and
eight patients (4.3%) had no available images. The plain radiograph
was limited to an anteroposterior pelvic view. Patients without
imaging, or only plain films, were more severely injured. A total
of 72 patients (39%) were imaged with a pelvic binder Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17)
and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient
for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to
their complexity, the increasing use of early treatment such as
with pelvic binders, and the absence of imaging altogether in important
patient sub-groups, such as those who die early of their injuries. Cite this article:
The October 2014 Trauma Roundup360 looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.
The June 2014 Foot &
Ankle Roundup360 looks at: peroneal tendon tears associated with calcaneal fractures; syndesmosis procedure for first ray deformities; thromboprophylaxis not necessary in elective Ilizarov surgery; ankle replacement gaining traction in academic centres; some evidence for PRP and; fusion nailing and osteotomy an effective treatment for symptomatic tibial malunion
Epidemiological studies enhance clinical practice
in a number of ways. However, there are many methodological difficulties
that need to be addressed in designing a study aimed at the collection
and analysis of data concerning fractures and other injuries. Most
can be managed and errors minimised if careful attention is given
to the design and implementation of the research. Cite this article:
The purpose of this study was to identify factors
that predict implant cut-out after cephalomedullary nailing of intertrochanteric
and subtrochanteric hip fractures, and to test the significance
of calcar referenced tip-apex distance (CalTAD) as a predictor for
cut-out. We retrospectively reviewed 170 consecutive fractures that had
undergone cephalomedullary nailing. Of these, 77 met the inclusion
criteria of a non-pathological fracture with a minimum of 80 days
radiological follow-up (mean 408 days; 81 days to 4.9 years). The
overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex
distance (TAD) (p <
0.001), CalTAD (p = 0.001), cervical angle
difference (p = 0.004), and lag screw placement in the anteroposterior
(AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters
were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507),
fracture type (AO classification) (p = 0.381), Singh Osteoporosis
Index (p = 0.575), lag screw placement in the lateral view (p =
0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575).
In the multivariate analysis, CalTAD was the only significant measurement
(p = 0.001). CalTAD had almost perfect inter-observer reliability
(interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD
is a predictor of cut-out. The finding of CalTAD as the only significant
parameter in the multivariate analysis, along with the univariate
significance of Parker’s ratio index in the AP view, suggest that
inferior placement of the lag screw is preferable to reduce the
rate of cut-out. Cite this article:
Unstable bicondylar tibial plateau fractures
are rare and there is little guidance in the literature as to the
best form of treatment. We examined the short- to medium-term outcome
of this injury in a consecutive series of patients presenting to
two trauma centres. Between December 2005 and May 2010, a total
of 55 fractures in 54 patients were treated by fixation, 34 with
peri-articular locking plates and 21 with limited access direct
internal fixation in combination with circular external fixation
using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively,
patient-reported outcome measures including the WOMAC index and
SF-36 scores showed functional deficits, although there was no significant
difference between the two forms of treatment. Despite low outcome scores,
patients were generally satisfied with the outcome. We achieved
good clinical and radiological outcomes, with low rates of complication.
In total, only three patients (5%) had collapse of the joint of
>
4 mm, and metaphysis to diaphysis angulation of greater than 5º,
and five patients (9%) with displacement of >
4 mm. All patients
in our study went on to achieve full union. This study highlights the serious nature of this injury and generally
poor patient-reported outcome measures following surgery, despite
treatment by experienced surgeons using modern surgical techniques.
Our findings suggest that treatment of complex bicondylar tibial
plateau fractures with either a locking plate or a TSF gives similar
clinical and radiological outcomes. Cite this article:
The February 2014 Foot &
Ankle Roundup360 looks at: optimal medial malleolar fixation; resurfacing in the talus; predicting outcome in mobility ankles; whether mal-aligned ankles can be successfully replaced; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; recalcitrant Achilles tendinopathy; and recurrent fifth metatarsal stress fractures.
The February 2014 Trauma Roundup360 looks at: predicting nonunion; compartment Syndrome; octogenarian RTCs; does HIV status affect decision making in open tibial fractures?; flap timing and related complications; proximal humeral fractures under the spotlight; restoration of hip architecture with bipolar hemiarthroplasty in the elderly; and short
The April 2013 Trauma Roundup360 looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction.
Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures.
Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues. With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.
This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.