Peter V Giannoudis

Fixation failure in the proximal femur is an uncommon phenomenon, occurring most commonly as a result of biomechanical failure. This may be due to failure to achieve reduction or utilisation of an incorrect entry point, both of which can result in a varus deformity. Where this occurs, the proximal femur must be valgised and rigidly secured. If there is a residual bone defect it will require management with either autograft, allograft or a bone substitute.

PurposeThe number of total knee replacements (TKRs) performed per year has been increasing annually and it is estimated that by 2030 demand would reach 3.48 million procedures per year in the United States Of America. The prevalence of periprosthetic fractures (PPFs) around TKRs has followed this trend with incidences ranging from 0.3% to 3.5%. Distal femoral PPFs are associated with significant morbidity and mortality. When there is sufficient bone stock in the distal femur and a fracture pattern conducive to fixation, locking compression plating (LCP) and retrograde intramedullary nailing (RIMN) are commonly used fixation strategies. Conversely, in situations with loosening and deficient bone stock, a salvage procedure such as a distal femoral replacement is recognized as an alternative. This meta-analysis investigates the rates of non-union, re-operation, infection, and mortality for LCPs and RIMNs when performed for distal femoral PPFs fractures around TKRs.

PurposeThis study aims to analyse papers concerning journal impact factors published in the Injury-International Journal of the Care of the Injured between 1997 and 2022. Through this analysis, the research offers valuable insights into the publication performance and contributors to the journal impact factor, encompassing papers, authors, institutions, and countries.MethodsArticles and reviews published in the Injury between 1995 and 2021 were examined using the Science Citation Index Expanded database. The study employed the journal impact factor contributing indicator to compare highly cited and high journal impact factor papers across various aspects, including papers, authors, institutions, and countries.ResultsA notable correlation exists between prolific authors, institutions, and countries, alongside those who contribute to high journal impact factors. However, a less distinct connection was observed …

Distal humerus fractures present with either intra-articular involvement or they are pure extra-articular fractures. Initial clinical evaluation must assess the neurovascular status of the affected extremity and associated injuries to the ipsilateral shoulder and wrist joints. A computed tomography (CT) scan must be obtained when extension of the fracture is suspected in the articular surface or when there is intra-articular involvement with comminution. Bic-column fixation usually provides optimum stability allowing early range of motion of the elbow joint reducing the risk of joint stiffness. We present a case that failed following fixation, analyse the aetiology of failure and discuss the treatment that was successfully implemented.

Failure of capitellum fixation is rare. The capitellum when fixed is susceptible to significant shear forces due to its anterior centre of rotation, particularly when loading the elbow in extension. Fixation should aim to best resist these forces, commonly attained through headless compression screws orthogonal to the fracture plane. Rehabilitation should be guarded, and whilst range of movement should be instigated early to regain range of motion, load bearing should be gradually reintroduced. Revision fixation should concentrate on achieving an anatomic reduction, and compression orthogonal to the fracture plane.

Failure of operative treatment of fifth metatarsal fractures may have a variety of aetiologies. The most common are technical errors, for example, inappropriate fixation methods, i.e. small screws that break, leading to non-union. However, overlooking the presence of a simultaneous cavovarus foot deformity and failure to address it during the index procedure may lead to overloading of the lateral column, thus predisposing to failure and/or non-union.

Intertrochanteric fractures are a common type of proximal femoral fracture, and account for high morbidity and mortality. Early recognition and management of such fractures is important, with surgery preferably undertaken within 48 hours. The choice of surgical strategy remains variable between centres and individual surgeons; in part because evidence to support a specific strategy has been weak. Herein, we provide the latest evidence on the management of these fractures.

PurposeObstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery.MethodA retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16–45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared.ResultsForty-four patients were included, comparison of the RM of …

Metal work failure after fracture fixation is not common. However, when established it may be associated with pain, limb deformity, functional impairment and need for revision surgery. While the causes can be multifactorial including non-compliance, poor bone stock, non-optimum fixation, selection of wrong implant, metal fatigue and infection, its true incidence remains unknown. Herein, we report the incidence of metal work failure after fracture fixation in different anatomical areas.

Failure of operative treatment of subtrochanteric femoral fractures may have various aetiologies. Subtrochanteric femur fractures are difficult to treat due to strong deforming forces at the fracture site, tenuous blood supply, and the immense load-bearing forces exerted through the peri-trochanteric region. Adequate reduction and stable fixation are paramount when treating these fractures to optimize patient outcomes. Special attention should be made to avoid poorly reduced fracture (varus malignment) and lack of medial cortical support.

The treatment of painful KOA in adult patients with ITP has not been well studied yet. We conducted a prospective, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intra-articular allogeneic PRP injections on symptoms and joint structure in patients with KOA and ITP. 80 participants were randomly allocated in a 1:1 ratio to allogeneic PRP group or saline group. The primary outcome was the WOMAC total score at 12 months post-injection. The number of patients in each group who achieved MCID of primary outcome showed a statistically significant difference only at 3-month (27/39 vs 5/39, P = .001) and 6-month (15/39 vs 3/38, P = .032). The difference in WOMAC total score exceeded the MCID only at 3-month (mean difference of -15.1 [95% CI -20.7 to -9.5], P < .001). Results suggest that allogeneic PRP was superior to placebo only with respect to symptoms at 3-month of follow-up.

Evaluation and management of syndesmosis fixation is challenging and controversial without a ‘one-approach fixes all.’ A relatively straightforward case of a failed ankle fixation, which underwent revision surgery, is presented herein. Several pertinent points are illustrated, and updated information on the diagnosis and treatment of these frequently intriguing injuries is presented.

Failure of plate osteosynthesis of humeral shaft fractures could be due to several factors. Lack of adequate mechanical stability is one of them as the humeral shaft is an anatomical area subjected to great displacing forces, particularly torsion, which must be effectively counteracted by a stable fixation until fracture union occurs. Herein, we report on a fixation failure of a humeral shaft fracture stabilized with plating and discuss the etiology of failure and subsequent treatment implemented.

Distal tibial extra-articular fractures may present difficulties to be reduced and to be stabilised with a load sharing device—intramedullary (IM) nailing. The surrounding soft tissue envelope of the distal tibia, particularly anteriomedially, is associated with a compromised blood supply to the bone and increased risk of wound-related problems that can lead to wound breakdown and development of secondary infection. Good reduction and optimum fixation are paramount to optimise patient outcomes. Failure of surgical treatment of extra-articular distal tibia fractures may have various aetiologies related to poor reduction, malalignment, mechanical instability and poor bone quality. Herein, a case of failure is presented discussing the aetiology of failure and the subsequent successful treatment plan implemented.

PurposeThe aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the rate of complications was different between the two groups.MethodsBetween January 2009 and December 2018 adult patients with distal femoral fractures managed in our unit with either LP or IMN for extra and intra-articular fractures were eligible to participate. Demographic details, fracture type, procedures performed, time to union, complications and functional scores (Oxford Knee Score) were recorded and analysed. The mean follow up was 4 years (12–120 months).ResultsOut of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were …

The fixation of distal radius fractures with closed manipulation and percutaneous pinning is a common practice that has better results than treatment with a cast alone. Infection of the pin entry point site and loss of reduction due to insufficient stability of the construct are examples of complications of this technique. Unstable distal radius fractures, or fractures in osteoporotic patients, are better treated with distal locking volar plates. This chapter illustrates a failed distal radius fracture fixation due to pin entry site infection and loss of reduction.

A narrative review of the literature was conducted to examine the data on femoral head fractures, with a particular focus on their management, complications and clinical outcomes.A PRISMA strategy was used. Medline and Scopus library databases were queried using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated based on OCEBM and GRADE systems. The 50 eligible articles that met the predefined inclusion criteria reported on 1403 femoral head fractures. A detailed analysis of the surgical approaches used was performed in 38 articles with 856 fractures.Most fractures were treated surgically (90,8 %) with preferred anatomical reconstruction in 76,7 % of all operatively treated cases. Posterior approaches were the most common (52.5 %). This was evenly split between surgical hip dislocation and the classic Kocher-Langenbeck approach. 70.5 % of surgically treated cases …

Open reduction and internal fixation of talar fractures remains challenging even for the most experience surgeons and can be associated with such complications as hindfoot varus, avascular necrosis and post-traumatic osteoarthritis. Herein, we present a case of talar fixation that developed hindfoot varus. The relevant surgical indications, technical skills, and other issues of the anatomical reconstruction with talar neck osteotomy and revision of fixation are discussed below.

Complications following fixation of intracapsular neck of femur fractures remain common; however, the provision of an appropriate mechanical environment can be employed to try and prevent them. We present a case of fixation failure due to the use of a technique that does not adequately resist the shear forces that occur during weight-bearing, resulting in shortening and varus collapse. Maintenance of length within the neck could be achieved through the use of fully threaded screws or a fixed angle device, whilst increased resistance against the shear stress experienced in this region may be achieved through the use of an orthogonal Pauwel screw.

Failure of operative treatment of acetabular posterior wall fractures may have a variety of aetiologies, with the most common being technical errors. Examples include intra-articular lag screw penetration, not recognizing fracture patterns that require either a spring or rim plate and inadequate use of bone graft for structural support in cases with an associated marginal impaction injury. This chapter illustrates an example of fixation failure of a posterior wall acetabular fracture secondary to buttress plate misplacement.

The mechanisms underlying AFF remain unclear, with hypotheses including bone turnover suppression and morphological variation. Recent studies have suggested a potential genetic susceptibility to AFF. A scoping review was conducted using PubMed to identify studies published since 2016. Twenty-one studies were identified, focusing on histological and genetic analysis of AFF patients and BP users. Biopsies and imaging modalities were used to assess histological and morphometric parameters, while genetic sequencing was performed to identify variants in target genes.Genetic studies identified variants in geranylgeranyl diphosphate synthase 1 (GGPS1) and CYP1A1 genes, which play roles in osteoclast function and drug metabolism, respectively. Functional analysis revealed reduced enzymatic activity in mutant variants of these genes, which could be further inhibited by BP use. Other genes, such as …

Acetabular fractures are a growing problem within the elderly population as a steady increase of their incidence among patients older than 60 years of age has been documented over the past decades [

Ankle fractures are intraarticular and therefore require anatomic reduction to obtain satisfactory results. Even slight malreduction can lead to late instability, pain and arthrosis. Ankle syndesmosis complex consists of a significant component of the ankle joint biomechanics and should therefore accurately addressed. However, the amount of diastasis that can be tolerated is not universally accepted. Studies have shown as little as 1 mm of talar displacement can increase joint contact loads by as much as 42%. This chapter illustrates the sequence of a failed ankle fixation and its management.

Failure of midshaft femoral fractures may have various aetiologies. Midshaft femur fractures can be challenging to treat if the surgeon cannot fully appreciate the implant used, patient factors and the plan they are aiming to achieve with the implant (absolute vs relative stabilisation). Adequate reduction and stable fixation are paramount when treating these fractures to optimize patient outcomes. Special attention should be made to the use of NCB plating systems and the appropriate fracture pattern should be selected for their use.

Olecranon fractures represent 10% of upper limb injuries. Transverse simple fractures of the olecranon can be treated with tension band wiring, representing a simple and effective technique for transforming the triceps distraction forces into forces that cause fracture compression. This valuable surgical fixation technique has basic rules that only succeed if followed. Post-fixation failure of olecranon fractures is not uncommon and can lead to morbidity and increased cost of care. Herein, we present a case of olecranon fixation failure and discuss the aetiology of failure and the strategy for revision surgery.

This first edition text book describes applicable step-wise approaches to successfully manage patients with failed fracture fixation. Cases are presented for a range of anatomical sites focusing on the aetiology of the failure, clinical examination along with the necessary investigations required for the initial patient assessment, pre-operative planning and its successful execution. Emphasis is placed on detailing when the timing of an intervention is required. A" tips and tricks" section is provided in each chapter enabling the reader to familiarize themselves with potential pitfalls associated with each technique covered and further develop their understanding of the content covered.Failed Fracture Fixation: Revision Surgery Made Easy is a comprehensive practically applicable guide to understand the aetiology of failure and to become familiar on how to use a range of relevant surgical techniques in a variety of …

Recent data from the UK's National Hip Fracture Database (NHFD) demonstrate an upward trajectory in the incidence of hip fractures, a trend which is expected to persist. In 2023 alone, the NHFD reported 72,160 cases, underscoring the prevalence of these injuries. These fractures are associated with significant morbidity, mortality, and economic costs. National guidelines for the surgical management of these fractures are established, although the implementation of total hip arthroplasty (THA) as a primary treatment modality varies. This review offers a narrative synthesis of contemporary literature on hip fractures, focusing on epidemiology, classification systems, and treatment options, with a particular emphasis on the outcomes of THA.

Bone void-filling cements are one of the preferred materials for managing irregular bone voids, particularly in the geriatric population who undergo many orthopedic surgeries. However, bone marrow mesenchymal stem/stromal cells (BM-MSCs) of older-age donors often exhibit reduced osteogenic capacity. Hence, it is crucial to evaluate candidate bone substitute materials with BM-MSCs from the geriatric population to determine the true osteogenic potential, thus simulating the clinical situation. With this concept, we investigated the osteogenic potential of shell nacre cement (SNC), a bone void-filling cement based on shell nacre powder and ladder-structured siloxane methacrylate, using older donor BM-MSCs (age > 55 years) and young donor BM-MSCs (age < 30 years). Direct and indirect cytotoxicity studies conducted with human BM-MSCs confirmed the non-cytotoxic nature of SNC. The standard colony-forming unit-fibroblast (CFU-F) assay and population doubling (PD) time assays revealed a significant reduction in the proliferation potential (p < 0.0001, p < 0.05) in older donor BM-MSCs compared to young donor BM-MSCs. Correspondingly, older donor BM-MSCs contained higher proportions of senescent, β-galactosidase (SA-β gal)-positive cells (nearly 2-fold, p < 0.001). In contrast, the proliferation capacity of older donor BM-MSCs, measured as the area density of CellTrackerTM green positive cells, was similar to that of young donor BM-MSCs following a 7-day culture on SNC. Furthermore, after 14 days of osteoinduction on SNC, scanning electron microscopy with energy-dispersive spectroscopy (SEM-EDS) showed that the amount …

Posterior shearing tibial plateau injuries represent unique fractures requiring meticulous evaluation and planning. Initial assessment must exclude neurovascular deficit followed by temporary stabilisation with an external fixator as indicated for resuscitation of the surrounding soft tissues and acquisition of computed tomography scan for a detailed evaluation of the fracture pattern and appropriate preoperative planning. Optimum fixation would support the early range of motion of the knee joint for preservation of cartilage and reducing the risk of joint stiffness. Herein we present a case that failed following reconstruction and discuss the aetiology of failure and the subsequent treatment that was performed successfully.

IntroductionInfected tibial non-unions with associated bone loss can be challenging to manage. At present, the two main methods utilized in the management of these fractures include the Ilizarov technique of Distraction Osteogenesis (DO) using external fixator devices, or alternatively, the Induced Membrane Technique (IMT), devised by Masquelet. As there is a paucity of data directly comparing the outcomes of these techniques, there is no universal agreement on which strategy a surgeon should choose to use.AimsThis systematic review and meta-analysis aimed to summarize the outcomes of both DO and IMT, in terms of primary outcomes (bone union and infection elimination), and secondary outcomes (complication rates and functional outcomes).MethodsA PRISMA strategy was used. Medline, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar library databases …

PurposeWhilst recurrence and amputation rates in post-traumatic osteomyelitis (PTOM) are described, limb specific functional outcomes are not, leading to a knowledge gap when counselling patients prior to management. We aim to investigate the patient reported outcomes (PROMS) of this patient group to provide reference for discussions with patients prior to embarking on treatment.MethodsSingle institution cross-sectional retrospective study of all patients presenting with PTOM of the tibia/femur over a 7-year period. Alongside recurrence and amputation rates, patient reported outcomes were recorded including the lower extremity functional scale (LEFS), EQ-5D-3L and EQ-VAS.ResultsSeventy-two patients (59 male; median age 46 years) were identified. Treatment was principle-based and included debridement (with Reamer–Irrigator–Aspirator (RIA) in 31/72), local antibiotics (52/72), soft tissue reconstruction …

Repairing critical-size bone defects still represents a critical clinical challenge in the field of trauma surgery. This study focuses on a physiological design and manufacturing of porous composite scaffold (titanium Ti with 10 % mole iron doped brushite DCPD-Fe3+) which can mimic the biomechanical properties of natural cortical bone, specifically for the purpose of repairing critical-size defects. To achieve this, the principle of design of experiments (DOE) was applied for investigating the impact of sintering temperature, mineral ratio, and volume fraction of porosity on the mechanical properties of the fabricated scaffolds. The fabricated scaffolds had open porosity up to 60 %, with pore size approximately between 100 μm and 850 μm. The stiffness of the porous composite scaffolds varied between 3.30 GPa and 20.50 GPa, while the compressive strength ranged from approximately 130 MPa–165 MPa at sintering …

PurposeThe primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy.Methods77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05.ResultsThe smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p …

Meta-analyses constitute fundamental tools of the Evidence-Based Medicine (EBM) aiming at synthesizing outcome data from individual trials in order to produce pooled effect estimates for various outcomes of interest. Combining summary data from several studies increases the sample size, improves the statistical power of the findings as well as the precision of the obtained effect estimates. For all these reasons, meta-analyses are thought of providing the best evidence to support clinical practice guidelines. However, the strength of the provided evidence is closely dependent on the quality of included studies as well as the rigour of the meta-analytic process. In addition, over the course of the evolution of the current meta-analytic methodology, some concerns have been expressed on the ultimate usefulness of such a complex and time consuming procedure on establishing timely, valid evidence on various …

This special issue of Injury is devoted to clinical research. It provides a unique window of opportunity to pause for a moment and reflect what“clinical research” nowadays means in trauma and orthopedics. In clinical practice, health-care professionals must reach time-critical decisions based on experience and heuristics while (unconsciously) remembering scientific background knowledge provided by guidelines and recent trials [1]. In an ideal world, different options of care are discussed with patients and their relatives, resulting in a consented treatment plan. We all know this ideal case scenario is far away from reality-without going any further into issues like time constraints, work overload, shortage of staff, documentation needs etc.[2]. Research may simplistically be defined as a systematic way of exploring why some things work while others don’t. It is driven by both need and curiosity, and its results change our …

Bone damage arising from fractures or trauma frequently results in infection, impeding the healing process and leading to complications. To overcome this challenge, we engineered highly porous chitosan scaffolds (S1, S2, and S3) by incorporating 30 (wt)% iron-doped dicalcium phosphate dihydrate (Fe-DCPD) minerals and different concentrations of cerium oxide nanoparticles (CeO2) (10 (wt)%, 20 (wt)%, and 30 (wt)%) using the lyophilisation technique. The scaffolds were specifically designed for the controlled release of antibacterial agents and were systematically characterised by utilising Raman spectroscopy, X-ray diffraction, scanning electron microscopy, and energy-dispersive X-ray spectroscopy methodologies. Alterations in the physicochemical properties, encompassing pore size, swelling behaviour, degradation kinetics, and antibacterial characteristics, were observed with the escalating CeO2 concentrations. Scaffold cytotoxicity and its impact on human bone marrow mesenchymal stem cell (BM-MSCs) proliferation were assessed employing the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) assay. The synthesised scaffolds represent a promising approach for addressing complications associated with bone damage by fostering tissue regeneration and mitigating infection risks. All scaffold variants exhibited inhibitory effects on bacterial growth against Staphylococcus aureus and Escherichia coli strains. The scaffolds manifested negligible cytotoxic effects while enhancing antibacterial properties, indicating their potential for reducing infection risks in the context of bone injuries.

IntroductionCarbon fibre-reinforced polyetheretherketone (CFR-PEEK) plates represent an exciting development within trauma and orthopaedic surgery, offering advantages including radiolucency, material properties similar to bone, and lack of localised tissue reaction. As more call for trials examining their use, there is no data available as to the acceptability of these implants to patients. This study aimed to therefore examine the acceptability of CFR-PEEK plates to patients undergoing fracture surgery.MethodsThis was a prospective cross-sectional survey of patients undergoing surgery for a fracture of the ankle, distal femur, distal radius, or proximal humerus. Once a decision had been made to pursue operative fixation with a plate, patients were provided with descriptions of both CFR-PEEK and stainless steel and titanium metal implants alongside the current clinical evidence. All patients undertook a …

Objectives:The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications.Design:This is a retrospective case series with prospectively collected data.Setting:Level I Trauma Centre in the United Kingdom.Patients and Intervention:Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up.Main Outcome Measurements:The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions.Results:Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 …

Background The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the ‘gold standard’ of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal. Objectives The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post‐operatively. Methods Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail …

We report on the treatment of a neglected displaced vertical shear pelvic fracture with functional impairment 6 months after injury in a 74-year-old woman with underlying osteoporosis. She was managed with open reduction and internal fixation and grafting of her left SI joint, while the ipsilateral pubic rami fractures were treated conservatively. She achieved union and pain free weight bearing 6 months postoperatively. Appropriate evaluation of the pathology and selection of the appropriate treatment in this elderly patient cohort is essential for a successful outcome. Experienced surgical team and individualized treatment approach are also vital to optimize the result of treatment.

Avascular necrosis of the femoral head (AVNFH) is relatively infrequent, but if undiagnosed or untreated, it may result in significant functional disability, and due to severe ongoing pain, a total hip replacement (THR) may be necessitated. Most cases are associated with trauma, but a number of established risk factors exist. Diagnosis can be challenging but relies on clinical history, physical examination, and radiology. X-ray and MRI are used to stage avascular necrosis (AVN) lesions, which in turn influence management decisions.We present a male in his early 40s, diagnosed with a right-sided AVNFH (Ficat-Arlet stage I) five years previously at another centre. A number of risk factors were identified, such as chronic alcohol abuse, smoking, obesity, and Klinefelter’s syndrome. A'watch and wait'approach was adopted, which included advice on reducing risk factors and commencement on aspirin and alendronic acid. However, his pain had recently increased, resulting in a significant reduction in mobility and an increased reliance on opiates. MRI demonstrated progression to Ficat-Arlet stage II, and the appearance of an additional smaller, second lesion located more medially in the same femoral head. Due to his symptom severity, he was offered a THR. In view of his young age, he came to our tertiary referral centre for a second opinion. He elected for a simultaneous dual surgical decompression of both AVN lesions and biological stimulation for bone-guided regeneration. This involved the delivery of growth factor (bone morphogenetic protein), progenitor cells, and a scaffold/matrix. At 36 months post-operatively, he continued to have the full, pain …

The Evidence-Based Medicine (EBM) movement, undoubtably one of the most successful movements in medicine, questions dogma and “clinical authority” and combines the “best available evidence” with clinical expertise and patient values in order to provide the best care for the individual patient. Although since its inception in the 1990s its strong theoretical foundations remain unaltered, a lot has changed in its practical implementation due to the electronic explosion of information and the unprecedented COVID-19 crisis. The purpose of this article is to succinctly provide the reader with an update on the major changes in EBM, including the important most recent ones that were “fast-tracked” due to the COVID-19 challenge.

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide …

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs.Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were …

IntroductionThere are currently no standardised guidelines on whether antibiotic prophylaxis is required for Kirschner wire (K-wire) fixation to minimise the risk of surgical site infection when used in patients undergoing clean orthopaedic surgery.PurposeTo compare the outcomes of antibiotic prophylaxis versus no antibiotic in K-wire fixation when used in either in trauma or elective orthopaedics.MethodsA systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all randomised controlled trials (RCTs) and non-randomised studies comparing the outcomes of antibiotic prophylaxis group versus those without antibiotic in patients undergoing orthopaedic surgery in which K-wire fixation was used. Incidence of surgical site infection (SSI) was the primary …

Periprosthetic acetabular fractures are rare but potentially devastating complications of total hip arthroplasty. As the number of total hip arthroplasties performed annually increases, so has the incidence of periprosthetic fractures, with the topic being spotlighted more frequently in the orthopaedic community. There is a particular sparsity of literature regarding periprosthetic acetabular fractures, with periprosthetic femoral fractures after total hip arthroplasty being traditionally far more commonly reported. This article aims to provide an up-to-date review of the epidemiology, risk factors, diagnostic challenges, classifications, and management strategies for periprosthetic acetabular fractures after total hip arthroplasty.

Reconstructive surgery of the clavicle using free vascularised fibula grafting (FVFG) is sometimes required for the management of severe bone loss or non-union. As the procedure is relatively rare, there is no universal agreement on the management and outcome. This systematic review aimed to first, identify the conditions for which FVFG has been applied; second, to gain an understanding of the surgical techniques used; and third, to report outcomes related to bone union, infection eradication, function and complications. A PRISMA strategy was used. Medline, Cochrane Central Register of Controlled Trials, Scopus and EMBASE library databases were interrogated using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated based on OCEBM and GRADE systems. Fourteen studies based on 37 patients were identified with a mean follow-up time of 33.3 months. The most common …

Tibial plateau fractures range from simple to complex. Most complex injury types are managed surgically but for some, a decision is made to treat without surgery. We present a case that was managed non-operatively but due to failure of bone union, later required surgical intervention. We discuss the choice of management and potential risk factors influencing outcome.

With a growing number of patients undergoing total knee replacements globally, coupled with an elderly population, the incidence of periprosthetic fractures around total knee replacements is increasing. As such, this is a highly topical subject that is gaining increasing interest within the orthopaedic community. This review provides a narrative synthesis of the most contemporary literature regarding distal femoral periprosthetic fractures. We review the related epidemiology, initial patient evaluation, the evolution and relevance of the classification systems and treatment options, particularly related to endoprosthetics and hybrid fixation constructs. The latest orthopaedic evidence related to this topic has been included.

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors.

Aims Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE …

PurposeThe unprecedented COVID-19 experience has posed severe challenges to the health care system and several of these are documented in orthopaedic surgery; however, although the pandemic has also brought positive changes, these have not been precisely documented. The purpose of this survey is to identify positive perceptions by orthopaedic surgeons at an international level. MethodsA cross-sectional, web-based survey inviting 120 orthopaedic surgeons was conducted in April 2020 querying about the positive lessons COVID-19 would teach us. From all responses, thematic codes were obtained and an exploratory thematic analysis was carried out to determine the prevalent themes. ResultsA total of 100 responses (83% response rate) from a total of seven countries were received. The variety of responses received were grouped into 13 different thematic codes. The thematic analysis generated …

Objective:The objective of this study was to compare clinical outcomes of patients with trochanteric hip fractures treated with specific different cephalomedullary nail (CMN) designs.Methods:A scoping review of the English literature was performed. Inclusion criteria were studies comparing perioperative and postoperative outcomes of trochanteric hip fractures fixated by CMNs for one of the following CMN designs: short versus long nails, blade versus screw fixation, dual versus single lag screw fixation, and application of cement augmentation. Inclusion criteria consisted of human comparative clinical trials (randomized and observational). Exclusion criteria included noncomparative studies, studies comparing CMN with non-CMN devices or with arthroplasty, studies with less than 3 months follow-up, studies that did not provide relevant clinical outcome measures, biomechanical, finite element analyses, animal, or in …

Introduction Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and …

PurposeAlthough bone transport is a well-recognised technique to address segmental bone defects, optimal management of docking sites is not absolutely determined. Some surgeons routinely intervene in all cases, and others prefer to observe and intervene only if spontaneous union does not occur. Primary aim of the study was to compare rates of docking site union between patients who underwent routine docking site intervention and those who did not.MethodsA systematic literature review using the keywords “bone transport”,“docking”,“tibia”, and “femur” was performed in PubMed using PRISMA guidelines. Studies published in English from January 2000 to August 2022 were included and assessed independently by two reviewers. Pooled analysis was undertaken dividing patients into two groups: those managed by routine intervention and those initially observed.ResultsTwenty-three clinical studies met the …

Complex extremity trauma, commonly the result of high energy injury, is usually characterized by extensive soft tissue destruction and concomitant bone loss. These injuries, during their course of management are frequently compounded by infection and non-union. An infected non-union, particularly when involving the tibia, which is characterized by a deficient soft-tissue envelope, is challenging to treat [1]. These injuries pose major therapeutic challenges to the limb reconstruction surgeons as several critical issues should be adequately addressed in order to achieve osseous union with simultaneous eradication of the infection and restoration of reasonable limb function. These critical issues include amongst others, bone loss (either due to the initial injury or to the subsequent surgical debridement), precarious soft tissue coverage, failed previous internal fixation, draining sinuses, leg-length discrepancies …

PurposeThe cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis–Ilizarov method (ILF), or with Masquelet technique (MIF).MethodsData of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF).ResultsThe average defect length was 5.6 cm (2.6–9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459–£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up …

PurposeTo establish the current peer-reviewed practices in the discipline of orthopaedic surgery and correlate these to the journal’s impact factor. Unfortunately, this is not receiving much attention and a critical literature gap in various disciplines; thus, determining the current practices in the discipline of orthopaedic surgery could provide valid insight that may be potentially applicable to other academic medicine disciplines as well.MethodsOrthopaedic surgery journals belonging to the Journal Citation Reports were queried, and the following was extracted: impact factor (IF) and blinding practices: single (SBPR), double (DBPR), triple (TBPR), quadruple (QBPR), and open (OPR) blinding review process and possibility of author-suggested reviewer (ASR) and non-preferred reviewer (NPR) options.ResultsOf the 82 journals, four were excluded as they allowed submission by invitation only. In the remaining, blinding …

The authors would like to thank Laubach and Hutmacher for bringing our attention to publications that are indeed relevant to our original article published in February 2022 [1]. We acknowledge that these studies have made significant contributions, especially the Zeiter et. al 2020 [2], Sparks et. al 2020 [3] and Kobbe et. al [4]. Zeiter et. al, 2020 [2] extensively analysed 169 in vivo studies in their review article based on bone tissue engineering. They found that majority of them (143 out of 169) were based on small animals and a small proportion (24 out of 169) focussed on large animal models. Sparks et. al 2020 established a methodology and comprehensively described the steps that may be followed to accomplish pre-clinical large-animal model for critical size bone defects impressively, within two years [3]. Kobbe et. al 2020 [4] presented and discussed a case report of using PCL-TCP based scaffolds for bone …

PurposeThe aim of this study was to examine the patient-reported outcomes of patients presenting with post-traumatic osteomyelitis (PTOM) of the lower limb over the past 15 years. This period was chosen to reflect modern treatment principles and increased centralisation of care.MethodsAn electronic literature search of the relevant databases (PubMed, Ovid Medline, Embase, and the Cochrane library) was conducted to identify studies published between January 2006 and July 2021 reporting series of greater than 10 patients with PTOM of the tibia or femur at the site of a previous fracture. Studies reporting septic non-union were excluded.ResultsSixteen eligible studies were identified and included in the final report. Remission of infection was achieved in 93.2% of cases (range 70–100%), whilst amputation was reported in 1–7% of cases. A variety of patient-reported outcome measures were utilised including the …

PurposeTo systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications.MethodsData sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted.Study selection: All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included. Data extraction: Basic information and specific injury-related information were collected.ResultsEight case reports were included. No study adequately reported the …

PurposeMetastatic disease of the pelvis is frequently associated with severe pain and impaired ambulatory function. Depending on the patient’s characteristics, primary tumor, and metastatic pelvic disease, the treatment choice may be varied. This study aims to report on the current management options of metastatic pelvic disease.MethodsWe comprehensively researched multiple databases and evaluated essential studies about current concepts of managing a metastatic bone disease of the pelvis, focusing on specific indications as well as on the result of treatment.ResultsPelvic metastases not in the periacetabular region can be managed with modification of weight-bearing, analgesics, bisphosphonates, chemotherapy and/or radiotherapy. Minimally invasive approaches include radiofrequency ablation, cryoablation, embolization, percutaneous osteoplasty, and percutaneous screw placement. Pathological or …

Periarticular fractures are complex injuries affecting the joint articular surface, the subchondral area, the metaphyseal region, the surrounding soft tissue envelope and not infrequently the ligamentous structures.The management of these injuries has evolved over the years, from one stage to two stage procedures thus facilitating soft tissue resuscitation, adequate pre-operative planning and the use of biologics optimizing the conditions for definitive fixation for a successful long-term outcome. Provisional fixation constitutes an essential step in the surgical treatment of these fractures. Herein, the role of provisional fixation as well as strategies on how they should be applied are discussed. The aim is to revisit this important step of provisional fracture fixation since its introduction by Albin Lambotte, in the early 1900′s.

Distal femoral fractures in elderly or osteoporotic patients constitute a challenging injury, especially in the settings of fracture comminution or periprosthetic fractures. A recent trend in the treatment of these difficult injuries is the double fixation with a nail and a plate, a strategy that comes with advantages including faster weight-bearing and lower risk for non-union. Although biomechanical studies have demonstrated the superiority of nail-plate constructs, there is a paucity in the literature regarding the indications and results of treatment. A review of the literature to date was carried out to identify which group of patients would benefit the most from this type of reconstruction and to evaluate the clinical outcomes.

BackgroundOur objective was to identify acetabular fractures in the elderly population (over 60 years of age), treated with open reduction and internal fixation (ORIF), and to examine their outcomes, primarily the risk for need for further surgery in the form of a total hip arthroplasty (THA), and factors associated with it. Additional outcomes such as infection, avascular necrosis (AVN) of the femoral head, and heterotopic ossification (HO) were also investigated.MethodsFollowing institutional review board (IRB) approval, a retrospective analysis of all consecutive patients presenting to a Level I Trauma Centre over a 13-years period (January 2003–February 2016) was conducted. Patients were excluded if their initial treatment was conservative or simultaneous ORIF with THA.ResultsA total of 62 patients with an age of 71.5 ± 8.04 years were included (14 female; follow-up 54.2 months, range 1–195 months). Sixteen …

During the past decade, more and more large-scale pragmatic clinical trials have been carried out in orthopedic trauma surgery. This trend is fueled by the common belief that the larger the numbers in a trial, the broader the eligibility criteria, and the less strict the regimentation of local treatment standards by protocol, the more trustworthy the findings would be. However, it must also be taken into account that the precision of an outcome measurement does not depend on the sample size alone, but the homogeneity of the studied population. Consequently, a small trial with stringent entry and assessment criteria may offer similarly precise answers as a large trial with less strict entry and assessment criteria because of the basic mathematical correlation between standard deviation and standard error of the mean. There is now a lively and controversial debate about the role of randomized controlled trials (RCT) in an …

The management of patients with multiple injuries remains challenging. Patients presenting with comorbidities, such as diabetes mellitus, may have additional unpredictable outcomes with increased mortality. Therefore, we aim to investigate the impact of major trauma centres in the UK on the outcomes of polytrauma patients with diabetes. The Trauma Audit and Research Network was used to identify polytrauma patients presenting to centres in England and Wales between 2012 and 2019. In total, 32,345 patients were thereby included and divided into three groups: 2271 with diabetes, 16,319 with comorbidities other than diabetes and 13,755 who had no comorbidities. Despite an overall increase in diabetic prevalence compared to previously published data, mortality was reduced in all groups, but diabetic patient mortality remained higher than in the other groups. Interestingly, increasing Injury Severity Score (ISS) and age were associated with increasing mortality, whereas the presence of diabetes, even when taking into consideration age, ISS and Glasgow Coma Score, led to an increase in the prediction of mortality with an odds ratio of 1.36 (p < 0.0001). The prevalence of diabetes mellitus in polytrauma patients has increased, and diabetes remains an independent risk factor for mortality following polytrauma.

A prospective, feasibility, randomised study was performed to compare intramedullary versus extramedullary fixation of unstable pertrochanteric fractures and to assess the feasibility of including patients with dementia. From July 2016 to November 2017, 60 consecutive patients with an unstable pertrochanteric (OTA/AO 31-A2) fracture were randomized to either receive a short cephalomedullary nail (Endovis EBA2, Citieffe) or a dynamic hip screw (DHS, Zimmer Biomet). Primary feasibility measures included randomisation, recruitment, and retention rates. Secondary outcomes included peri-operative parameters, patient-reported outcomes and radiographic outcomes. Patients were followed-up at two, four, and twelve weeks. There was no difference in the randomisation rate between patients with and without cognitive impairment. Significantly more patients without cognitive impairment attended the 12-week follow-up. The overall recruitment rate was 0.9 patients per week. Patients treated with the nail had less pain at 2 weeks and less neck collapse, medialisation, and leg shortening at all time points. The rest of secondary outcomes were similar. Patients with dementia can successfully be enrolled in a randomised trial on hip fractures. Patients treated with the Endovis nail had lower levels of pain at two weeks and better radiographic outcomes.

Multiple myeloma (MM) shows constitutive activation of canonical and noncanonical nuclear factor κB (NF-κB) signaling via genetic mutations or tumor microenvironment (TME) stimulations. A subset of MM cell lines showed dependency for cell growth and survival on the canonical NF-κB transcription factor RELA alone, suggesting a critical role for a RELA-mediated biological program in MM pathogenesis. Here, we determined the RELA-dependent transcriptional program in MM cell lines and found the expression of the cell surface molecules interleukin-27 receptor-α (IL-27Rα) and the adhesion molecule JAM2 to be responsive to RELA at the messenger RNA and protein levels. IL-27Rα and JAM2 were expressed on primary MM cells at higher levels than on healthy long-lived plasma cells (PCs) in the bone marrow. IL-27 activated STAT1, and to a lesser extent STAT3, in MM cell lines and in PCs generated …

Non-union is the failure of a fracture to unite in a timely fashion with an incidence reported to range from 2%-10%[1]. The aetiology is often multifactorial, involving a complex interplay relating to the biological pre-requisites and mechanical environment, as well as the physiological state of the host [2]. It is believed that the evolution of fracture healing involves the participation and optimum interaction of the key players (growth factors, stem cells, osteoconductive scaffolds and adequate mechanical environment) according to the ‘diamond concept’[2]. There is a lack of current clinical treatment guidance on the topic, as well as varying definitions of non-union which further adds to the challenge of managing non-union.

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980–May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by …

IntroductionTrauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region.MethodsOVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item …

Our aim was to systematically review literature of trauma related rotator cuff tears in order to evaluate the outcome and healing integrity in relation to time of surgery. Our research question was whether earlier surgical repair leads to superior functional results. This review was conducted according to PRISMA statement. A literature search of Pubmed, Embase, Cohrane was conducted, with two researchers assessing studies for eligibility and quality. A total of 20 studies, published between 1980 and 2019, met the inclusion criteria and were divided into two groups based on duration of symptoms before surgery. Group A comprised of studies in which duration was< 3 months and Group B> 3 months. Within each group there was a statistically significant improvement in the CS from pre-operative to post-operative outcome, but the improvement for Group A was statistically higher in comparison to Group B (P= 0.01). Nevertheless, there was no significant difference in the final outcome for the two groups (P= 0.29). The re-tear rate per 100 patients was calculated 28.5 (±7.2) for Group A, and 17.2 (±12.56) for Group B (P= 0.056). Our results suggest that functional outcome and tendon healing may not be valid arguments for early surgical repair. Therefore, repair of traumatic RCTs could be recommended whenever technically possible.

Patterson et al. investigated whether there is a difference in the incidence of venous thromboembolism (VTE) in patients with hypotension and pelvic fractures who were managed either with preperitoneal pelvic packing (PPP) or angioembolization (AE). They used the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. The matching of patients was possible using a propensity score approach. The primary outcome was the risk of VTE after matching on the propensity score for treatment, whereas the secondary outcomes included inpatient development of deep vein thrombosis, pulmonary embolism, or respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit length of stay.Patterson et al. report that PPP was associated with 9.8%(95% confidence interval [CI], 3.5% to 16.1%) greater absolute risk of VTE (relative …

IntroductionIntramedullary (IM) nails are considered the ‘gold’ standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population.Aims/objectivesOur study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit.MethodsA retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long …

Purpose The aim of this study was to identify factors associated with the need for open reduction in subtrochanteric femoral fractures and investigate the effect of cerclage wiring compared to open reduction alone, on the development of complications, especially infection and non-union. Methods All consecutive patients with a fracture involving the subtrochanteric region were retrospectively identified, over an 8-year period. Data documented and analysed included patient demographics, fracture characteristics, patient comorbidities, time to fracture union and development of complications. Results A total of 512 patients met the inclusion criteria (523 fractures). Open reduction was performed in 48% (247) of the fractures. Following matching and regression analysis, we identified diaphyseal extension of the fracture to be associated …

Background Long bone fractures display significant non-union rates, but the exact biological mechanisms implicated in this devastating complication remain unclear. The combination of osteogenetic and angiogenetic factors at the fracture site is an essential prerequisite for successful bone regeneration. The aim of this study is to investigate the results of the clinical implantation of growth factors for intraoperative enhancement of osteogenesis for the treatment of long bone fractures and non-unions. Methods A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed and Web of Science databases from the date of inception of each database through to 10 January 2022. Specific inclusion and exclusion criteria were applied in order to identify relevant studies reporting on the treatment of upper and lower limb long bone non-unions treated with osteoinductive or cellular factors. Results Overall, 18 studies met the inclusion criteria and examined the effectiveness of the application of Bone Morphogenetic Proteins-2 and -7 (BMPs), platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Despite the existence of limitations in the studies analysed (containing mixed groups of open and close fractures, different types of fractures, variability of treatment protocols, different selection criteria and follow-up periods amongst others), their overall effectiveness was found significantly increased in patients who received them compared with the controls (I2 = 60%, 95% CI = 1.59 [0.99–2.54], Z =1.93, p = 0.05). Conclusion Administration of …

IntroductionThe recently developed femoral neck system (FNS) for treatment of femoral neck fractures (FNF), comprises theoretical biomechanical advantages compared to other implants. The aim of this study was to validate the safety and to report outcomes of patients treated with the FNS.MethodA retrospective multicentric analysis of patients treated by FNS with a minimum of three months of follow-up. Details analysed from three medical centres were operative duration, estimated blood loss, initial hospitalisation duration, fixation quality as well as complications and reoperation rate. Patients who had revision surgery were compared to all other patients to identify risk factors for failure. In addition, a literature review was performed to analyse data on FNS clinical implementation and patient’s outcomes. The two data sets were combined and analysed.ResultsOne-hundred and two patients were included in this …

Several years ago, we proposed the above scoring system in order to assist surgeons with the complex analysis associated with fracture non-union surgery. The scoring system was developed based on the clinical experience of the authors carrying out this type of reconstructive surgery and the existing research evidence at that period of time. By attributing values to clinical features that we felt were important we included such parameters as bone quality, original fracture characteristics (closed or open), number of previous interventions, invasiveness of previous interventions, adequacy of previous surgery, bone alignment, presence of bone defect, state of the soft tissues, and the American Society of Anesthesiologists (ASA) grade of the patient. The severity of non-union was graded using a scale of 0 to 100, with a higher score indicating a greater severity. Moreover, based on the final score computed, the result …

PurposeHigh clinical success rates have been reported with the Masquelet technique in the treatment of traumatic bone loss. An increasing number of studies suggest that various factors can influence the properties of induced membranes. Goal of this systematic review is to answer the following questions: (1) which are the ideal spacer properties (material, surface topography, antibiotic supplementation) to booster the quality and osteogenic potential of induced membranes? (2) what is the ideal time to perform the second-stage operation?MethodsA systematic search using the keywords “((Masquelet) OR (Induced Periosteum)) AND ((Spacer) OR (Time))” was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines. Studies published up to the 23rd of February 2022 were included and assessed independently by two reviewers.ResultsThirteen animal and 1 clinical studies were …

Musculoskeletal trauma refers to injuries of the spine, pelvis and extremities and is primarily managed by Orthopaedic Surgeons. Its burden to society is tremendous and involves both direct costs (related to the healthcare provided) and indirect costs, such as the long-lasting consequences of physical and psychological impairment to citizens, loss of income and employment and therefore reduced taxpayer contributions. Currently, there are scarce statistics to estimate the scale of the problem, which is huge. If the numbers are not known, then prompt actions that will save money and provide optimal health care cannot be implemented. One solution could be National Trauma Registries: these are databases that collect such information in a systematic way. The EuroTARN project was started in 2005 to enable EU Member States to create such registries and to combine them at a Federal Level. It has stalled and needs political support to complete.

Traumatic bone defects represent a complex clinical scenario and a major cause of patient disability. Advances in fixation methods, bone reconstruction, soft tissue management, and antibiotics have led to an increase in limb salvage rates. Autogenous bone grafting remains the gold standard for small defects, while distraction osteogenesis, vascularized bone grafts and the induced membrane technique among others, offer solutions for the larger defects. Each method carries unique advantages and shortcomings.These debilitating injuries must be managed in specialized units with input from a multidisciplinary team.The rehabilitation may be prolonged, while the end result may be associated with a degree of residual functional impairment.

Introduction Higher than expected rates of tibial loosening with the ATTUNE® total knee arthroplasty (TKA) implant has been reported. Component loosening can be associated with the development of radiolucency lines (RLL) and our study aim was to systematically assess the reported rates of these. Methodology A systematic search was undertaken using the Cochrane methodology in four online databases. Identified studies were assessed and screened against predetermined inclusion criteria. Meta-analysis was conducted using a random-effects model. Results Nine studies (n=2,727 TKAs) from 6,590 titles met the inclusion criteria: 1 Randomised Controlled Trial (n=74), 1 prospective cohort (n=200), 4 retrospective cohort (n=1,639), and 3 case-series (n=814). All used the 2013 ATTUNE® design. In meta-analysis: 8 studies (n=1,440 ATTUNE TKAs …

Fracture non-union, prosthetic joint infection and fracture-related infections are complications frequently encountered by the trauma and orthopaedic surgeon. Moreover, they pose a significant socioeconomic and healthcare burden to the society. A clear understanding of the molecular biology surrounding fracture healing, as well as the pathophysiology of orthopaedic-related infections, is of paramount importance to their successful management. The first section of this article aims to explain the basic science critical to the understanding of DNA, RNA, gene and protein expression, and the molecular techniques most commonly deployed in the diagnostic and research fields of trauma and orthopaedics. The second section provides a general overview of the molecular physiology of fracture healing and biofilm, the molecular characteristics and genetic predisposition of fracture non-union, followed by discussing recent …

Critical-size long bone defects represent one of the major causes of fracture non-union and remain a significant challenge in orthopaedic surgery. Two-stage procedures such as a Masquelet technique demonstrate high level of success however their main disadvantage is the need for a second surgery, which is required to remove the non-resorbable cement spacer and to place the bone graft into the biological chamber formed by the ‘induced membrane’. Recent research efforts have therefore been dedicated towards the design, fabrication and testing of resorbable implants that could mimic the biological functions of the cement spacer and the induced membrane. Amongst the various manufacturing techniques used to fabricate these implants, three-dimensional (3D) printing and electrospinning methods have gained a significant momentum due their high-level controllability, scalable processing and relatively low …

BackgroundHemophilic knee arthritis is one of the most common presenting symptoms of hemophilia, and its management continues to be challenging to practitioners. Preliminary research has suggested that platelet-rich plasma (PRP) may have short-term efficacy in the treatment of hemophilic knee arthritis, but evidence for this treatment is limited.

Over the last year, with the social isolation imposed by the coronavirus disease pandemic, there has been a significant increase in complaints associated with physical violence against women. In the present study, an exploratory literature review was carried out on the role of the on-call orthopedic surgeon when faced with a suspicion of domestic violence, in accordance with Brazilian legislation. The main objective of the study was to show the role of this specialist in identifying victims of domestic violence by recognizing their profiles and associated risk factors. The secondary objectives were to demonstrate the most common skeletal and non-skeletal injuries in this type of violence and to present a quick and practical guide on how to identify, approach, and manage cases of domestic violence against women. The findings revealed that the main aggressors were close partners, such as spouses and ex-spouses …

With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy. Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents. Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.

Articular fractures of the distal humerus in adults are challenging fractures requiring adequate surgical exposure for optimum reconstruction. Most commonly, an articular osteotomy of the olecranon is performed, but complications have been reported related to both creating and repairing the articular osteotomy. We describe the use of an extra-articular olecranon osteotomy for approaching articular fractures of the distal humerus. We highlight the surgical steps required to obtain adequate exposure facilitating anatomical reduction, stable fixation, and early range of motion of the elbow joint. This technique can be added to the surgeon's armamentarium for the management of these complex injuries. [Orthopedics. 2022;45(4):e220–e225.]

Objectives:To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct.Design:Retrospective.Setting:Two Level-1 trauma centers in Germany and United Kingdom.Methods:Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals–Tower criteria.Results:A total of 32 patients …

Treatment of fractures remains challenging and carries a high economical burden to both patients and society. In order to prevent some of the complications, the use of bone adhesives has been proposed, but up to date, bone adhesives are not part of the current clinical practice. Early results of use of bone cements and bone glues are promising, focusing in the areas of highly fragmented fractures, fixation of long bone fractures, filling bone voids and defects, promoting osseointegration, preventing non-union while maintaining the reduction of fracture fixation. This review aims to describe the state-of-the-art of the development, properties and use of adhesives in fracture treatment.

“Dear readers, greetings for the day. We hope this editorial finds you well.” These introductory words will certainly sound familiar to you, from the numerous spam emails that reach your email inbox every day. The senders of these invitations invite you to submit your research work, review articles or a short communication to journals with names that sound similar to well-known and established journals. These so-called predatory journals promise everything a scientist would like to see: secure publication within a short period of time managed by a short peer review process and an almost 100% acceptance rate. In addition, the article processing charges (APC) offered are low compared to open access charges posed by journals from established publishers (eg Elsevier) that makes predatory journals particularly attractive for researchers from middle and low-income countries. This financial aspect with APC appears to …

By definition, anteroposterior (AP) compression type 1 (APC-1) injury is a type of pelvic ring injury, which is widely acknowledged as ‘stable’. Unstable forms of this injury are very rare and present a challenge for diagnosis and clinical management. Detailed herein is a man in his early 30s, referred to our institution with a 2-year history of pubic symphysis pain following a road traffic accident. Radiological investigation revealed an unstable APC-1 injury. This was subsequently managed with surgical reconstruction leading to the successful return of the patient to former function and recreational activities.

The first published surgical treatment of patella fracture was in 1841 by Dieffenbach who cut both the patellar and quadriceps tendons and used compressive bandage to oppose the fragments [1]. However, historically, American surgeon George McClellan is credited by later authors to be the first one who successfully internally fixed a patella fracture around 1838, using holes to pass a softiron wire to approximate the fragments, although earlier unsuccessful attempts resulting in patient death have also been reported [1]. Before the antiseptic era, many attempts focused on the use of the percutaneous “Malgaigne hooks” to approximate the fragments, with several authors reporting on modifications of the original 1843 device by Malgaigne, however this was complicated by high rates of infection leading to septic arthritis and death by septic shock [1]. Non-operative methods including for example extension splinting …

Despite the somewhat melodramatic and provocative title, the content of Professor Cameron’s editorial [1] contains considered points worthy of discussion. Although I feel it is a little early to call time on the Major Trauma Centre, it is a reminder that any clinical service must adapt to the changing needs of the population they serve, and as highlighted, two areas stand out as targets for improvement, the fate of the elderly trauma patient, and the role of inter-hospital transfer in trauma. Elderly trauma patients are different to those that Major Trauma Centres were initially designed to serve. They have differing needs from the traditional multi-injured patient, they are frail and have high mortality from lesser injuries, and that mortality relates as much if not more, to their preexisting frailty and medical comorbidity as to their injury. Their needs are as much medical and social as surgical, and it is right to say that services need to …

PurposeTo investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated.MethodsPUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was …

Dicalcium Phosphate Dihydrate (DCPD) mineral scaffolds alone do not possess the mechanical flexibility, ease of physicochemical properties’ tuneability or suitable porosity required for regenerative bone scaffolds. Herein, we fabricated highly porous freeze-dried chitosan scaffolds embedded with different concentrations of Dicalcium Phosphate Dihydrate (DCPD) minerals, i.e., 0, 20, 30, 40 and 50 (wt)%. Increasing DCPD mineral concentration led to increased scaffold crystallinity, where the % crystallinity for CH, 20, 30, 40, and 50-DCPD scaffolds was determined to be 0.1, 20.6, 29.4, 38.8 and 69.9%, respectively. Reduction in scaffold pore size distributions was observed with increasing DCPD concentrations of 0 to 40 (wt)%; coalescence and close-ended pore formation were observed for 50-DCPD scaffolds. 50-DCPD scaffolds presented five times greater mechanical strength than the DCPD mineral-free scaffolds (CH). DCPD mineral enhanced cell proliferation for the 20, 30 and 40-DCPD scaffolds. 50-DCPD scaffolds presented reduced pore interconnectivity due to the coalescence of many pores in addition to the creation of closed-ended pores, which were found to hinder osteoblast cell proliferation.

The first Trauma and Orthopaedic unit dates back to 1780, originally dedicated to the treatment of children's deformities. The specialty has subsequently become multifaceted, with a plethora of subspecialty areas of which orthopaedic trauma is the most commonly practiced. Recently there has been a significant demand for an evidence base with more than 130,000 of the 162,000 publications in the last century occurring within the past 20 years. This narrative review will summarise some of the more landmark changes within orthopaedic trauma that have been made within the past 20 years, whilst also attempting to predict where the specialty will continue to develop as we move forward.