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Purpose: The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). Methods: A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. Results: All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12–28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4–12) from debridement. No patients developed aseptic wound leak. Conclusions: Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator. [ABSTRACT FROM AUTHOR]

Purpose: Talar neck and body fractures are uncommon injuries that are challenging to manage with high reported complication rates, including post-traumatic arthritis, avascular necrosis, and poor functional outcomes. The aim of this study was to assess the complication rates for patients with talus fractures across three major trauma centres (MTCs) in England. Methods: A retrospective analysis was performed of prospectively collected trauma databases. Data were collected from three English MTCs. Patients with talar neck and/or body fractures sustained between August 2015 and August 2019 were identified and their clinical course reviewed radiologically and clinically. Isolated process fractures, osteochondral defects and paediatric patients were excluded. Patients were analysed by fracture type and for definitive treatment method with separation into non-operative and operative management groups. Procedure type was identified in the operative group. Superficial infection, deep infection, non-union, avascular necrosis, post-traumatic arthritis and removal of metalwork rates were analysed. Results: Eighty-five patients with talar neck and/or body fractures were included. Seventy-five patients received operative management, 10 non-operative. The overall AVN rate was 5.9% (five patients), overall post-traumatic arthritis rate was 18.8% (16 patients), deep infection rate 1.2% (one patient), non-union rate 4.7% (four patients). Removal of metalwork rate was 9.4% (eight patients). Conclusion: Our reported outcomes and complication rates are generally lower than those previously described. This may be a result of improved techniques, a higher frequency of open reduction with direct visualisation or by surgery occurring in centralised specialist centres. [ABSTRACT FROM AUTHOR]

Purpose: In treating distal third tibial fractures, restoration of the axial alignment and therefore accurate reduction of the distal fragment minimise the risk of tibiotalar joint malalignment. The aim of this study is to investigate whether there was a difference in accuracy of reduction and axial alignment, when nailing distal third tibial fractures using either the suprapatellar or the infrapatellar tibial nailing entry technique. Methods: This retrospective cohort study compared alignment of intramedullary nails performed for distal third tibial fractures between 2015 and 2018 through the suprapatellar and infrapatellar approach at a UK Level 1 trauma centre. It compared a consecutive series of 74 suprapatellar nails and 51 infrapatellar nails, with radiographic assessment of tibial alignment in the antero-posterior and sagittal planes. It included inter- and intra-observer analyses of radiographic measurements. Results: In the coronal plane, mean malalignment in the suprapatellar technique group was 2.8 ± 0.7° and 4.7 ± 0.9° in the infrapatellar technique group (P < 0.01). In the sagittal plane, mean malalignment in the suprapatellar technique group was 4.0 ± 0.8° and 3.5 ± 0.9° in the infrapatellar technique group (P = 0.42). Intra- and inter-observer analysis showed strongly positive correlations between observers. Conclusions: We suggest that the suprapatellar technique may improve coronal plane alignment when intramedullary nailing distal tibial fractures. There was no significant difference in alignment in the sagittal plane. We conclude that the suprapatellar technique may be superior in preventing malalignment when treating distal third tibial fractures, potentially improving clinical outcome. [ABSTRACT FROM AUTHOR]

Introduction: Anterior knee pain and kneeling pain are some of the most common complications following intramedullary nailing of tibial shaft fractures. With the increased uptake of suprapatellar nailing at our institution, we undertook a service evaluation to assess anterior knee pain and kneeling pain in patients who underwent the suprapatellar tibial nailing technique compared with the infrapatellar approach. Methodology: Data from all consecutive intramedullary tibial nailing operations between January 2014 and July 2017 were analysed from a prospectively collected database. All acute diaphyseal fracture nailing procedures were included. All patients were reviewed between six-month and four-year post-operation. Each patient was asked to complete a standardised questionnaire with three main outcome measures: pain on kneeling, presence of anterior knee pain and the severity of pain. Results: After exclusions, a total of 148 patients were identified. A total of 102 responses were received, 41 in the infrapatellar group (73.2%) and 61 in the suprapatellar group (66.3%). A longer time from surgery to telephone follow-up response was noted in the infrapatellar group: 32.4 months (interquartile range, 16.1) vs. 19.3 months (interquartile range, 17.4), p < 0.001. A trend towards lower reported anterior knee pain was noted in the suprapatellar group (67.9% VS 53.7%). Most patients reported mild or no pain on kneeling, with no significant difference between the two groups. There was also no significant difference in severity of knee pain between the two groups and no significant effect on the Kujala score. Conclusion: With the comparable pain outcomes between the two groups, our analysis supports the continued use of the suprapatellar tibial nailing technique for tibial shaft fractures at our institution. [ABSTRACT FROM AUTHOR]

Purpose: The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. Methods: Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the United Kingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. Results: Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. Conclusions: Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures. [ABSTRACT FROM AUTHOR]