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Introduction: Infected 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. Aims: This 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). Methods: A PRISMA strategy was used. Medline, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar library databases were interrogated using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated using OCEBM and GRADE systems. Results: Thirty-two studies with 1136 subjects met the inclusion criteria. With respect to the primary outcomes of interest, union was observed in 94.6% (DO method) and 88.0% (IMT method); this difference, however, was not significant between the two techniques (p = 0.45). In addition, infection elimination rates were also higher in the Ilizarov DO group when compared to Masquelet (Mq) IMT (93.0% vs 80.4% respectively). Again, no significant difference was observed (p = 0.06). For all secondary outcomes assessed (unplanned re-operations, re-fracture rates amputation rate), no statistically significant differences were documented between the treatment options. Conclusion: This study demonstrated that there is no clinical difference in outcomes for patients treated with Ilizarov DO versus Mq IMT techniques. The evidence base at present is relatively sparse and, therefore, we would recommend for further Level I studies to be conducted, to make more meaningful conclusions. [ABSTRACT FROM AUTHOR]

Mesenchymal stem cells are core to bone homeostasis and repair. They both provide the progenitor cells from which bone cells are formed and regulate the local cytokine environment to create a pro-osteogenic environment. Dysregulation of these cells is often seen in orthopaedic pathology and can be manipulated by the physician treating the patient. This narrative review aims to describe the common applications of cell therapies to bone healing whilst also suggesting the future direction of these techniques. [ABSTRACT FROM AUTHOR]

Purpose: Acute compartment syndrome (ACS) remains a devastating complication of orthopaedic trauma. The tibial diaphysis is especially implicated in the development of ACS, both at the time of injury and after operative management. Identification of risk factors for ACS for these distinct scenarios has been investigated in a large cohort of patients. Methods: This is a retrospective cohort study of all adults (age 18 years and older) presenting to a level 1 trauma centre with a diaphyseal tibia fracture. ACS was determined by a combination of clinical signs and symptoms and compartmental pressure monitoring. Potential risk factors were subject to univariate analysis with significant variables undergoing binary logistic regression analysis. Results: 1147 tibial diaphyseal fractures over a twelve year period were studied. Age, multifragmented fracture pattern, male gender, high energy mechanism and intra- articular extension all showed a statistically significant association for ACS. Increasing body mass index (BMI) and treatment with an intramedullary nail favoured development of ACS post-operatively. Conclusion: Risk factors for the development of ACS specifically in tibial diaphyseal fractures have been highlighted. Patients managed with IMN or high BMI may warrant particular observation following operative intervention. [ABSTRACT FROM AUTHOR]

Purpose: The epidemiology of paediatric fractures has been previously described, however there is limited data available on open fractures in this population. The purpose of this study was to investigate trends, mechanism of injury (MOI) and severity of paediatric open fractures and undertake an epidemiological study. Methods: All children ≤ 16.0 years presenting with open fractures were identified between 01/04/2013 and 01/04/2023. Those with craniofacial, thoracic and distal phalangeal fractures were excluded. Incidence was calculated based on those presenting within the local geographical region. Social deprivation was measured using the Index of Multiple Deprivation (IMD). Results: There were 208 open fractures with a median age of 11.0(q1 7.4-q3 13.4) years, and 153(74.6%) were in males. The MOIs were road traffic collisions 73(35.1%), sports/play 45(21.6%), fall > 2m 29(13.9%), simple fall 25(12.0%), crush 16(7.7%), bites 8(3.8%), assault 6(2.9%), and other 6(2.9%). Nineteen children (9.1%) presented with polytrauma. Gustilo-Anderson grade for long bone fractures were I-61(29.3%), II-24(11.5%), IIIa-36(17.3%), IIIb-30(14.4%) and IIIc-7(3.4%). There were 129 children presenting within the local geographical region providing an annual incidence of 8.0/100,000. Radius and ulna were the most frequently injured 49(38.0%) followed by tibia and fibula 44(34.1%). There were 69(53.5%) children presenting from an IMD quintile 1 with open fractures. Conclusion: Paediatric open fractures are commonly seen in the adolescent male and affect those who are from a more socially deprived background. These injuries account for 3.2% of fractures admitted to a MTC. Data suggests children principally sustain open fractures through two distinct injury patterns and ten-year trends suggests that there is a gradual decline in the annual incidence. [ABSTRACT FROM AUTHOR]

Purpose: Metastatic 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. Methods: We 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. Results: Pelvic 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 impending periacetabular fracture, excessive periacetabular bone defect, radioresistant tumor, and persistent debilitating pain despite non-surgical treatment and/or minimally invasive procedures can be managed with different surgical techniques. Overall, treatment can be divided into nonoperative, minimally invasive, and operative based on specific indications, the expectations of the patient and the lesion. Conclusion: Different treatment modalities exist to manage metastatic pelvic bone disease. Decision-making for the most appropriate treatment should be made with a multidisciplinary approach based on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Background: Although segmental femoral shaft fractures (SFSF) are very challenging to manage, there has been no critical evaluation of the current practices and outcomes. The aim of this study is to evaluate their characteristics, management trends, outcomes, and complications. Methods: A literature search was conducted via the SCOPUS, Embase (via SCOPUS) and MEDLINE (via PubMed) between 1995 and 2023. Studies were included if they reported patient demographics, mechanism of injury, classification of fractures, associated injuries, type of management, outcomes, and complications. Exclusion criteria: only diaphyseal fractures were included and proximal and distal femoral fractures were excluded from this study. Results: Overall, 22 studies met the inclusion criteria reporting on 313 patients. Mean age was 36.2 years with male–female ratio of 4.8 to 1. The majority were high-energy fractures secondary to road traffic accidents and 16% were open. The most commonly associated injuries included chest injury (27%) and lower leg fractures (24%). Treatment consisted of intramedullary nailing (IMN) (72%), plating (22%) or both combined (6%). Outcomes reported: good in 70%, fair in 10%, excellent in 19% and poor in 2% of cases. Mean time to union was 20 weeks. Complications are reported in 24% of cases, with most common delayed union (5%) and non-union (4%). Conclusion: SFSF are high-energy fractures occurring most commonly in young males, are open in 16% of cases and have significant associated injuries. In their overwhelming majority, IMN is the mainstay of treatment. The expected outcome is generally good in 70% of cases, although not devoid of complications in 24% of cases and patients must be aware of this during the consent process. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre. Methods: Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate. Exclusion criteria were patients that died or were lost to follow-up and cases in which the nail was used in a chronic setting, such as malunion and non-union. Main parameters evaluated were fracture union, complications and functional outcomes. The functional outcome was assessed using the Olerud–Molander Ankle Score (OMAS). The minimum follow-up was 12 months. Results: Thirty-two consecutive patients (12 males) with a mean age of 80.2 years (range 66–98) met the inclusion criteria and formed the basis of this study. Fracture union was achieved in 93.8% of the cases at a mean time of 3.9 months (range 2–8). Two patients developed surgical site infections and underwent reoperation before union. The overall complication rate was 25.1%, while the respective reintervention rate was 18.8%. In terms of functional outcomes, the mean OMAS score was 45, ranging from 20 to 70. Conclusion: Tibiotalocalcaneal nailing can be considered as an acceptable less invasive option with good functional outcomes for the treatment of complex distal tibia and ankle fractures in frail patients with problematic local soft tissues. [ABSTRACT FROM AUTHOR]

Purpose: Although 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. Methods: A 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. Results: Twenty-three clinical studies met the eligibility criteria for pooled analysis, including 1153 patients, 407 in the routine intervention and 746 in the observed group. The rate of union after initial treatment was 90% in the routine intervention group and 66% in the observed group (p < 0.0001). Overall union rates at the end of treatment were similar at 99% in both groups. Patients in the observed group required an average of 2.2 procedures to achieve union overall compared with 3.8 in the routine intervention group. Time in frame was similar between groups. Conclusion: Based on the current literature, routine docking site interventions cannot be recommended, since this may lead to unnecessary interventions in two thirds of patients. Timely selective intervention in those at high risk or after a defined period of observation would appear to be a logical approach. [ABSTRACT FROM AUTHOR]

Purpose: Obstetric 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. Method: A 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. Results: Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate. Conclusion: Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies. [ABSTRACT FROM AUTHOR]

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 reasons for the procedure were: fracture non-union; tumours requiring resection; post-radiation treatment osteonecrosis and osteomyelitis. The operation approaches were similar, involving graft retrieval, insertion and fixation and vessels chosen for reattachment. The mean clavicular bone defect size was 6.6 cm (± 1.5), prior to FVFG. Bone union occurred in 94.6% with good functional outcomes. Complete infection eradication occurred in those with preceding osteomyelitis. The main complications were broken metalwork, delayed union/non-union and fibular leg paraesthesia (n = 20). The mean re-operation number was 1.6 (range 0–5.0). The study demonstrates that FVFG is well tolerated and has a high success rate. However, patients should be advised about complication development and re-intervention requirement. Interestingly, overall data is sparse with no large cohort groups or randomised trials. [ABSTRACT FROM AUTHOR]

Purpose: The 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. Methods: Between 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). Results: Out of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were treated with LP. Mean age was 64.2 (18–99) and 70.1 (18–100) for the IMN and LP groups respectively. Overall, the two groups had similar demographics and there was no significant difference in the type of fractures sustained (p > 0.05). The Oxford Knee Score was highest for patients fixed with LP, mean 37.3 (6–48, SD 7.3) versus 28.4 (3–48, SD 14.4), (p = < 0.02) compared to the IMN group. In terms of complications, the rate of non-union was higher in the LP group 8.6% versus 4% in those patients treated with an IMN, p value < 0.01. Conclusion: While the rate of non-union was higher in the LP group and the functional results were superior in the plating group. [ABSTRACT FROM AUTHOR]

Introduction: Carbon 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. Methods: This 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 questionnaire examining their views as to the advantages and disadvantages of CFR-PEEK plates, and whether they would be happy to participate in a trial comparing both. Results: Ninety-nine patients were happy to participate (64 females, mean age 50). Eighty-seven patients reported that they would want a CFR-PEEK implant for their fracture, and 76 reported that they would be willing to participate in an RCT comparing their use. Commonly reported advantages included radiolucency, low weight and biocompatibility. Disadvantages reported included cost and concerns regarding durability. Conclusions: This study demonstrates that CFR-PEEK implants would be acceptable to patients undergoing fracture surgery, with high numbers of patients stating that they would be willing to participate in a randomised study examining their use. [ABSTRACT FROM AUTHOR]

Purpose: To 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. Methods: Data 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. Results: Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies. Conclusion: The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries. [ABSTRACT FROM AUTHOR]

Purpose: High 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? Methods: A 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. Results: Thirteen animal and 1 clinical studies were identified to address the above questions. Spacer materials used were PMMA, silicone, titanium, polypropylene, PVA, PCL and calcium sulfate. With the exception of PVA sponges, all solid materials could induce membranes. Low union rates have been reported with titanium and rough surfaced spacers. Scraping of the inner surface of the IM also increased bony union rates. In terms of the ideal timing to perform the second-stage evidence suggests that membranes older than 8 weeks continue to have regenerative capacities similar to younger ones. Conclusion: Membranes induced by smooth PMMA spacers loaded with low concentrations of antibiotics showed powerful osteogenic properties. Other materials such as Polypropylene or Calcium sulfate can also be used with good results. Despite current recommendation to perform the second stage operation in 4–8 weeks, membranes older than 8 weeks seem to have similar regenerative capacities to younger ones. [ABSTRACT FROM AUTHOR]

Purpose: The 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. Methods: An 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. Results: Sixteen 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 lower extremity functional scale, short musculoskeletal functional assessment, Enneking score, and EQ-5D-3L. Limb-specific functional outcomes returned to levels similar to that of the general population although poorer outcomes were noted in specific cohorts including those with complex anatomic disease and active medical comorbidities. Conclusion: Infection following fracture fixation remains a difficult problem to treat. Regardless, using modern treatments and techniques patients can have comparable functional outcomes to that of the general population. High-quality studies are required to advance our knowledge into which types of treatments offer a benefit and how to further improve outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The 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. Methods: A 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. Results: A 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 two major themes: "Virtual reorganization" and "Wellness and sustainability". Fifty-four per cent of the participants reported positive changes in service reorganization and virtual consultation, whereas 30% replied with an increased feeling of well-being which overlapped with environmental benefits, including reduced paperwork, reduced travelling and increased quality time for family and reflection. Conclusions: Despite the negative aspects of the pandemic, responders reported several positive changes particularly relating to service reorganization and personal well-being. This study prompts further larger scale research to unravel further detail in those positive aspects and strongly enhance our future orthopaedic practice. [ABSTRACT FROM AUTHOR]

Introduction: There 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. Purpose: To compare the outcomes of antibiotic prophylaxis versus no antibiotic in K-wire fixation when used in either in trauma or elective orthopaedics. Methods: A 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 outcome. Random effects modelling was used for the analysis. Results: Four retrospective cohort studies and one RCT were identified with a total of 2316 patients. There was no significant difference between the prophylactic antibiotic and no antibiotic groups in terms of incidence of SSI (odds ratio [OR] = 0.72, P = 0.18). Conclusions: There is no significant difference in administering peri-operative antibiotics for patients undergoing orthopaedic surgery using K-wire. [ABSTRACT FROM AUTHOR]

Purpose: To 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. Methods: Orthopaedic 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. Results: Of the 82 journals, four were excluded as they allowed submission by invitation only. In the remaining, blinding was as follows: SBPR nine (11.5%), DBPR 52 (66.7%), TBPR two (2.6%), QBPR zero (0%), and OPR three (3.8%), and in 12 (15.4%), this was unclear. ASR and NPR options were offered by 34 (43.6%) and 27 (34.6%) journals respectively, whereas ASR was mandatory in eight (10.2%). No correlation between IF and any other parameter was found. Conclusion: The rules of the "game" are unclear/not disclosed in a significant number of cases, and the SBPR system, along with the ASR (mandatory sometimes) and NPR, is still extensively used with questionable integrity and fairness. Several recommendations are provided to mitigate potentially compromising practices, along with future directions to address the scarcity of research in this critical aspect of science. [ABSTRACT FROM AUTHOR]

Purpose: The 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). Methods: Data 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). Results: The 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 visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9. Conclusions: The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice. [ABSTRACT FROM AUTHOR]

Background: Our 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. Methods: Following 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. Results: A 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 patients required a THA as a secondary procedure due to symptomatic post-traumatic arthritis (25.8%), five (8.1%) of whom having a THA within a year from the original trauma (three patients presenting with loss of reduction and two patients with early AVN). No associations with progression to THA were identified. Surgical approach (ilioinguinal) was the only factor associated with increased risk of development of HO (p = 0.010). The median post-operative survival following an acetabular fracture treated with ORIF was calculated at 90.1 months (95% CI 72.9–107.2). Conclusion: Acetabular fractures ORIF in the elderly, is a safe and reliable option. The relatively incidence of development of severe post-operative arthritis was 45.2%. Conversion to THA was 25.8%, with 8.1% having the arthroplasty procedure within a year of the original trauma surgery. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The 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. Methods: 77 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. Results: The 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 < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05). Conclusion: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks. [ABSTRACT FROM AUTHOR]

Purpose: Whilst 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. Methods: Single 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. Results: Seventy-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 (21/72) and systemic antibiotic therapy in all cases. PROMS were collected in 84% of all eligible patients at a median of 112-month post-treatment. Twelve patients experienced recurrence, whilst nine underwent amputation. The median LEFS was 60, the EQ-5D-3L index score was 0.760, and the EQ-VAS was 80. These scores are substantially lower than those seen in the general population (77, 0.856 and 82.2, respectively). LEFS was significantly higher, where RIA was utilised (69.6 vs 52.8; p = 0.02), and in those classified as BACH uncomplicated (74.4 vs 58.4; p = 0.02). EQ-5D-3L was also higher when RIA was utilised (0.883 vs 0.604; p = 0.04), with no difference in EQ-VAS scores. Conclusions: Patients with PTOM report functional outcomes below that of the general population, even when in remission. Improved outcomes were associated with uncomplicated disease and the use of RIA. [ABSTRACT FROM AUTHOR]

Purpose: To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures. Methods: Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status. Results: Out of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70). Conclusion: In this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication. [ABSTRACT FROM AUTHOR]

Breast cancer is the commonest malignancy of women and with its incidence on the rise, the need to identify new targets for treatment is imperative. There is a growing interest in the role of lipid metabolism in cancer. Carnitine palmitoyl-transferase-1 (CPT-1); the rate limiting step in fatty acid oxidation, has been shown to be overexpressed in a range of tumours. There are three isoforms of CPT-1; A, B and C. It is CPT-1A that has been shown to be the predominant isoform which is overexpressed in breast cancer. We performed a bioinformatic analysis using readily available online platforms to establish the prognostic and predictive effects related to CPT-1A expression. These include the KM plotter, the Human Protein Atlas, the cBioPortal, the G2O, the MethSurvand the ROC plotter. A Network analysis was performed using the Oncomine platform and signalling pathways constituting the cancer hallmarks, including immune regulation as utilised by NanoString. The epigenetic pathways were obtained from the EpiFactor website. Spearman correlations (r) to determine the relationship between CPT-1A and the immune response were obtained using the TISIDB portal. Overexpression of CPT-1A largely confers a worse prognosis and CPT-1A progressively recruits a range of pathways as breast cancer progresses. CPT-1A’s interactions with cancer pathways is far wider than previously realised and includes associations with epigenetic regulation and immune evasion pathways, as well as wild-type moderate to high penetrant genes involved in hereditary breast cancer. Although CPT-1A genomic alterations are detected in 9% of breast carcinomas, both the alteration and the metagene associated with it, confers a poor prognosis. CPT-1A expression can be utilised as a biomarker of disease progression and as a potential therapeutic target. [ABSTRACT FROM AUTHOR]

Introduction: The 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. Method: A 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. Results: One-hundred and two patients were included in this study cohort with an average follow-up of seven months (range 3–27). Ten papers were included in the literature review, reporting data on 278 patients. Overall, 380 patients were analysed. Average age was 62.6 years, 52% of the fractures were classified as Gardens 1–2. Overall, the revision rate was 9.2% (14 patients diagnosed with cut-out of implant, 10 with AVN, 8 with non-union and 8 with hardware removal). For the 102 patients in the cohort risk factors for reoperation included patients age, surgeon seniority and inadequate placement of the implant. Conclusion: This study shows that FNS is a safe treatment option for FNF. Intra-operative parameters and failure rates are comparable to previously reported rates for this implant and other frequently used implants. [ABSTRACT FROM AUTHOR]

Purpose: To 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. Methods: PUBMED, 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 also conducted. Results: Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7–8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3–2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7–85.4%) and 74.1% (95% CI 31.5–100%), respectively. Conclusion: A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve. [ABSTRACT FROM AUTHOR]

Introduction: Trauma 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. Methods: OVID 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 bank. Results: 57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57). Conclusion: Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries. No funding was received. Clinical Trial Registration: PROSPERO CRD42020220380. [ABSTRACT FROM AUTHOR]

Introduction: Intramedullary (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/objectives: Our 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.Methods: A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan-Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0).Results: A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan-Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit.Conclusion: We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit. [ABSTRACT FROM AUTHOR]

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 with an open reduction (OR: 2.30; 95% CI 1.45–3.65; p < 0.001). Open reduction was also associated with an increased risk of superficial infection (OR: 7.88; 95% CI 1.63–38.16; p = 0.010), transfusion within 48 h following surgery (OR: 2.44; 95% CI 1.96–4.87; p < 0.001) and a prolonged surgical time (OR: 3.09; 95% CI 1.96–4.87; p < 0.001). The risk of non-union, deep infection and overall mortality was not increased with open reduction. The use of cerclage wires [50 out of 201 fractures (24.9%) treated with an open reduction] to achieve anatomical reduction as compared to open reduction alone significantly reduced the risk of non-union (OR: 0.20; 95% CI 0.06–0.74; p = 0.015). Conclusion: Open reduction of subtrochanteric fractures is not associated with an increased risk of deep infection and non-union, even though it is associated with an increased risk of superficial infection, prolonged surgical time and transfusion. The use of cerclage wire is associated with reduced risk of non-union with little evidence of an increase in complications. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications. Methods: A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out. Results: Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups. Conclusion: CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating. [ABSTRACT FROM AUTHOR]

Purpose: There is relatively limited large scale, long-term unified evidence to describe how quality of life (QoL) and functional outcomes are affected after polytrauma. The aim of this study is to review validated measures available to assess QoL and functional outcomes and make recommendations on how best to assess patents after major trauma. Methods: PubMed and EMBASE databases were interrogated to identify suitable patient-reported outcome measures (PROMs) for use in major trauma, and current practice in their use globally. Results: Overall, 81 papers met the criteria for inclusion and evaluation. Data from these were synthesised. A full set of validated PROMs tools were identified for patients with polytrauma, as well as critique of current tools available, allowing us to evaluate practice and recommend specific outcome measures for patients following polytrauma, and system changes needed to embed this in routine practice moving forward. Conclusion: To achieve optimal outcomes for patients with polytrauma, we will need to focus on what matters most to them, including their needs (and unmet needs). The use of appropriate PROMs allows evaluation and improvement in the care we can offer. Transformative effects have been noted in cases where they have been used to guide treatment, and if embedded as part of the wider system, it should lead to better overall outcomes. Accordingly, we have made recommendations to this effect. It is time to seize the day, bring these measures even further into our routine practice, and be part of shaping the future. [ABSTRACT FROM AUTHOR]

Background: Bilateral acetabular fractures constitute a rare entity, and their optimal management is unknown. Materials and Methods: A systematic literature search was conducted in PubMed, Embase and Cochrane Library between 1995 and 2020. Inclusion criteria were studies presenting cases of bilateral acetabular fractures and reporting outcomes. Extracted data included patient demographics, injury mechanism, fracture classification, associated injuries, management and outcomes. Results: Thirty-seven studies (47 cases; 35 males vs 12 females) were included. Mean age was 46 years old (range 13–84) and mean follow-up was 19.8 months (range 1.5–56). High-energy injuries (49%) and seizures (45%) were the most common injury mechanisms. Fracture type distribution differed according to injury mechanism. Treatment was surgical in 70% of cases (75% open reduction and internal fixation vs 25% acute total hip arthroplasty). Outcomes were excellent/good in 58% of patients. Complications included heterotopic ossification (11%), nerve injury (11%), degenerative arthritis (6%), DVT (6%), and infection (3%). Conclusions: Bilateral acetabular fractures most commonly occur either after trauma or seizures and are commonly managed operatively. They are not devoid of complications, however, more than half (58%) achieve complete functional recovery. [ABSTRACT FROM AUTHOR]

Purpose: To identify if older adults are more susceptible to acute muscle atrophy compared to younger adults. Methods: All studies whose design involved a period of enforced immobilisation and a comparison between an older (> 40) and a younger cohort (< 40) were included. Outcome of interest was change in muscle mass, measured by radiological techniques or histological analysis of fibre size. Medline, Embase and Cochrane databases were systematically searched and records screened by two independent reviewers. Studies selected for inclusion were critically appraised and individually assessed for risk of bias. GRADE framework guided the assessment of quality of studies. Results: Eight articles were included (193 participants). 14 (7.3%) were female and 102 (52.8%) were in older groups. Mean age for older adults was 66.3 years and for younger adults 23.3 years. Immobilisation periods spanned 4–14 days as simulated by bed rest, limb brace or limb cast. Studies measured muscle mass by DXA, CT, MRI or fibre cross-sectional area, or a combination of each. Muscles studied included quadriceps, adductor pollicis, vastus lateralis or combined lean leg mass. Of the radiological measures, three studies (74 participants) reported greater atrophy in the older group, three studies (76 participants) reported greater atrophy in the younger group. Reduction in muscle mass varied in older adults between 0.19 and 0.76% per day, and for younger adults between 0.06 and 0.70% per day. Due to substantial heterogeneity, a meta-analysis was not performed. Five studies reported fibre size. Change in fibre size varied considerably between each study, with no convincing overall trend for either older or younger groups. Conclusion: The current literature suggests that there is no difference in the rate of muscle atrophy after immobilisation in older people compared to younger people, and therefore that older people are not more susceptible to atrophy in the acute setting. However, the findings are inconsistent and provide statistically significant but opposing results. There is a lack of high-quality research available on the topic, and there is a paucity of literature regarding atrophy rates in women. [ABSTRACT FROM AUTHOR]

Purpose: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. Patients and methods: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. Results: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). Conclusion: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification. [ABSTRACT FROM AUTHOR]

Purpose: Brain metastases (BM) are an increasing clinical problem. This study aimed to assess paired primary breast cancers (BC) and BM for aberrations within TP53, PIK3CA, ESR1, ERBB2 and AKT utilising the MassARRAY® UltraSEEK® technology (Agena Bioscience, San Diego, USA). Methods: DNA isolated from 32 paired primary BCs and BMs was screened using the custom UltraSEEK® Breast Cancer Panel. Data acquisition and analysis was performed by the Agena Bioscience Typer software v4.0.26.74. Results: Mutations were identified in 91% primary BCs and 88% BM cases. TP53, AKT1, ESR1, PIK3CA and ERBB2 genes were mutated in 68.8%, 37.5%, 31.3%, 28.1% and 3.1% respectively of primary BCs and in 59.4%, 37.5%, 28.1%, 28.1% and 3.1% respectively of BMs. Differences in the mutations within the 5 genes between BC and paired BM were identified in 62.5% of paired cases. In primary BCs, ER-positive/HER2-negative cases harboured the most mutations (70%), followed by ER-positive/HER2-positive (15%) and triple-negatives (13.4%), whereas in BMs, the highest number of mutations was observed in triple-negative (52.5%), followed by ER-positive/HER2-negative (35.6%) and ER-negative/HER2-positive (12%). There was a significant association between the number of mutations in the primary BC and breast-to-brain metastasis-free survival (p = 0.0001) but not with overall survival (p = 0.056). Conclusion: These data demonstrate the discordancy between primary BC and BM, as well as the presence of clinically important, actionable mutations in BCBM. The UltraSEEK® Breast Cancer Panel provides a tool for BCBM that can be utilised to direct more tailored treatment decisions and for clinical studies investigating targeted agents. [ABSTRACT FROM AUTHOR]

Bone healing is a complex process, and if not managed successfully, it can lead to non-union, metal-work failure, bacterial infections, physical and psychological patient impairment. Due to the growing urgency to minimise antibiotic dependency, alternative treatment strategies, including the use of nanoparticles, have attracted significant attention. In the present study, cerium oxide nanoparticles (Ce4+, Ce3+) have been selected due to their unique antibacterial redox capability. We found the processing routes affected the agglomeration tendency, particle size distribution, antibacterial potential, and ratio of Ce3+:Ce4+ valence states of the cerium oxide nanoparticles. The antibacterial efficacy of the nanoparticles in the concentration range of 50–200 µg/ml is demonstrated against Escherichia coli, Staphylococcus epidermis, and Pseudomonas aeruginosa by determining the half-maximal inhibitory concentration (IC50). Cerium oxide nanoparticles containing a more significant amount of Ce3+ ions, i.e., FRNP, exhibited 8.5 ± 1.2%, 10.5 ± 4.4%, and 13.8 ± 5.8% increased antibacterial efficacy compared with nanoparticles consisting mainly of Ce4+ ions, i.e., nanoparticles calcined at 815 °C. [ABSTRACT FROM AUTHOR]

Background: Infra-acetabular screws enhance the fixation strength in acetabular fractures with separation of both columns. Placement without iatrogenic femoral head violation is challenging. Purpose: To assess the impact of the acetabular configuration, the patients' age and gender on safe infra-acetabulum screw insertion. Methods: In 112 patients (69 females; mean age: 34 years, range 17–88; n = 200 hips), the lateral center–edge angle (LCE) was measured on radiographs. Using corresponding axial CT scans the residual distance from (the lateral border) of the screw to (the medial border of) the femoral head ("Screw-to-Femoral Head distance"; "RD_SFH") was determined. Statistical analysis was carried out using linear regression, multiple linear regression and normal distribution estimation. Results: The mean (range) LCE angle was 30° (7°–51°) and the mean (range) "RD_SFH" was 5 mm (1–14 mm). The linear regression model shows a significant linear relation between LCE and "RD_SFH" with a slope parameter of − 0.15 (p value < 0.0001), the Pearson correlation between LCE and "RD_SFH" is − 0.56 (CI [− 0.71, [− 0.40]). Age did not have a significant impact on the relation between LCE and "RD_SFH" (p value 0.85). Compared to male patients, in females, the intercept is 4.62 mm (p value 0.0005) less, the slope parameter is 0.09 (p value 0.029) larger. Conclusion: The virtual possibility to place an infra-acetabular screw was given in all patients. An increasing depth of the acetabulum correlated with a decrease in residual distances. As hip joint cartilage thickness was not considered in measurements, intraoperative rule-out of screw mispositioning especially in deep acetabular sockets and females is still of utmost importance. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the available tibial fracture non-union prediction scores and to analyse their strengths, weaknesses, and limitations. Methods: The first part consisted of a systematic method of locating the currently available clinico-radiological non-union prediction scores. The second part of the investigation consisted of comparing the validity of the non-union prediction scores in 15 patients with tibial shaft fractures randomly selected from a Level I trauma centre prospectively collected database who were treated with intramedullary nailing. Results: Four scoring systems identified: The Leeds-Genoa Non-Union Index (LEG-NUI), the Non-Union Determination Score (NURD), the FRACTING score, and the Tibial Fracture Healing Score (TFHS). Patients demographics: Non-union group: five male patients, mean age 36.4 years (18–50); Union group: ten patients (8 males) with mean age 39.8 years (20–66). The following score thresholds were used to calculate positive and negative predictive values for non-union: FRACTING score ≥ 7 at the immediate post-operative period, LEG-NUI score ≥ 5 within 12 weeks, NURD score ≥ 9 at the immediate post-operative period, and TFHS < 3 at 12 weeks. For the FRACTING, LEG-NUI and NURD scores, the positive predictive values for the development of non-union were 80, 100, 40% respectively, whereas the negative predictive values were 60, 90 and 90%. The TFHS could not be retrospectively calculated for robust accuracy. Conclusion: The LEG-NUI had the best combination of positive and negative predictive values for early identification of non-union. Based on this study, all currently available scores have inherent strengths and limitations. Several recommendations to improve future score designs are outlined herein to better tackle this devastating, and yet, unsolved problem. [ABSTRACT FROM AUTHOR]

Background: Nonunion continues to be the most frequent and challenging complication to treat following fracture fixation. Herein, we carried out a bibliometric analysis aiming to identify the key researchers, centres and research trends developed during the past 30 years in this important clinical condition. Methods: The Science Citation Index Expanded database and the Web of Science Core Collection were interrogated for manuscripts published between 1990 and 2019 in the topic domain, utilising title, abstract, author keywords and KeyWords Plus. Overall, such citation indicators were used as TCyear, Cyear and CPPyear to help analyse the identified manuscripts. Results: Over the prespecified period, there was a steady increase in the number of articles published in fracture nonunion. In total, 12 languages were the primary languages in the documents, with English being the most prevalent. The CPP sharply increased to reach a plateau in three full years and up to a peak in ten full years. A total of 8976 nonunion-related articles in Science Citation Index Expanded (SCI-EXPANDED) were published in 790 journals. The 8976 articles were published by 26,079 authors among 101 different countries. There is a slightly fluctuating steady increase of articles from 116 in 1991 to 201 in 2003, and thereafter, the number of articles sharply increased to reach a plateau in 2015. Seven possible main research foci in nonunion-related research were identified including: epidemiology, classification, aetiology, diagnosis/prediction, treatment modalities, functional outcomes and health economics. Conclusions: This bibliometric analysis revealed information on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. The current research activity on fracture nonunion identified key opinion leaders and leading research institutions focusing on this important clinical condition. It is hoped that the informed included will aid to guide research work in the foreseeable future. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero–Livani) for humeral shaft fractures. Methods: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero–Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. Results: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14–13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. Conclusion: The modified Belangero–Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. Level of evidence: Level IV; Case series with no comparison group; Treatment study [ABSTRACT FROM AUTHOR]

Aim: This UK based multi-centre study reports clinical characteristics, early outcomes and predictors of mortality in 34 consecutive COVID-19-positive hip fractures so that the lessons learnt could be utilised in other parts of World who are at a different phase of the pandemic. Methods: This study analysed patient admitted with hip fractures with COVID positive swabs, between March and May'2020 in three large hospitals covering a population of nearly two million. Data was collected on demographic profile, peri-operative variables, post-operative complications and mortality. The specific aim was to identify any variables, which could predict high 30-day mortality. Results: Overall, 12% of hip fractures were COVID positive with the mortality rate of 41.2%. The higher age (p = 0.036) and male gender (p = 0.025) was significantly associated with mortality and most of the deaths were between American Society of Anaesthesiologists (ASA) grade 3 and 4 patients. The patients having intramedullary (IM) nailing were more likely to die (p = 0.02). There was no difference in laboratory parameters but there was significant difference in findings on chest radiographs (p < 0.001), post-operative oxygen requirements (p = 0.006) and early respiratory complications (p = 0.006). Conclusion: This study suggests that the mortality following surgery for a hip fracture in COVID-positive patients is strikingly high and is associated with higher age and male gender. Higher mortality has been observed for extracapsular fracture operated with intramedullary nailing. In the immediate post-operative period, rapid deterioration of chest imaging, higher oxygen requirement and early pulmonary complications can serve as warning signs and predicting factors for higher mortality. [ABSTRACT FROM AUTHOR]

Osteoarthritis (OA), the most common joint disorder, is characterised by progressive structural changes in both the cartilage and the underlying subchondral bone. In late disease stages, subchondral bone sclerosis has been linked to heightened osteogenic commitment of bone marrow stromal cells (BMSCs). This study utilised cell sorting and immunohistochemistry to identify a phenotypically-distinct, osteogenically-committed BMSC subset in human OA trabecular bone. Femoral head trabecular bone tissue digests were sorted into CD45-CD271+CD56+CD146-, CD45-CD271+CD56-CD146+ and CD45-CD271+CD56-CD146-(termed double-negative, DN) subsets, and CD45+CD271-hematopoietic-lineage cells served as control. Compared to the CD146+ subset, the CD56+ subset possessed a lower-level expression of adipocyte-associated genes and significantly over 100-fold higher-level expression of many osteoblast-related genes including osteopontin and osteocalcin, whilst the DN subset presented a transcriptionally 'intermediate' BMSC population. All subsets were tri-potential following culture-expansion and were present in control non-OA trabecular bone. However, while in non-OA bone CD56+ cells only localised on the bone surface, in OA bone they were additionally present in the areas of new bone formation rich in osteoblasts and newly-embedded osteocytes. In summary, this study reveals a distinct osteogenically-committed CD271+CD56+ BMSC subset and implicates it in subchondral bone sclerosis in hip OA. CD271+CD56+ subset may represent a future therapeutic target for OA and other bone-associated pathologies. [ABSTRACT FROM AUTHOR]

Aim Of the Study: The aim of this case-control study was to develop a clinical decision rule to support assessment of the risk of long-bone non-union and plan for appropriate early intervention.Methods: Two hundred patients (100 cases and 100 controls) were recruited. Risk factors identified to contribute to the development of non-union were recorded and analysed with a multivariable logistic regression model. Tabulation of the outcome (non-union/union) against each risk factor in turn (univariable analysis) was carried out. Odds ratios and confidence intervals were derived using Wald's method. A receiver-operator curve was calculated and the area under the curve was computed. Having established the eight most important risk factors, a non-union risk index was developed as the count of the risk factors present in each patient.Results: The five risk factors for non-union with greater effect size were post-surgical fracture gap > 4 mm (odds ratio (OR) = 11.97 95% CI (4.27, 33.53)), infection superficial/deep (OR 10.16 (2.44, 42.36)), not optimum mechanical stability (OR 10.06 (3.75, 26.97)), displacement > 75% of shaft width (OR 6.81 (2.21, 20.95)), and site of fracture-tibia (OR 4.33 (1.32, 14.14)). The ROC curve for the non-union index was 0.924, sensitivity 91%, specificity 77%.Conclusions: The non-union index derived from counting risk factors predicts union for 0-4 risk factors and non-union for 5-8 risk factors. It can be readily applied and can guide clinicians about the risk of development of long-bone non-union. It can become a powerful aid for assessing fracture fixation outcome and to support early intervention. [ABSTRACT FROM AUTHOR]

Purpose: The incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve the quality of services provided to these patients.Methods: A cohort study was contacted to test the impact of (1) using a specific clinical algorithm and (2) using different antiosteoporotic drugs. Multivariate regression analysis was used to determine prognostic factors. Study endpoints were the time-to-healing, length-of-stay, return to pre-injury mobility, union status, mortality and complications.Results: A total of 132 elderly patients (≥65 years) admitted during the period 2012-2014 with FPFs were enrolled. High-energy fractures, acetabular fractures, associated trauma affecting mobility, pathological pelvic lesions and operated FPFs were used as exclusion criteria. The majority of included patients were females (108/132; 81.8%), and the mean age was 85.8 years (range 67-108). Use of antiosteoporotics was associated with a shorter time of healing (p = 0.036). Patients treated according to the algorithm showed a significant protection against malunion (p < 0.001). Also, adherence to the algorithm allowed more patients to return to their pre-injury mobility status (p = 0.039).Conclusions: The use of antiosteoporotic medication in elderly patients with fragility pelvic fractures was associated with faster healing, whilst the adherence to a structured clinical pathway led to less malunions and non-unions and return to pre-injury mobility state. [ABSTRACT FROM AUTHOR]

Introduction: We hypothesised that the use of a polyaxial locking plate design offers the same clinical benefits as a monoaxial locking plate system following distal femoral osteoporotic/periprosthetic fracture fixation.Method: A multicentre prospective randomised pilot trial was conducted. Inclusion criteria were patients over 60 years with a displaced osteoporotic or periprosthetic distal femoral fracture. Details documented included time to union, complications, reinterventions and functional outcomes according to the Oxford knee score and EuroQol EQ-5D. Analysis of factors influencing an early fracture healing response was performed between those with clear features of radiological callus formation at three months. Statistical analysis was performed using a logistic regression model with multiple covariates assessed for each plate system (1:1 ratio) over a follow-up period of one year.Results: Forty patients (34 females) with a mean age of 77 (60-99) were recruited. Four patients deceased within the first six months. Twenty-five patients united by the six month follow-up. Six more patients progressed to union between six and nine months. Five patients developed non-union (two patients had implant failure; one in each group) and all underwent revision surgery. Malunion was evident in two cases, one with 15° of valgus (monoaxial plate), and one with 12° of recurvatum (polyaxial plate). Between the two plate systems, statistical analysis revealed no significant differences in most of the recorded parameters. Radiological features of early bone healing were present when the surgical approach was smaller (p = 0.015), and when a greater working length of the bridging plate was present (p = 0.016).Conclusion: Both plate systems demonstrated good union rates and limited implant related complications. Good reduction, mechanically sound construct and respect of the local fracture biology was more important than the particular plate design characteristics. [ABSTRACT FROM AUTHOR]

Objective: The lack of universally accepted treatment principles and protocols to manage infected intramedullary (IM) nails following tibial fractures continues to challenge us, eliciting a demand for clear guidelines. Our response to this problem was to create an ORS/ISFR taskforce to identify potential solutions and trends based on published evidence and practices globally.Materials and Methods: A questionnaire of reported treatment methods was created based on a published meta-analysis on the topic. Treatment methods were divided in two groups: A (retained nail) and B (nail removed). Experts scored the questionnaire items on a scale of 1-4 twice, before and after revealing the success rates for each stage of infection. Inter- and intra-observer variability analysis among experts' personal scores and between experts' scores was performed. An agreement mean and correlation degree between experts' scores was calculated. Finally, a success rate report between groups was performed.Results: Experts underestimated success rate of an individual treatment method compared to published data. The mean difference between experts' scores and published results was + 26.3 ± 46 percentage points. Inter-observer agreement mean was poor (< 0.2) for both rounds. Intra-observer agreement mean across different treatment methods showed a wide variability (18.3 to 64.8%). Experts agree more with published results for nail removal on stage 2 and 3 infections.Conclusions: Experts' and published data strongly agree to retain the implant for stage 1 infections. A more aggressive approach (nail removal) favoured for infection stages 2 and 3. However, literature supports both treatment strategies.Evidence: Clinical Question. [ABSTRACT FROM AUTHOR]

Cuboid fractures are rare injuries. A number of different treatment methods have been proposed including plaster immobilization, open reduction, and internal fixation or external fixation. Bone grafting is commonly used to restore bony length. The majority of the current literature suggests that the loss of length of the lateral column and articular congruency are the two criteria opting for the surgical management of these fractures. Nevertheless, the exact indications and ideal management of these fractures are not established mainly due to the rarity of these injuries and the paucity of literature. [ABSTRACT FROM AUTHOR]

The technique for application of implants at the sciatic buttress has been well described in the pelvic and acetabular fracture reconstruction literature. We described a new use of the inlet-obturator oblique view for the identification of the anterior inferior iliac spine, which is the entry point of implants, and we provide a detailed fluoroscopic and radiographic description of this view. A small series of 15 patients who underwent an application of an anterior inferior pelvic external (supra-acetabular) fixator via this technique is presented. We consider the use of the obturator oblique for the identification of the entry point unnecessary, and we advocate for the use of only the inlet-obturator oblique and iliac oblique views when implants are applied to the sciatic buttress. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this study was to report on the mid-term outcomes after quadrilateral plate reconstruction of acetabular fractures using a buttress/spring plate through an ilioinguinal approach.Methods: Between 2003 and 2011, 30 adult patients (25 males) with mean age 54 years (range 17-80) who underwent surgical fixation for an acetabular fracture and had minimum follow up of 24 months (mean 46.2, range 24-78.6) were retrospectively reviewed. Standard demographics, admission and hospitalization data (concomitant injuries, number of operative procedures, time to operating theatre, early and late complications) were correlated to the clinical (Harris Hip Score) and radiological (Matta Reduction Score and Matta Arthritis Score) outcome.Results: Three patients underwent a Total Hip Replacement. Functional score was excellent in 17 (56.6 %), good in 4 (13.3 %), fair in 6 (20 %) and poor in 3 (10 %) cases. Surgery-related complications included two patients with temporary lateral femoral cutaneous palsy and three with heterotopic ossification. The quality of the postoperative reduction was associated to Harris Hip Score (p = 0.015) and postoperative arthritis (p = 0.010). Strong association was evident between age and both post-operative reduction (p = 0.010) and arthritis (p = 0.014). The presence of quadrilateral plate comminution and gull-sign were associated to poor post-operative reduction (p = 0.016) and low Harris Hip Score (p = 0.049) respectively.Conclusion: Quadrilateral plate reconstruction with a buttress plate though the ilioinguinal approach remains a valid method of fixation in acetabular surgery. Additional studies are needed to compare the efficiency of this method to new surgical approaches and fixation implants. [ABSTRACT FROM AUTHOR]