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Aims The aims of this meta-analysis were to assess: 1) the prevalence of coronavirus disease 2019 (COVID-19) in hip fracture patients; 2) the associated mortality rate and risk associated with COVID-19; 3) the patient demographics associated with COVID-19; 4) time of diagnosis; and 5) length of follow-up after diagnosis of COVID-19. Methods Searches of PubMed, Medline, and Google Scholar were performed in October 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Search terms included “hip”, “fracture”, and “COVID-19”. The criteria for inclusion were published clinical articles reporting the mortality rate associated with COVID-19 in hip fracture patients. In total, 53 articles were identified and following full text screening 28 articles satisfied the inclusion criteria. Results A total of 28 studies reported the mortality of COVID-19-positive patients, of which 21 studies reported the prevalence of COVID-19-positive patients and compared the mortality rate to COVID-19-negative patients. The prevalence of COVID-19 was 13% (95% confidence interval (CI) 11% to 16%) and was associated with a crude mortality rate of 35% (95% CI 32% to 39%), which was a significantly increased risk compared to those patients without COVID-19 (odds ratio (OR) 7.11, 95% CI 5.04 to 10.04; p < 0.001). COVID-19-positive patients were more likely to be male (OR 1.51, 95% CI 1.16 to 1.96; p = 0.002). The duration of follow-up was reported in 20 (71.4%) studies. A total of 17 studies reported whether a patient presented with COVID-19 (n = 108 patients, 35.1%) or developed COVID-19 following admission (n = 200, 64.9%), of which six studies reported a mean time to diagnosis of post-admission COVID-19 at 15 days (2 to 25). Conclusion The prevalence of COVID-19 was 13%, of which approximately one-third of patients were diagnosed on admission, and was associated with male sex. COVID-19-positive patients had a crude mortality rate of 35%, being seven times greater than those without COVID-19. Due to the heterogenicity of the reported data minimum reporting standards of outcomes associated with COVID-19 are suggested. Cite this article: Bone Joint Res 2020;9(12):873–883.

Non-union is a devastating consequence of a fracture. Non-unions cause substantial patient morbidity with patients suffering from loss of function of the affected extremity, increased pain, and a substantial decrease in the quality of life. The management is often associated with repeated, unsuccessful operations resulting in prolonged hospital stays, which has social and economic consequences to both the patient and the healthcare system. The rates of non-union following intramedullary (IM) nailing vary according to anatomical location. There is currently no consensus regarding the treatment of infected non-unions following IM nailing, but the most common procedures reported are; exchange IM nail with antibiotic suppression or excision of the non-union, (stabilisation with external fixation or less commonly plate or IM nail) and then reconstruction of the bone defect with distraction osteogenesis or the Masquelet technique. This article explores the general principles of treatment, fixation modalities and proposes a treatment strategy for the management of infected non-unions following intramedullary nailing.

Approximately a third of patients presenting with long-bone non-union have undergone plate fixation as their primary procedure. In the assessment of a potential fracture non-union it is critical to understand the plating technique that the surgeon was intending to achieve at the primary procedure, i.e. whether it was direct or indirect fracture repair. The distinction between delayed union and non-union is a diagnostic dilemma especially in plated fractures, healing by primary bone repair. The distinction is important as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ~40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. Methods to improve the sensitivity of investigation in the search of infection include the use of; sonication of implants, direct inoculation of theatre specimens into broth, and histological examination of non-union site tissue. Awareness should be given to the potential anti-osteogenic effect of bisphosphonates (in primary fracture repair) and certain classes of antibiotics. Early cases of delayed/non-union with sufficient mechanical stability and biologically active bone can be managed by stimulation of fracture healing. Late presenting non-union typically requires revision of the fixation construct and stimulation of the callus to induce fracture union.

Purpose To determine the relationship between the length of the ulna as a proportion of height (proportional ulnar length [PUL]), forearm and wrist ranges of motion, and degree of observable deformity in people with hereditary multiple exostoses. Methods One hundred forty-two people with hereditary multiple exostoses were examined; 35 were under the age of 15 years and therefore were presumed to be skeletally immature. Elbow, forearm, and wrist motion were measured, and the radius and ulna were palpated for osteochondromas. Ulnar length was estimated as a proportion of height (PUL) in skeletally immature subjects. The relationships between total active motion, number of palpable osteochondromas, and proportional length were examined for one randomly selected limb from each subject. Results A negative correlation was found between the number of palpable osteochondromas and range of forearm rotation. The degree of forearm motion in those under the age of 15 years was directly related to PUL and indirectly related to the number of palpable osteochondromas. Children whose PUL is within the normal range have a normal range of motion. Conclusions In a child with hereditary multiple exostoses affecting the forearm, the PUL is associated with the range of movement and deformity, and it can be a useful adjunct in deciding the appropriate management.

Infection in bone and joints is a potentially very serious condition. Prompt recognition, appropriate referral and expeditious treatment are essential in order to avoid serious long term sequelae. Acute septic arthritis is an orthopaedic emergency which requires removal of the pus from the joint and intravenous antibiotics. Acute osteomyelitis, if diagnosed early, will usually settle with a course of antibiotics alone (these should be started immediately after obtaining blood cultures). If the diagnosis is delayed, the patient will require surgical drainage. Chronic osteomyelitis is a variable condition unless. If it is causing minimal morbidity it can be treated non-operatively, more commonly, however, it requires surgical treatment to drain the pus and remove the areas of dead bone. In some cases of implant related sepsis, it is possible to retain the prosthesis but in the majority, the implant has to be revised. In general, in patients with orthopaedic infections, wherever possible, it is preferable to obtain a microbiological diagnosis before initiating antibiotic therapy as appropriately targeted antibiotic therapy increases the chances of eradication of infection.

The objective of this study was to assess the vascularity of atrophic non-unions using an experimental animal model. Twenty skeletally mature female rabbits were randomly divided into control and experimental groups that were killed 1, 8, or 16 weeks after surgery. The experimental groups underwent surgery to induce an atrophic non-union whereas the control groups underwent a similar operation but which resulted in union. Using immunocytochemical techniques blood vessels were identified in histological sections obtained from the osteotomy site. The concentration of the vessels within the osteotomy gaps was measured, as was the serum concentration of an important angiogenic factor: endothelial cell-stimulating angiogenesis factor (ESAF). The results demonstrated a significant difference between the control and the experimental groups in the concentration of vessels within the gap at 1 week but there was no significant difference between those groups at 8 weeks. There were no significant differences in the ESAF concentration between the groups at any time points. We concluded that established atrophic non-unions can be well vascularised and that measurements of serum levels of ESAF could not distinguish between those osteotomies that would unite and those that would progress to non-union.