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Unlabelled: Combining autologous bone graft and recombinant human bone morphogenetic protein-7 (BMP-7) to treat long-bone fracture aseptic atrophic nonunions theoretically could promote bone healing at higher rates than each of these grafting agents separately. We retrospectively reviewed prospectively collected data on patient general characteristics, clinical outcomes, and complications over 3 years to determine the healing rates and the incidence of complications and adverse events of this "graft expansion rationale." There were 45 patients (32 male) with a median age of 43 years (range, 19-76 years). Minimum followup was 12 months (mean, 24.5 months; range, 12-65 months). There were seven humeral, 19 femoral, and 19 tibial nonunions. The median number of prior operations was two (range, 1-7). All fractures united. Clinical and radiographic union occurred within a median of 5 months (range, 3-14 months) and 6 months (range, 4-16 months), respectively. Thirty-nine (87%) patients returned to their preinjury occupation at a mean of 4.2 months (range, 3-6 months). The median visual analog scale pain score was 0.9 (range, 0-2.8; maximum 10), and the median functional score was 86 (range, 67-95; maximum 100) at the final followup. BMP-7 as a bone-stimulating agent combined with conventional autograft resulted in a nonunion healing rate of 100% in these 45 patients.Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Unlabelled: Although acute management of pelvic fractures and their long-term functional outcome have been widely documented, important information regarding malunion and nonunion of these fractures is sparse. Despite their relative rarity, malunions and nonunions cause disabling symptoms and have major socioeconomic implications. We analyzed the factors predisposing a pelvic injury to develop malunion/nonunion, the clinical presentation of these complications, and the efficacy of the reported operative protocols in 437 malunions/nonunions of 25 clinical studies. Treatment of these demanding complications appeared effective in the majority of the cases: overall union rates averaged 86.1%, pain relief as much as 93%, patient satisfaction 79%, and return to a preinjury level of activities 50%. Nevertheless, the patient should be informed about the incidence of perioperative complications, including neurologic injury (5.3%), symptomatic vein thrombosis (5.0%), pulmonary embolism (1.9%), and deep wound infection (1.6%). For a successful outcome, a thorough preoperative plan and methodical operative intervention are essential. In establishing effective evidence-based future clinical practice, the introduction of multicenter networks of pelvic trauma management appears a necessity.Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The advent of locking plates for the management of metaphyseal fractures, and subsequent experience of biological fracture fixation, has led to the development of minimally invasive percutaneous osteosynthesis (MIPO), which is now proven to have multiple advantages. Soft tissue stripping is minimized, with preservation of vascular pedicles, and the fracture haematoma around the site of injury remains undisturbed promoting fracture healing. While early published results are encouraging, MIPO technique is not applicable to every fracture. To avoid complications, defining the correct indications is of paramount importance. [ABSTRACT FROM AUTHOR]

Lisfranc fracture dislocations are complex lesions which, when combined with additional trauma of the ankle and foot region, create a difficult to treat injury pattern. This article presents a case of a patient with Lisfranc fracture dislocation combined with metatarsophalangeal dislocation of the second toe and ankle fracture-dislocation. The sequence of medical acts and complications included: reduction of dislocations, cast immobilization, compartment syndrome and fasciotomies, external fixator application, fasciotomies closure, and final internal fixations. The following examinations were performed: radiography, computed tomography (CT), and intracompartmental pressure measurement. Despite the compartment syndrome incidence, which was effectively managed, the patient regained an ankle- and foot-pain-free full range of motion. Although this is an isolated case of a rare injury, several recommendations can be made. Early CT scan should be used for injuries of the Lisfranc joints to fully assess the distorted anatomy of the midfoot and forefoot, which is essential for preoperative planning, medicolegal issues, and prognosis of the injury. The use of a spanning external fixator, especially in complex injuries as the one described, should be preferred to cast immobilization and should be performed as a priority surgical procedure early on in the patient's admission. The development of compartment syndrome should be monitored and intracompartmental pressures measured especially in unconscious patients. There should be a high degree of suspicion for early complications in complex fracture patterns, even if the initial clinical assessment is reassuring. [ABSTRACT FROM AUTHOR]

Summary: The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9-317 mo). Patients had undergone a median of 2 (range 0-11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3-15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute. [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., (© 2023. The Author(s).)

Objectives: The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications., Design: This is a retrospective case series with prospectively collected data., Setting: Level I Trauma Centre in the United Kingdom., Patients and Intervention: Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up., Main Outcome Measurements: The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions., Results: Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection)., Conclusions: The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role. For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature. What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review. Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented. A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented. As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic. Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest in relation to the content of this manuscript., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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., (© 2022. The Author(s).)

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., (© 2022. Crown.)

Background: Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities., Methods: A case-control study on 9266 consecutive trauma fatalities (between 1996 and 2005) from a regional autopsy-based trauma registry. Injuries were classified according to the Abbreviated Injury Scale-1990 edition (AIS-90) and the Injury Severity Score (ISS) was calculated. Hospitalized victims were categorized according to the presence or absence of PE on autopsy. Univariate comparisons and multivariate logistic regression analysis for probabilities of association (odds ratios-OR) were performed., Results: Out of 2705 subjects who met the inclusion criteria, 116 had autopsy findings of PE and constituted the PE group (incidence of 4,3%), while the remaining victims formed the control group. The survival time of the PE group ranged from 0.66 to 104.73 days. Victims in the PE group were older (median age 69.5 vs 59), had lower ISS values (median 16 vs 26) and longer post-injury survival times (median 13.6 vs 5.7 days). Positively associated risk factors were AIS2-5 pelvic ring injuries (OR:2.23) and secondary deaths following an uneventful hospital discharge (OR:3.97), while AIS2-5 head (OR:0.33) and abdominal injuries (OR:0.23) showed a reverse association., Conclusions: Trauma fatalities with autopsy findings of PE were associated with less severe trauma indicating that PE was likely detrimental to the fatal outcome. Both the early and delayed occurrence of PE was reaffirmed. Prophylactic measures should be initiated promptly and extended post discharge for high risk patients to prevent secondary deaths., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Introduction: The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs., Patients and Methods: A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed., Results: The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%)., Conclusion: This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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., (© 2021. Crown.)

Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects., Design: Retrospective study of prospectively collected data (Level IV)., Setting: Level I trauma center in the UK., Patients/participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss.Intervention: Two-stage Masquelet Procedure for the tibia., Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union., Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4-8 cm) and an 88.2% union rate at a mean of 8 months (range 5-18 months). Mean range of motion was 95 degrees of knee flexion (range 80°-130°). All patients but 2 returned to their previous occupation., Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick as a bailout in this difficult situation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Ltd.)

Posterior-wall acetabular fractures have been reported to be associated with marginal impaction characteristics in approximately 16% to 38% of cases 1-3 . Early recognition of this special entity of joint impaction is essential for effective preoperative planning, intraoperative execution, and favorable outcomes. The 2-level reconstruction technique is safe and effective in experienced hands., Description: The procedure is performed with the patient under general anesthesia, placed under traction in either the prone or lateral position with use of a radiolucent flat-top fracture table and fluoroscopic guidance. The Kocher-Langenbeck approach is utilized. The big posterior wall fracture is identified and reflected in order to visualize the joint surface. Subsequently, traction is applied to facilitate visualization of the marginal impaction area(s). With use of an osteotome, the impacted fragments are disimpacted and elevated. The femoral head is utilized as a template for accurate reduction of the impacted fragments to the acetabular joint surface. The resultant subchondral void is assessed and may be grafted with use of a variety of bone graft materials. The 2-level reconstruction technique may also be considered when the surgeon desires to optimize stability of the impacted fragments and maintain anatomical reduction. The big posterior wall fragment is reduced and fixed with use of the standard posterior-wall reconstruction technique. Finally, irrigation and wound closure in layers is performed., Alternatives: Treatment alternatives include either delayed or acute primary total hip arthroplasty in elderly patients >70 years old., Rationale: Preoperative identification of the marginal impaction is critical because articular incongruency leads to the development of early posttraumatic osteoarthritis. Achieving joint congruency is especially important in the young population in order to avoid an otherwise unnecessary early total hip arthroplasty., Expected Outcomes: Expected radiographic outcomes are excellent or good in 82% of cases, as measured with use of the Matta radiographic score 1-3 . Expected function outcomes are good to excellent in 67.5% of patients, as measured with use of the Modified Merle d'Aubigné system 1-3 . Total hip arthroplasty has been reported as a secondary procedure within 2 years postoperatively in 7.6% of patients 1-3 ., Important Tips: Joint irrigation is crucial in order to clarify the details of the fragmentation and facilitate removal of debris. Impacted articular cartilage fragments are often rotated and face away from the femoral head. Utilize osteotomes to elevate the impacted area, taking care to mobilize adequate subchondral bone and the accompanying cartilage in case the 2-level reconstruction technique is needed and can be successfully applied. Utilize the femoral head as a template after traction is released to facilitate anatomical reduction. A 1.6-mm Kirschner wire should be available in case it is needed to temporarily stabilize the impacted fragments. Avoid overstuffing the void with bone graft because this may subsequently hinder successful reduction of the posterior wall fragment., Acronyms and Abbreviations: CT = computed tomographyAP = anteroposteriorK wire = Kirschner wirePDS = polydioxanone sutureAVN = avascular necrosis., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Periprosthetic femoral fractures (PPFs) represent a challenging clinical problem with a fast-rising incidence. Interprosthetic fractures (IPFs) represent one of its most difficult variants. There is a paucity of data regarding the financial burden of PPFs, and none for IPFs. This study aims to estimate the direct medical cost of the surgical treatment of IPFs in NHS, and analyse the factors influencing this when using different methods of surgical treatment., Methods: A cohort of patients with IPFs treated in a single academic unit over a period of 8-years with different surgical methods was studied. In-hospital details, as well as outpatient follow-up data, were gathered relevant to their clinical and radiological outcome until discharge. Local and national NHS data were acquired from the financial department, as well as industry-related resources. The economic analysis was structured as a cost identification analysis (CIA) of the overall cohort, but also as a comparative best-case scenario (uncomplicated course till discharge) comparison between the 3 main different management strategies (a) revision arthroplasty (RTHA), b) plate fixation (ORIF), c) combination of implants (COMBO)., Results: Data from 28 patients (22 females) with IPFs were analysed with a median age of 78.4 years. The overall direct medical cost of treating this cohort of patients was £468,330, with a median of £15.625 (range £10,128 to 33,060). Comparing the three different surgical modalities, the median cost in groups a, b, and c was £20,793 (range £12,110 to £24,116), £12,979 (range £10,128 to £20,555), and £22,316 (range £10,938 to £23,081) respectively. In all groups, the 2/3 of the identified costs were relevant to the inpatient stay. Transfusions were the highest (3 units of cRBC on average) to the patients that received a revision THA vs the other two groups (p=0.022). There was statistically significant higher mean overall cost between the RTHA and the ORIF groups (£19,453 vs. £14,201, p=0.0242), but not when compared with the COMBO cases (£19,453 vs. £18,788, p=0.86)., Conclusion: The first cost identification study and "best case scenario" comparative analysis for IPFs demonstrated a significant overall direct medical cost, when managing these complex fractures with variable contemporary techniques. Evidence based reimbursement strategies should be developed to allow the sustainability of the clinical service we offer in this challenging patient population., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest regarding the content of this manuscript., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome., Patients and Methods: A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality., Results: Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%., Conclusion: Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2020. Published by Elsevier Ltd.)

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., (© 2021. The Author(s).)

Biofilm represents an organized multicellular community of bacteria having a complex 3D structure, formed by bacterial cells and their self-produced extracellular matrix. It usually attaches to any foreign body or fixation implant. It acts as a physical protective barrier of the bacteria from the penetration of antibodies, bacteriophages, granulocytes and biocides, antiseptics, and antibiotics. Biofilm-related infections will increase in the near future. This group of surgical site infections is the most difficult to diagnose, to suppress, to eradicate, and in general to manage. Multispecialty teams involved in all stages of care are an effective way to improve results and save resources and time for the benefit of patients and the health system. Significant steps have occurred recently in the prevention and development of clever tools that we can employ in this everlasting fight with the bacteria. Herein, we attempt to describe the nature and role of the "biofilm" to the specific clinical setting of surgical site infections in the field of orthopaedic trauma surgery., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Nonunion remains a major complication of the management of long bone fractures. The primary aim of the present study was to investigate whether raised levels of C-reactive protein (CRP) and white blood cell count (WBC), in the absence of clinical signs, are correlated with positive intraoperative tissue cultures in presumptive aseptic long-bone nonunions. Infection was classified as positive if any significant growth of microorganisms was observed from bone/tissue samples sent from the theater at the time of revision surgery. Preoperatively all patients were investigated with full blood count, white blood count differential as well as C-reactive protein (CRP). A total of 105 consecutive patients (59 males) were included in the study, with an average age of 46.76 years (range 16-92 years) at the time of nonunion diagnosis. The vast majority were femoral (56) and tibial (37) nonunions. The median time from the index surgical procedure to the time of nonunion diagnosis was 10 months (range 9 months to 10 years). Positive cultures revealed a mixed growth of microorganisms, with coagulase-negative Staphylococcus (56.4%) being the most prevalent microorganism, followed by Staphylococcus aureus (20.5%). Pseudomonas , Methicillin-Resistant Staphylococcus aureus (MRSA), coliforms and micrococcus were present in the remainder of the cases (23.1%). Overall, the risk of infection with normal CRP levels (<10 mg/L) was 21/80 = 0.26. Elevated CRP levels (≥10 mg/L) increased the risk of infection to 0.72. The relative risk given a positive CRP test was RR = 0.72/0.26 = 2.74. Overall, the WBC count was found to be an unreliable marker to predict infection. Solid union was achieved in all cases after an average of 6.5 months (3-24 months) from revision surgery. In patients with presumed aseptic long bone nonunion and normal CRP levels, the risk of underlying low-grade indolent infection can be as high as 26%. Patients should be made aware of this finding, which can complicate their treatment course and outcomes.

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.Less invasive osteosynthesis, balanced plate-bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing. Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050., Competing Interests: ICMJE Conflict of interest statement: The authors declare no conflict of interest relevant to this work., (© 2021 The author(s).)

Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is limited and of varying quality. In the present study we report on the incidence, pathophysiology, diagnostic and treatment modalities for PGP in patients suffering from Hypermobility Spectrum Disorder (HSD) and Hypermobility-Type Ehlers-Danlos Syndrome (hEDS). Recommendations are made for clinical practice by elaborating on screening, diagnosis and management of such patients to provide a holistic approach to their care. It appears that this cohort of patients are at greater risk particularly of mental health issues. Moreover over, they may require a multidisciplinary approach for their management. Ongoing research is still required to expand our understanding of the relationship between PGP, HSD and hEDS by appropriately diagnosing patients using the latest updated terminologies and by conducting randomised control trials to compare outcomes of interventions using standardised patient reported outcome measures.

Aims To analyse the learning points from the first 30 days of the COVID-19 lockdown at our institution. Patients & methods Following ethical approval, data were collected prospectively on all patients admitted under orthopaedics between March 23, 2020, and April 22, 2020. This included baseline demographics (sex, age), biochemical (blood tests), radiological (chest X-ray (CXR), computed tomography (CT)), nature and mechanism of injury, comorbidities, regular medication, observations, specific respiratory symptoms of COVID-19, management, operations, time to theatre, and outcome including mortality incidence. The nature of injury and operations performed were compared to the same period of the previous year (2019). Results During the study period, 162 (74 males) patients were admitted, with a mean age of 60.7 (range 1-101, SD 2.1). On admission, 66 (41%) patients were tested for COVID, out of which eight (13.7%) patients tested positive. Subsequently, another four patients tested positive, who developed symptoms after admission. Four out 12 (33%) confirmed COVID patients died. During this period, 4/150 other patients also died of other causes (mortality incidence 2.6%). The average ages of COVID non-survivors vs survivors were 88, SD 1, vs 76, SD 12, respectively; 2/4 had concurrent diabetes and cancer, another cancer alone, and another complex autoimmune disease managed by immunosuppressive medication. Overall admissions significantly reduced by almost 50% compared with the previous year (162 vs 373, p=<0.05), including cases of polytrauma (15 vs 33). Time to surgery was increased by an average of one day, mainly due to time taken for COVID-19 swab results to come back, and in positive patients, this was an average of 2.75 days (0-13). Lymphopenia was a useful biomarker of COVID, with levels significantly different between groups (p=<0.05). Of the clinical symptoms assessed, 8/12 patients experienced positive chest symptoms or pyrexia but only four had positive CXR changes. Discussion & lessons learnt Eight out of 12 patients who contracted COVID-19 survived without needing intensive care. Non-survivors were older with significant comorbidities. Lymphopenia is a good biomarker of the disease, but suspicious CXR was not sensitive for excluding it. Trauma volume reduced. We have highlighted significant changes to expect should there be a second wave of the virus. Key lessons learnt were that reduction in trauma volume and cessation of elective operating allowed for redeployment, including taking over the minor injury unit; more senior, consultant decision-makers 'at the front door' reduced unnecessary admissions. Increased use of conservative practice was effective at reducing operations required. Expedited COVID swab test processing allowed early de-escalation of isolation, reducing time to surgery. We expect approximately 12% of the typical orthopaedic population to be admitted with COVID, and up to 33% of these patients to die within 28 days of contracting the virus. The vast majority of patients, however, can be managed appropriately with ward-level care. An early decision on escalation and resuscitation status in the emergency department improves patient flow significantly. Remote working was effective and could be extended in the future. We have highlighted the significant changes to expect should there be a second wave of the virus and effective solutions for managing the problems that arise, which could be useful for other units., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Andrzejowski et al.)

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064., Competing Interests: ICMJE Conflict of interest statement: PVG reports a research grant to study the effect of platelet reach plasma (PRP) and mesenchymal stem cells (MSCs) on fracture healing of tibial fractures from Zimmer Biomet; consulting fees or honorariam from Depuy Synthes, Smith & Nephew and ZimmerBiomet. He is President of European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT), outside the submitted work. The other authors declare no conflict of interest relevant to this work., (© 2020 The author(s).)

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.

Introduction: The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery., Step 1 Preoperative Planning: Review the patient's general condition and imaging studies and plan the sequence of reduction and fixation., Step 2 Preparation and Patient Positioning: Position the patient supine on the fracture table, induce anesthesia, prepare the surgical field, administer intravenous antibiotics, and apply traction., Step 3 Ilioinguinal Approach: Make a long curvilinear incision over the affected lower flank, develop the 3 working windows, and reduce and stabilize the fracture while protecting the neurovascular structures and the bladder (Video 2)., Step 4 Fracture Reduction and Fixation: For reduction of a both-column acetabular fracture, connect the mobile parts of the acetabulum to the iliac segment that is attached to the sacrum, noting that, in most cases, the usual sequence involves the reduction of the anterior column to the intact ilium followed by the reduction of the posterior column (Video 7)., Step 5 Wound Closure and Postoperative Aftercare: Perform meticulous hemostasis, apply drains, and ensure watertight closure, which are the final steps of the operation (Video 8)., Results: The ilioinguinal approach remains 1 of the standard approaches for the management of acetabular fractures 10 .

Introduction: The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach 1,2 ., Step 1 Preoperative Planning: Review the patient's general condition and imaging studies, plan the sequence of reduction and fixation, and make sure that all of the necessary equipment is available., Step 2 Preparation and Patient Positioning: Induce anesthesia, administer intravenous antibiotics as per local hospital protocol, apply antiembolism stockings, and insert a Foley catheter to the bladder., Step 3 Kocher-Langenbeck Approach: Make an incision that is 15 to 20 cm long and has 2 parts (proximal and distal), which are centered over the greater trochanter., Step 4 Fracture Reduction and Fixation: The reconstruction of posteriorly based fractures depends on the specific fracture type, and the goal is to provide stable column fixation and anatomical reconstruction of the acetabular articular surface, with column fixation performed before the reconstruction of the posterior wall., Step 5 Wound Closure and Postoperative Care: Meticulous hemostasis, application of drains, and watertight closure are the final steps of the operation., Results: The Kocher-Langenbeck approach is the workhorse for the surgical management of acetabular fractures and provides sufficient access to the majority of posterior based acetabular fractures 15 .

Background: Surgical site infection remains a significant concern in treating patients with open fractures. In prevention of such, current guidelines support the immediate administration of antibiotic agents. The duration of antibiotic treatment is still controversial. A maximum of 72 hours, even in the absence of definitive soft tissue coverage, is recommended in a number of recent guidelines and consensus reports. The aim of this meta-analysis was to review and analyze all published literature evidence with regard to antibiotic duration in open fracture treatment., Methods: We conducted a comprehensive review of the available literature from the 1970s until the present, including five comparative (1284 open fractures) and 27 observational (5408 open fractures) studies. A subgroup analysis was further performed, based on the Gustilo type of open injury and the anatomic location of the fracture. In addition, we investigated the effect of antibiotic regimes shorter than 72 hours on infection rates., Results: In the comparative studies, the summarized estimate of infection rate favored less than a 72-hour duration of antibiotic treatment, because prolongation of antibiotic treatment more than 72 hours did not seem to offer any protective effect against septic complications of open fractures (odds ratio: 0.85, 95% confidence interval [CI]: 0.60-1.21). The same trend was also documented in the observational studies, where the overall pooled estimate of infection rate was 10% (95% CI: 6.8%-14%) when antibiotic treatment did not exceed 72 hours and 9.2% (95% CI: 6.6%-12.2%) for more than 72 hours of antibiotic treatment (p = 0.53). In Gustilo I and II open fractures, the calculated pooled estimate of infection rate did not differ significantly when antibiotic treatment exceeded 72 hours (6%, 95% CI: 3.3%-9%) compared with shorter (up to 72 h) antibiotic protocols (4%, 95% CI: 1.8%-7%) (p = 0.52). In Gustilo III open fractures also, the calculated pooled estimate of infection rate (21.3%, 95% CI: 13%-31%) when duration of antibiotic treatment was more than 72 hours did not differ significantly compared with a shorter (less than 72 h) antibiotic treatment (17.7%, 95% CI: 12.5%-23.5%) (p = 0.39). A further subgroup analysis indicated that even shorter antibiotic regimes (24-48 h) were also equivalent to prolonged regimes of more than 72 hours in terms of infection rates., Conclusions: The results of the present systematic review and meta-analysis could not substantiate any benefit against septic complications of a prolonged duration of antibiotic treatment of open fractures, irrespective of their severity.

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.

Intramedullary nailing, as the gold standard stabilisation method of most long bones, has been tailed by its extensive use as the basic tool of investigating the immune response to trauma in many large and small animal models, as well as at the clinical setting. Over the last few decades a complex map of interactions between pro and anti-inflammatory pathways has been the result of these significant global research efforts. Parallel to the evolution of modern nailing and reaming techniques, significant developments at the fields of other disciplines relevant to trauma care, has improved the contemporary management of injured patients, challenging previous concepts and altering clinical barriers. The current article aims to summarise the current understanding of the effect of instrumenting the medullary canal after trauma, and hint on potential future directions., (Copyright © 2017. Published by Elsevier Ltd.)

Objectives: To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients., Design: A single center retrospective chart review., Setting: A level-1 trauma center., Patients and Methods: We reviewed all the polytrauma patients (ISS>16) between 2007 and 2012 that had a PEF applied more than 30days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al., Results: 59 patients with mean age of 38.4 (16 - 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30-104) days. The average follow-up was 403days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p=0.034) but no correlation to the functional outcome was evident., Conclusion: PEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome., Level of Evidence: Therapeutic Level III., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18-80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean length of the bone defect area was 4.2 cm (range 2-12 cm). All patients were managed with the two stage technique receiving composited grafting (Autologous bone graft (Iliac crest/RIA), graft expander as required, osteoprogenitor cells, growth factor) during the second stage. There was one failure (humeral infected non-union) in a previous background of bone radiation that necessitated reconstruction with a free fibula vascularized graft. One patient had a fall and sustained implant failure (humeral defect) 3 months after reconstruction and following re-plating progressed to union 4 months later. Two patients required re-grafting due to failure of healing in one of the defect sides. One patient presented with a discharging sinus 2 years after successful healing of a tibial defect that was treated successfully with soft tissue and bone debridement without necessitating further interventions. One patient despite union (distal 1/3 tibia) underwent a below knee amputation due to a dysfunctional ankle/foot (previous foot compartment syndrome-regional pain syndrome). Of those patients, with lower limb injuries, 4 patients had leg length discrepancies of 1 cm, 1.5 cm, 2 cm (two patients) respectively. The mean time to radiological union was 5.4 months (range 2-12 months). The average time of healing of 1 cm bone defect was 1.24 months. Patients with upper limb reconstruction recovered earlier than those with lower limb injuries. At the latest follow up all patients were able to mobilize full weight bearing without residual pain. The induced membrane technique appears to be an alternative good option for the management of large bone defects secondary to acute bone loss or infected non-unions. The incidence of re-interventions was low in this challenging cohort of patients. The technique should be considered in the surgeon's armamentarium as it is effective and is associated with a low rate of complications., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The management of upper limb non-unions can be challenging and often with unpredictable outcomes. In this study we present our experience with the use of BMP-7 in the treatment of upper limb non-unions. Between 2004 and 2011 all consecutive patients who were treated with BMP-7 were followed up prospectively until fracture union. Fracture union was assessed with regular radiological and clinical assessment. At the final follow up clinical assessment included the short Disabilities of the Arm, Shoulder and Hand (DASH) score. The minimum follow up was 12 months (12-36). In total 42 patients met the inclusion criteria with a mean age of 47 years. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal forearm, 14 humeri, 6 distal radius and 3 clavicle. 35 patients had atrophic non-union, 11 had previous open fractures, and 10 had bone loss (range 1-3 cm). The mean number of operations performed and the mean time from injury to BMP-7 application was 1.5 and 26 months, respectively. 40 fractures had both clinical and radiological union whereas 2 patients had partial radiological union but a pain free range of motion. BMP-7 was applied in isolation in 1 case and in 41 cases the application was combined with autologous bone grafting. DASH scores were available at final follow up in 23 (55%) patients with a mean of 33 score (range 2-86.4). This study supports the view that the combination of ABG and BMP-7 can be considered as a successful treatment modality for the treatment of recalcitrant upper limb non-unions. Further studies preferably randomised controlled trials are desirable to throw more light into the role of BMP-7 in the treatment of upper limb nonunions., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures., Patients and Methods: We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions., Results: 181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141)., Conclusion: Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12-32). In total 64 patients (34 males) with a mean age of 45 years (17-83) were evaluated. Anatomical distribution of non-unions included the femur (54.68%), tibia (34.38%), humerus (4.68%), radius (3.13%) and clavicle (3.13%). The median number of previous interventions was 1 (range 1-5). The majority of patients (82.62%) underwent revision of fixation whereas only bone grafting was performed 9.38% of patients. Three patients developed superficial wound infection (one was MRSA), 1 had deep vein thrombosis and 1 developed heterotopic bone formation. Union was successful in 63/64 (98.4%) non-unions at a mean time of 6 months (range 3-12). All patients were mobilising pain free and returned to their daily living activities at the final follow up. The application of the "diamond concept" in this cohort of patients was associated with a high union rate by providing an optimal mechanical and biological environment. Such an approach should be considered in the surgeon's armamentarium particularly in such cases where difficulty of bone repair is foreseen., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Infected non-union is a devastating complication post fracture fixation. While its incidence is small, its management is lengthy, challenging and costly. Complex reconstruction surgery is often required with unpredictable outcomes despite the significant advances that have been made in diagnostics, surgical techniques and antibiotic protocols. In this article we present recent approaches to the surgical treatment of this condition., (Copyright © 2015 Elsevier Ltd. All rights reserved.)