Aims. The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures. Methods. A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively. Results. Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group. Conclusion. The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions. Cite this article: Bone Joint Res 2024;13(11):647–658

Aims. The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. Methods. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders. Results. The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively. Conclusion. This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development. Cite this article: Bone Joint J 2021;103-B(12):1821–1830

Objectives. As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures. Methods. A comprehensive literature search was performed in PubMed, Web of Science, and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared with systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis. Results. In total, eight studies which included 2738 patients were eligible for quantitative synthesis. The effect of antibiotic-loaded poly(methyl methacrylate) beads was investigated by six of these studies, and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.6%; 91/1986) than in the control group receiving standard systemic prophylaxis alone (16.5%; 124/752) (p < 0.001) (odds ratio 0.30; 95% confidence interval 0.22 to 0.40). Conclusion. This meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity, and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution. Cite this article: M. Morgenstern, A. Vallejo, M. A. McNally, T. F. Moriarty, J. Y. Ferguson, S. Nijs, WJ. Metsemakers. Bone Joint Res 2018;7:447–456. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. DOI: 10.1302/2046-3758.77.BJR-2018-0043.R1

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Aim. The primary aim of this quality improvement project was to assess compliance with BOAST 4 guidelines for the delivery of antibiotic prophylaxis in patients presenting to a major trauma centre with open limb fracture and evaluate the impact of implemented changes on attainment of these guidelines. Secondary aims were to assess adherence to local guidelines for the type of antibiotic prescribed. Method. A multi-cycle audit and quality improvement project was carried out for all patients presenting to Brighton and Sussex University Hospitals NHS Trust (BSUH) with open limb fractures from 1st September 2018 to 31st January 2019, and 1. st. November 2019 to 31. st. March 2020. Patients were identified through retrospective screening of electronic operation records (Bluespier) by authors, and paper records were subsequently reviewed for data pertaining to antibiotic prescriptions. Following the initial audit cycle, targeted teaching was carried out for orthopaedic trainees, new posters were placed in key clinical areas to highlight local guidelines, and alterations to the trauma clerking proforma were implemented, to include BOAST 4 guidelines. Results. In cycle 1, a total of 52 patients received surgical treatment for open limb fractures, of which 48 (92.3%) were prescribed antibiotics prior to definitive management, with a mean time to administration of 271 minutes. Of these, 41 (78.8%) received prescriptions according to BSUH guidelines. The use of STAT prescriptions was found to significantly reduce the mean time to administration from 298 minutes to 144 minutes (p = 0.044). In cycle 2, a total of 29 patients received surgical treatment for open limb fractures, of which all 100% were prescribed antibiotics prior to definitive management, with a reduced mean time to administration (233 minutes). Of these, 26 (89.7%) received prescriptions according to BSUH guidelines, and a significantly greater proportion (p = 0.0003) received initial STAT ‘once-only’ prescriptions (51.7% vs. 15.4%). Conclusions. This quality improvement project has demonstrated the successful implementation of targeted changes to improve the attainment of BOAST 4 guidelines. Following a multi-cycle audit, all patients now receive antibiotic prophylaxis, with a higher proportion receiving antibiotics according to local BSUH guidelines. Furthermore, the use of STAT ‘once-only’ prescriptions, which was shown to be beneficial during the first audit cycle, has now significantly increased following intervention

Abstract. Introduction. Clinic letters to the general practitioner (GP) form an essential part of communication in a patient's care. One essential variable requiring 100% compliance is the laterality/side of the diagnosis. Rationale of this audit was to check compliance of the same in clinic letters, to implement changes within the department initially followed by trust wide change in policy to improve the same. Material and Methods. Clinic letters over a period of time were read through in retrospect to see for mention of side. The exclusion criteria were COVID consenting letters over phone, “did not attend” letters and letters for spinal pathology. After 1st limb of audit following actions were taken: doctor education, secretaries to remind the dictating doctor to mention side in the letter and putting up of laminated prompters in all T&O clinic rooms to remind doctors. Following this a 2nd limb was conducted with similar parameters. Results. 1st Limb:. Total letters 271: Fracture clinic- 126. Elective/orthopaedic clinic – 106. Excluded letters– 39. 2nd Limb:. Total letters 169: Fracture clinic- 91. Elective/orthopaedic clinic – 62. Excluded letters– 16. Letters without the mention of side of diagnosis. 1st Limb: Fracture clinic – 28 out of 126 (22.3%). Orthopaedic clinic – 12 out of 106 (11.3%). 2nd Limb: Fracture clinic – 2 out of 91 (2.2%). Orthopaedic clinic – 2 out of 62 (3.2%). Conclusion. With the changes there was an overall compliance of 97.8% in fracture clinic and 96.8% compliance elective clinic dictations

Objectives. Open fracture classification systems are limited in their use. Our objective was to classify open tibia and femur fractures using the OTS classification system in a region with high incidence of gunshot fractures. One hundred and thirty-seven patients with diaphyseal tibia and femur open fractures were identified from a prospectively collected cohort of patients. This database contained all cases (closed and open fractures) of tibial and femoral intramedullary nailed patients older than 18 years old during the period of September 2017 to May 2021. Exclusion criteria included closed fractures, non-viable limbs, open fractures > 48 hours to first surgical debridement and patients unable to follow up over a period of 12 months (a total of 24). Open fractures captured and classified in the HOST study using the Gustilo-Anderson classification, were reviewed and reclassified using the OTS open fracture classification system, analysing gunshot fractures in particular. Ninety percent were males with a mean age of 34. Most common mechanism was civilian gunshot wounds (gsw) in 54.7% of cases. In 52.6% of cases soft tissue management was healing via secondary intention, these not encompassed in the classification. Fracture classification was OTS Simple in 23.4%, Complex B in 24.1% and 52.6% of cases unclassified. The OTS classification system was not comprehensive in the classification of open tibia and femur fractures in a setting of high incidence of gunshot fractures. An amendment has been proposed to alter acute management to appropriate wound care and to subcategorise Simple into A and B subdivisions; no soft tissue intervention and primary closure respectively. This will render the OTS classification system more inclusive to all open fractures of all causes with the potential to better guide patient care and clinical research

Acetabulum fractures caused by civilian firearms represent a unique challenge for orthopaedic surgeons. Treatment strategies should include the assessment of infection risk due to frequently associated abdominal injuries and maintenance of joint function. Still, internationally accepted treatment algorithms are not available. The aim of the study was to increase knowledge about civilian gunshot fractures of the acetabulum by describing their characteristics and management at a high-volume tertiary hospital. All adult patients admitted to our hospital between January 2009 and December 2022 with civilian gunshot fractures of the acetabulum were included in this descriptive retrospective study. In total our institution treated 301 patients with civilian gunshot fractures of the hip joint and pelvis during the observation period, of which 54 involved the acetabulum. Most patients were young males (88,9%) with a mean age of 29 years. Thirty patients (55,6%) had associated intraabdominal or urological injuries. Fracture patterns were mostly stable fractures with minor joint destruction amenable to conservative fracture treatment (n=48, 88,9%). Orthopaedic surgical interventions were performed in 21 patients (38,9%) with removal of bullets in contact with the hip joint via arthrotomy or surgical hip dislocation as most frequent procedures. Most patients received antibiotics on admission (n=49, 90,7%). Fracture related infections of the acetabulum were noted in six patients (11,1%) while the mortality in the study population was low with one demised patient (1,9%) due to the trauma burden. Most civilian acetabulum gunshot fractures are associated with intraabdominal or urological injuries. In comparison to the literature on extremity gunshot fractures, there is an increased risk of infection in our study population. The decision for surgical wash-out and bullet removal should be based on contamination and anticipated joint destruction, while osteosynthesis or primary arthroplasty are rarely necessary for these injuries

Aim. Alongside debridement and irrigation, soft tissue coverage and osseous stabilization, systemic antibiotic prophylaxis is considered the gold standard in the management of open fractures and considerably reduces the risk of subsequent fracture-related Infections (FRI). The direct application of antibiotics into the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures. Method. A comprehensive literature search was performed in PubMed, Web-of- Science and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared to systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis. Results. Eight studies, with a total of 2738 patients were eligible for quantitative synthesis. Six of these studies investigated the effect of antibiotic loaded PMMA beads and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.7%;94/1996) than in the control group receiving standard systemic prophylaxis alone (16.2%;129/797) (p-value < 0.001) (OR 0.30; 95%CI 0.22–0.40). Conclusions. This meta-analysis suggests a clear risk reduction in FRI if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution

Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association. We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year. Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment. To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA). Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73). When accounting for other variables, late irrigation does not independently increase risk of reoperation

The “Toddler Fracture” is an un-displaced oblique distal tibia fracture seen in children 9–36months of age presenting with refusal to walk, often after an unwitnessed or minor injury. Diagnosis is often made clinically, because initial x-rays are negative in up to 50% of patients, and then confirmed by the presence of periosteal reaction on follow up x-ray 7–10 days later. Point of Care Ultrasound (POCUS) has shown excellent ability to detect distal radius, clavicle and other extremity fractures and published case reports suggest that POCUS can also detect Toddler Fractures. The objective of this proof of concept study was to establish the feasibility and preliminary sensitivity and specificity of POCUS in the diagnosis of Toddler Fractures, and to characterize the POCUS findings in patients presenting with clinical Toddler Fractures. This was a prospective reviewer-blinded cross-sectional study of patients presenting to the emergency department of a paediatric tertiary care centre with presumed toddler fractures. All patients with suspected toddler fracture underwent lower limb x-ray. Those enrolled in the study also underwent POCUS of both lower extremities by a specialized provider. Treating clinicians were blinded to ultrasound results, and study sonographers were blinded to x-ray results. Study patients were then seen in paediatric orthopaedic follow up clinics 7–10 days later, and clinical assessment and follow up x-ray were performed as necessary to confirm diagnosis. Toddler Fracture was confirmed in 5 of 27 patients enrolled in the study. Preliminary results demonstrate that these POCUS findings were detected on the scan in all 5 confirmed toddler fractures. Three of these patients had an initial positive x-ray and 2 went on to have toddler fracture confirmed on follow up x-ray and orthopaedic assessment. POCUS findings consistent with a toddler fracture were found to be cortical disruption and periosteal hematoma. POCUS may be a useful adjunct to confirming a diagnosis of a toddler fracture when clinical suspicion is high and initial x-ray is negative. This pilot study provides positive impetus for further prospective study. The use of POCUS to confirm toddler fracture can decrease further radiation exposure to patients, allow early guidance to families on the management and expected recovery, and has potential to decrease burden on families and the healthcare system by potentially eliminating unnecessary follow-up appointments. Future study will help to better guide diagnostic and technical criteria, and provide guidance for appropriate medical education in this technique and interpretation

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

QCT permits a direct measure of bone and muscle size and assessment of bone/muscle relationship. We have studied cross-sectional QCT variables in mid-thigh as predictors of incidental limb fractures in the AGES-Reykjavik Study, a cohort of 66–96-year-old men (n=2160) and women (n=2385) drawn from an established population based cohort and not taking medications affecting bone metabolism. We used 4-detector Siemens CT system, a single axial section through the right mid-thigh (10 mm slice thickness). The variables included in the Cox’s proportional hazard model were; total cross-sectional cortical area (CSA), derived cortical thickness, shaft BMD, shaft bending strength index (BSI), medullary area and buckling ratio, total cross-sectional muscle and quadriceps area and bone/muscle area ratio. All low trauma limb fractures (including proximal end of femur but excluding toes, foot, hand and finger fractures) during mean 3.5 years of follow-up were validated by medical and radiological records, altogether 170 in women and 61 in men, including 87 hip fractures. Results: with sex as a confounding variable the most significant risk factor was the buckling ratio (ratio of bone radius to cortical thickness) with more than twofold greater risk in the top compared to the lowest tertile. This variable was mostly independent of muscle area which was however a significant protective factor independent of bone variables. Bone/muscle area ratio and BSI were not significant in multivariate analysis. The area under the ROC curve, using these QCT predictors and age, was 0.70 (CI 0.66–0.73). We conclude that cortical instability associated with decreasing cortical thickness due to medullary expansion is a significant risk factor for limb fractures including hip fractures in old age. Further knowledge on factors affecting buckling ratio might be of importance in the prevention of these fractures in the elderly

The most challenging complications in orthopaedic trauma surgery are fracture-related infections (FRI). The incidence ranges from approximately 1% after closed fractures or joint replacement, to more than 30% in complex open limb fractures. Despite tremendous efforts with prolonged antibiotic therapy and multiple revision surgeries, these complications are associated with considerable rates of recurrent infections as well as permanent functional impairment. The primary aim for the clinician is to prevent infection, because once established, an infection is difficult to eradicate. The main reason for this is biofilm formation on the implanted device, which allows pathogens to protect themselves from host immune response and antimicrobial therapy. In open fractures with a considerable wound contamination and soft- tissue damage, systemically-delivered antibiotics may not reach sufficient local concentrations to eradicate the bacteria. Locally delivered antibiotics can overcome this problem by providing high local concentrations. Currently, several antibiotic loaded biomaterials for local infection prophylaxis and/or treatment are available. In this talk, next to the diagnostic challenges of FRIs, the currently available antimicrobial-loaded biomaterials will be described. Against a backdrop of increasing infection and antimicrobial resistance, the prudent use and availability of such materials will become even more important

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views do not agree with those of the clinicians. This study compared patient and clinician views of outcome one to two years after an operatively managed extremity fracture and described any discordance. There were significant differences between groups, especially in areas such as pain and disruption of their personal and work lives. A discordance was observed between patient and physician views of recovery after fracture, likely associated with disruptions to personal life, unaccounted for in a clinician’s view of outcome. Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views differ from those of clinicians’. The purpose of this study is to compare patient and clinician views of outcome one to two years after an extremity fracture and to describe any discordance. Cross-sectional survey of patients one to two years after an operatively managed upper or lower extremity fracture. Patients were recruited from two tertiary care centres and completed a mailback questionnaire that included measures of health (DASH, SMFA), self-rated recovery, burden of illness (Illness Intrusiveness, Loss of self), symptoms, and work status. These were linked with clinical records of radiologic and clinical recovery. Two hundred and fifty-five patients returned usable questionnaires. Mean age was forty-two years and 42% were female. Sixty-seven patients said that they were completely better (CB), one hundred and thirty-four almost better (AB) and fifty-four not completely better (NCB). Significant differences were found between groups. In four variables, NCB was distinct from AB/CB, while in all other variables, such as pain, disability and disruption of their personal and work lives, all three groups were unique (Duncan’s post hoc). However, of the patients who said they were not better, the radiologist and clinician reports stated that thirty (68%) and twenty-eight (64%) were healed, respectively. A discordance was observed between patient and physician views of recovery after fracture. It appeared associated with disruptions to personal life that may not be accounted for in a clinician’s view of outcome. Funding: Canadian Institutes of Health Research (CIHR)

Patient specific instrumentation (PSI) for elective knee replacements in arthritic knees with severe deformities and in revision scenarios is becoming increasingly popular due to the advantage of restoring the limb axes, improved theatre efficiency and outcomes. Currently available systems use CT scan or MRI for pre-operative templating for design considerations with varied accuracy for sizing of implants. We prospectively evaluated 200 knees in 188 patients with arthritic knees with deformities requiring serial clinical assessment, radiographs and CT scans for PSI templating for TruMatch knee system (DepuySynthes, Leeds, UK). The common indications included severe arthritic deformities, previous limb fractures and in obese limbs with difficult clinical assessment. Surgical procedure was performed on standard lines with the customised cutting blocks. The ‘lead up’ time between the implant request and the operating date was 5 weeks on an average. We compared the pre op CT images and the best fit post-operative x- rays. The sizing accuracy for femur and tibia was 98.93 % and 95.75% respectively. All blocks fitted the femur and tibia. There were no bail outs, no cutting block breakage, 1 patient had residual deformity of 20 degrees, and 1 patient had late infection. The length of hospital stay, economic viability in terms of theatre turnover, less operating time, cost of sterilisation in comparison to conventional knee replacement surgery with other factors being unchanged was also assessed. The projected savings was substantial along with improved geometrical restoration of the knee anatomy. We recommend the use of PSI based on CT scan templating in difficult arthritic knees

Aims

Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning.

Aims

Acquired heterotopic ossification (HO) is a debilitating disease characterized by abnormal extraskeletal bone formation within soft-tissues after injury. The exact pathogenesis of HO remains unknown. It was reported that BRD4 may contribute to osteoblastic differentiation. The current study aims to determine the role of BRD4 in the pathogenesis of HO and whether it could be a potential target for HO therapy.