Aims. The aim of this study was to describe the management and associated outcomes of patients sustaining a femoral hip periprosthetic fracture (PPF) in the UK population. Methods. This was a multicentre retrospective cohort study including adult patients who presented to 27 NHS hospitals with 539 new PPFs between 1 January 2018 and 31 December 2018. Data collected included: management strategy (operative and nonoperative), length of stay, discharge destination, and details of post-treatment outcomes (reoperation, readmission, and 30-day and 12-month mortality). Descriptive analysis by fracture type was performed, and predictors of PPF management and outcomes were assessed using mixed-effects logistic regression. Results. In all, 417 fractures (77%) were managed operatively and 122 (23%) conservatively. The median time to surgery was four days (interquartile range (IQR) 2 to 7). Of those undergoing surgery, 246 (59%) underwent revision and/or fixation and 169 (41%) fixation alone. The surgical strategy used differed by Unified Classification System for PPF type, with the highest rate of revision in B2/B3 fractures (both 77%, 176/228 and 24/31, respectively) and the highest rate of fixation alone in B1- (55/78; 71%) and C-type (49/65; 75%) fractures. Cemented stem fixation (odds ratio (OR) 2.66 (95% confidence interval (CI) 1.42 to 4.99); p = 0.002) and B2/B3 fracture type (OR 7.56 (95% CI 4.14 to 13.78); p < 0.001) were predictors of operative management. The median length of stay was 15 days (IQR 9 to 23), 12-month reoperation rate was 5.6% (n = 30), and 30-day readmission rate was 8.4% (n = 45). The 30-day and 12-month mortality rates were 5.2% (n = 28) and 21.0% (n = 113). Nonoperative treatment, older age, male sex, admission from residential or nursing care, and sustaining the PPF around a revision prosthesis were significant predictors of an increased 12-month mortality. Conclusion. Femoral hip PPFs have mortality, reoperation, and readmission rates comparable with hip fracture patients. However, they have a longer wait for surgery, and surgical treatment is more complex. There is a need to create a national framework for data collection for this heterogeneous group of patients in order to understand the outcomes of different approaches to treatment. Cite this article: Bone Joint J 2022;104-B(8):997–1008

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

Aims. The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years. Patients and Methods. Patients were randomised to either non-operative management or operative management with either tension-band wiring or fixation with a plate. They were reviewed at six weeks, three and six months and one year after the injury. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at one year. Results. A total of 19 patients were randomised to non-operative (n = 8) or operative (n = 11; tension-band wiring (n = 9), plate (n = 2)) management. The trial was stopped prematurely as the rate of complications (nine out of 11, 81.8%) in the operative group was considered to be unacceptable. There was, however, no difference in the mean DASH scores between the groups at all times. The mean score was 23 (0 to 59.6) in the non-operative group and 22 (2.5 to 57.8) in the operative group, one year after the injury (p = 0.763). There was no significant difference between groups in the secondary outcome measures of the Broberg and Morrey Score or the Mayo Elbow Score at any time during the one year following injury (all p ≥ 0.05). . Conclusion. These data further support the role of primary non-operative management of isolated displaced fractures of the olecranon in the elderly. However, the non-inferiority of non-operative management cannot be proved as the trial was stopped prematurely. Cite this article: Bone Joint J 2017;99-B:964–72

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

This prospective study explores the outcomes of the Forth Valley Protocol (FVP) for the management of acute Achilles tendon ruptures. The protocol uses ultrasound as the primary mechanism to guide treatment. All patients presenting with acute tendoachilles rupture over a three-year period were included. Patients under 18 years of age, chronic ruptures, or prior surgery to the Achilles tendon were excluded. Patients with a gap ≤2cm had conservative management following an Early Rehabilitation Protocol (ERP) and >2cm underwent surgery (if an appropriate surgical candidate). Achilles Tendon Rupture Scores (ATRS) were obtained retrospectively. Fischer's exact test was used to determine statistical significance. 158 patients were included with a mean age of 53 (range 20–89). Ultrasound scans were obtained for 121 patients (76.5%), demonstrating a mean tendon gap of 1.61cm. 143 patients managed conservatively and 15 surgically. The overall re-rupture rate was 3.8% (n=6). All the re-ruptures occurred in patients treated conservatively, but this was not found to be statistically significant (n=6, P=1.0). The overall complication rate (excluding re-ruptures) was 1.9%. ATRS was comparable between both treatment modalities (P=0.382, 0.422), with a mean score of 86.6 in the conservative group and 81.4 in the surgical group. The FVP demonstrates low re-rupture and complication rates in line with other published studies. Patients with gaps ≤2.0cm on the ultrasound can be successfully treated conservatively with an ERP. This has potential benefits in terms improved patient outcomes, satisfaction, and preservation of resources

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence. Cite this article: Bone Joint J 2013;95-B:151–9

This study describes the introduction of a virtual pathway for the management of suspected scaphoid fractures and reports patient-reported outcome measures (PROMs) and satisfaction following treatment with this service. All adult patients that presented with a clinically suspected scaphoid fracture that was not visible on presentation radiographs over a one-year period were eligible for inclusion in the pathway. Demographics, examination findings, clinical scaphoid score (CSS) and standard four view radiographs were collected at presentation. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year post presentation and included the QuickDASH, EQ-5D-5L, the Net Promoter Score (NPS) and return to work. There were 221 patients referred to the virtual pathway. The mean age was 41 (range 16–87; SD 18.4 years) and there were 99 men (45%). There were 189 (86%) patients discharged with advice and 19 (9%) patients were recalled for clinical review (seven undisplaced scaphoid fractures, six other acute fractures of the hand or wrist, two scapholunate ligament injuries, and four cases where no abnormality was detected). Thirteen patients (6%) initiated follow-up with the hand service; no fracture or ligament injury was identified within this group. PROMs were available for 179 (81%) patients at a mean of 19 months follow-up (range: 13 – 33 months). The median QuickDASH score was 2.3 (IQR, 0–15.9), the median EQ-5D-5L was 0.85 (IQR, 0.73–1.00), the NPS was 76, and 173 (97%) patients were satisfied with their treatment. There were no documented cases of symptomatic non-union one year following injury. This study reports the introduction of a virtual pathway for suspected scaphoid fractures, demonstrating high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases

Periprosthetic femur fracture (PPF) are heterogeneous, complex, and thought to be increasingly prevalent. The aims were to evaluate PPF prevalence, casemix, management, and outcomes. This nationwide study included all PPF patients aged >50 years from 16 Scottish hospitals in 2019. Variables included: demographics; implant and fracture factors; management factors, and outcomes. There were 332 patients, mean age 79.5 years, and 220/332 (66.3%) were female. One-third (37.3%) were ASA1-2 and two-thirds (62.3%) were ASA3+, 91.0% were from home/sheltered housing, and median Clinical Frailty Score was 4.0 (IQR 3.0). Acute medical issues featured in 87/332 (26.2%) and 19/332 (5.7%) had associated injuries. There were 251/332 (75.6%) associated with a proximal femoral implant, of which 232/251 (92.4%) were arthroplasty devices (194/251 [77.3%] total hip, 35/251 [13.9%] hemiarthroplasty, 3/251 [1.2%] resurfacing). There were 81/332 (24.4%) associated with a distal femoral implant (76/81 [93.8%] were total knee arthroplasties). In 38/332 (11.4%) there were implants proximally and distally. Most patients (268/332; 80.7%) were treated surgically, with 174/268 (64.9%) requiring fixation only and 104/268 (38.8%) requiring an arthroplasty or combined solution. Median time to theatre was longer for arthroplasty versus fixation procedures (120 vs 46 hours), and those requiring inter-hospital transfer waited longer (94 vs 48 hours). Barriers to investigating PPF include varied classification, coding challenges, and limitations of existing registries. This is the first study to examine a national PPF cohort and presents important data to guide service design and research. Additional findings relating to fracture patterns, implant types, surgeon skill-mix, and outcomes are reported herein

Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

Aims. The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT). Patients and Methods. Data was grouped into annual intervals from 2008 to 2017. All adult inpatient episodes that involved emergency surgery for fractures of the distal radius were included. Results. In 2008 Kirschner-wire (K-wire) fixation accounted for 59% of operations for fractures of the distal radius, and plate fixation for 21%. In 2017, the rate of K-wire fixation had fallen to 30%, and the proportion of patients who underwent plate fixation had risen to 62%. Conclusion. There is an increasing trend towards open reduction and internal fixation for fractures of the distal radius in Ireland. This has been accompanied by a decrease in popularity for K-wire fixation. DRAFFT did not appear to influence trends in the management of fractures of the distal radius in Ireland. Cite this article: Bone Joint J 2019;101-B:1550–1556

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture. A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period. The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction. Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) on nonunion. Over a ten-year period, 734 humeral diaphyseal fractures (732 consecutive patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients; median age 57yrs [16–96], 54% female [n=359/662]) which formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs. Median follow-up was five months (1.2–74). Nonunion occurred in 22.7% of non-operatively managed injuries (n=119/524). Multivariate analysis demonstrated pre-injury NSAIDs (adjusted OR [AOR] 40.8, 95% CI 2.6–632.3; p=0.008), being underweight (BMI <18.5kg/m2; AOR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25–29.9kg/m2; AOR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35–39.9kg/m2; AOR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) than non-operative management (AOR for non-operative/operative 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo operative fixation to avoid one nonunion. Pre-injury NSAIDs and BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion

Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

Non-operative management of displaced olecranon fractures in elderly low demand patients is reported to result in a satisfactory outcome despite routinely producing a nonunion. The aim of this study was to assess whether there is evidence of dynamic movement of the fracture fragment during the elbow arc of movement. Five consecutive patients (≥70 years of age) with a displaced olecranon fracture (Mayo 2A) that were managed with non-operative intervention were recruited. All underwent ultrasound evaluation at six weeks and follow-up questionnaires at six months including the DASH and Oxford Elbow Score (OES). There were three women and two men with a mean age of 79yrs (range 70–88). All injuries were sustained following a fall from standing height. The mean fracture gap in extension was 22.5mm (95% CI 13.0–31.9), midflexion 21.8mm (11.6–32.0) and in deep flexion 21.8mm (10.9–32.8). Although the amount of fracture displacement varied between patients, it remained static in each patient with no significant differences observed throughout the arc of motion (ANOVA p=0.99). The six-month median DASH score was 7.5 (IQR range, 4.2–39.3) and the OES was 44.0 (29.0–47.5). Four out of the five patients were satisfied with their function. Ultrasound evaluation of displaced olecranon fractures following non-operative management suggests the proximal fragment may function as a sesamoid type bone within the triceps sleeve. This could explain how a functional arc of movement with a minimum level of discomfort can usually be expected with non-operative management in select patients

Patellofemoral instability (PFI) is a common cause of knee pain and disability in the paediatric population. Patella alta, lateralised tibial tubercle, medial patellofemoral ligament (MPFL) deficiency, genu valgum and trochlear dysplasia are well known risk factors.

A prospective database was created including patients referred through our physiotherapy pathway following first-time patella dislocation. Patella alta and lateralisation of the tibial tuberosity was treated with a Fulkerson-type tibial tubercle osteotomy(TTO). Medial patellofemoral ligament was reconstructed using quads tendon autograft pull-down technique. A modified Sheffield protocol was used postoperatively allowing weightbearing in a hinged knee brace.

Forty patients were identified with 8 patients having bilateral presentations. Male to female ratio was 12:28 with an age range of 4–17 years. Eight patients had congenital PFI, five patients acquired PFI through traumatic patella dislocation and twenty-seven patients developed PFI from recurrent dislocations. Structural abnormalities were found in 38(95%) of patients. Patella alta (Caton-Deschamps index >1.2) was identified in 19(47%) patients, genu valgum in 12(30%) patients, increased tibial tubercle-trochlear groove distance(TT-TG>20mm) was present in 9(22.5%) patients and persistent femoral anteversion(> 20 deg) in 7(17%) patients.

Eight patients were treated with TTO and MPFL reconstruction, three patients with MPFL reconstruction alone and five patients had guided growth for genu valgum correction. Ten patients are awaiting surgery. No postoperative patients had recurrence of PFI at their latest follow up.

PFI is a common problem in the adolescent paediatric population with identifiable structural abnormalities. Correcting structural pathology with surgery leads to predictable and safe outcomes.

Aims. The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT. Methods. A systematic search was performed in CINAHL, The Cochrane Library, Embase, Ovid MEDLINE, and PubMed. We included articles from 1 January 1980 to 30 September 2019. Studies with a minimum sample size of five cases, where the IMT was performed primarily in adult patients (≥ 18 years old), in a long bone were included. Multivariate regression models were performed on patient-level data to determine variables associated with nonunion, postoperative infection, and the need for additional procedures. Results. A total of 48 studies were included, with 1,386 cases treated with the IMT. Patients had a mean age of 40.7 years (4 to 88), and the mean defect size was 5.9 cm (0.5 to 26). In total, 82.3% of cases achieved union after the index second stage procedure. The mean time to union was 6.6 months (1.4 to 58.7) after the second stage. Our multivariate analysis of 450 individual patients showed that the odds of developing a nonunion were significantly increased in those with preoperative infection. Patients with tibial defects, and those with larger defects, were at significantly higher odds of developing a postoperative infection. Our analysis also demonstrated a trend towards the inclusion of antibiotics in the cement spacer having a protective effect against the need for additional procedures. Conclusion. The IMT is an effective management strategy for complex segmental bone defects. Standardized reporting of individual patient data or larger prospective trials is required to determine the optimal implementation of this technique. This is the most comprehensive review of the IMT, and the first to compile individual patient data and use regression models to determine predictors of outcomes. Cite this article: Bone Joint J 2020;102-B(12):1723–1734

Aims. Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. Patients and Methods. A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management. Results. Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001). Conclusion. Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119–25

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort. Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship. The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01). This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future

Aims. Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods. A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results. There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion. The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169