This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering interventions for treating distal femur fractures in adults; ultrasound and shockwave therapy for acute fractures in adults; and local corticosteroid injection versus placebo for carpal tunnel syndrome

Acute fractures of the scaphoid were randomly allocated for conservative treatment in a Colles’-type plaster cast with the wrist immobilised in either 20° flexion or 20° extension. The position of the wrist did not influence the rate of union of the fracture (89%) but when reviewed after six months the wrists which had been immobilised in flexion had a greater restriction of extension. We recommend that acute fractures of the scaphoid should be treated in a Colles’-type cast with the wrist in slight extension

Aims. The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. Methods. This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed. Results. Mean follow-up was 8.4 years (5 to 11). There were no significant differences in mean absolute (p = 0.125) or adjusted (p = 0.569) Constant, UCLA (p = 0.088), QuickDASH (p = 0.135), VAS-pain (p = 0.062), or range of movement at the final follow-up. However, patient satisfaction was significantly lower in the fracture group (p = 0.002). The complication rate was 1.5% (one patient) versus 9.3% (six patients), and the revision rate was 1.5% (one patient) versus 7.8% (five patients) in the fracture and arthropathy groups, respectively. The ten-year arthroplasty survival was not significantly different (p = 0.221). Conclusion. RSA may be used not only for patients with irreparable rotator cuff deficiencies, but also for those with acute complex proximal humeral fractures. We found that RSA provided similar functional outcomes and a low revision rate for both indications at long-term. However, satisfaction is lower in patients with an acute fracture. Cite this article: Bone Joint J 2020;102-B(11):1555–1559

We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C. Lesions of the cartilage were found in 228 ankles (79.2%), more often on the talus (69.4%) than on the distal tibia (45.8%), the fibula (45.1%), or the medial malleolus (41.3%). There were more lesions in men than in women and in general they were more severe in men (p < 0.05). They also tended to be worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05). Within each type of fracture the lesions increased from subgroups 1 to 3 (p < 0.05). The anterior tibiofibular ligament was injured with increased frequency from type-B.1 to type-C.3 fractures (p < 0.05), but it was not torn in all cases. While lateral ligamentous injuries were seen more often in type-B than in type-C fractures (p < 0.05), no difference was noted in the frequency of deltoid ligamentous lesions. Our findings show that arthroscopy is useful in identifying associated intra-articular lesions in acute fractures of the ankle

A series of 103 acute fractures of the coronoid process of the ulna in 101 patients was reviewed to determine their frequency. The Regan-Morrey classification, treatment, associated injuries, course and outcomes were evaluated. Of the 103 fractures, 34 were type IA, 17 type IB, ten type IIA, 19 type IIB, ten type IIIA and 13 type IIIB. A total of 44 type-I fractures (86%) were treated conservatively, while 22 type-II (76%) and all type-III fractures were managed by operation. At follow-up at a mean of 3.4 years (1 to 8.9) the range of movement differed significantly between the types of fracture (p = 0.002). Patients with associated injuries had a lower Mayo elbow performance score (p = 0.03), less extension (p = 0.03), more pain (p = 0.007) and less pronosupination (p = 0.004), than those without associated injuries. The presence of a fracture of the radial head had the greatest effect on outcome. An improvement in outcome relative to that of a previous series was noted, perhaps because of more aggressive management and early mobilisation. While not providing complete information about the true details of a fracture and its nature, the Regan-Morrey classification is useful as a broad index of severity and prognosis

In a prospective randomized trial, we divided a group of patients with a clinically suspicious, although radiographically normal, acute fracture of the scaphoid into 2 groups, 1 treated with a cast (group I), the other with a splint (group II). There were 14 patients in group I, and 18 in group II. Patients were reviewed at 2,6, and 12 weeks for range of movement, grip strength, pain and satisfaction rating. Work disability costs were also calculated for both groups. Patients in group II had better range of movement and grip strength at 2 weeks, although complained of more pain. There was no difference in range of movement, grip strength, or pain at 6 or 12 weeks. Group II was more satisfied at 2 weeks, although not at 6 or 12 weeks. Group I required more time off work, and disability costs were significantly higher [€15,209 per person compared to €3,317 per person]. We recommend that all patients, with only a clinical suspicion of a fractured scaphoid, should have a short period of splint immobilization until symptoms resolve, or until further investigations reveal a fracture which can be appropriately treated. This policy is cost efficient and improves the short term outcome

We performed dynamic MRI of the femoral head within 48 hours of injury on 22 patients with subcapital fracture of the neck of the femur and on a control group of 20 of whom ten were healthy subjects and ten were patients with an intertrochanteric fracture. Three MRI patterns emerged when the results between the fractured side and the contralateral femoral head were compared. In all of the control group and in those patients who had undisplaced fractures (Garden stages I and II), perfusion of the femoral head was considered to be at the same level as on the unaffected side. In patients with displaced fractures (Garden stages III and IV) almost all the femoral heads on the fractured side were impaired or totally avascular, although some had the same level of perfusion as the unaffected side. We conclude that dynamic MRI, a new non-invasive imaging technique, is useful for evaluating the perfusion of the femoral head.

Reconstructing a shoulder fracture with an arthroplasty is analogous to solving a jigsaw puzzle. Before beginning the task of assembling the pieces of a puzzle, the final “picture” must be seen, as this will guide the proper location for the individual puzzle pieces. And, only when all the pieces are properly placed will the final picture be defined and recognised as a piece of art!

In the same way, following a three or four part displaced fracture of the shoulder, reassembly of the various pieces requires time and skilful appreciation of the three dimensional anatomy of bone, ligament and muscle. These tissues are like puzzle pieces which, when assembled according to the rules of anatomy and physiology, will lead to successful outcome measured by minimal pain and functional recovery of shoulder motion.

This presentation will examine each of these puzzle pieces – the bone fragments, the muscle, and the ligaments – individually and functionally integrated. We will review their importance in the overall scheme of shoulder reconstruction following a complex fracture. The critical concerns of humeral length, humeral version and myofascial sleeve tension will be discussed in detail. It is the recognition of these anatomic and physiologic necessities, which allow the final shoulder radiograph and the patient, to indeed resemble a piece of art.

Dislocation after total hip arthroplasty in individuals treated for acute hip fracture is up to 10 times more frequent than in elective patients. Whilst approach plays a role, the effect of head sizes in conventional THA and dual mobility cups (DMC) is less studied in fracture cases. The total dislocation rate at 1-year and 3-year revision rates were recorded in this observational study on 8,031 patients with acute hip fracture, treated with a THA 2005–2014. Swedish Arthroplasty Register data were linked with the National Patient Register. Cox multivariable regression models were fitted to calculate adjusted hazard ratios stratified by approach and head size. The cumulative risk of dislocation during year 1 was 2.7% (95% CI 2.2–3.2) with lateral approach and 8.3% (7.3–9.3) with posterior approach (KM estimates). In the posterior approach group DMC was associated with a lower risk of dislocation compared to cTHA=32mm (HR=0.21; 0.07–0.68), whilst a head size <32mm carried a higher risk (HR=1.47; 1.10–1.98). These differences were no longer visible when revision in general was used as outcome. Neither of the implant designs influenced the dislocation risk when direct lateral approach was used. Male gender and severe comorbidity increased the risk. DMC with lateral approach was associated with a reduced risk of revision in general (HR=0.36; 0.13–0.99). Head size did not influence the revision risk. When aiming to reduce the risk of any dislocation, lateral approach – regardless of cup/head design – is referable. If, for any reason, posterior approach is used, DMC is associated with the lowest risk of dislocation. This is not reflected in analysing revision in general as outcome. An interpretation could be that there are different thresholds for dislocation prompting revision

To determine whether elderly patients presenting with a fracture of the proximal femur have an underlying vitamin D deficiency.

We identified 59 consecutive cases of a fracture of the proximal femur over a 10-week period. 16 patients were excluded as they had a secondary underlying cause of bone loss which included chronic renal disease, rheumatoid arthritis, thyroid/parathyroid disorders, long term steroid usage and malignancy.

Of the 43 that were eligible for the study, 7 were men and the average age was 81 years. 9 had sustained previous osteoporotic fractures. The majority mobilised independently or with 1 stick prior to the fall and the mechanism in all cases was a low velocity injury from standing height or less.

The mean vitamin D3 level in these cases was 28. 3 nmol/ l. 28 of the 43 had a pathologically low level of vitamin D3 as defined as < 30nmol/l.

The mean PTH level was 53. 7 nmol/ l. 15 of the 43 had an elevated PTH and all 15 were also deficient in vitamin D.

The mean Albumin, an indicator of nutritional status, was 29 g/l.

This study highlights that 65% of the patients who present with a fracture of the proximal femur are depleted in vitamin D. The ageing process is associated with a reduction in the intake of vitamin D, gut absorption and its sunlight activation. Repletion of vitamin D and suppression of parathyroid hormone, both prophylactically or at the time of injury, may reduce future fracture risk and assist in fracture repair.

Aims

Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure.

The number of patients in the United Kingdom being admitted with Neck of Femur Fractures (NOF) is increasing each year. Primary first aid for these patients includes adequate analgesia. The commonest forms of analgesia are opioids and in some units regional blockade. However, both have limitations. Regional block is skill dependent while opiates are known to have many side effects.

Paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. Intravenous paracetamol has a far higher predictable bio-availibilty than oral, within standard dosage. This study is to assess the suitability of using intravenous Paracetamol as an alternative.

Method: Prospective study: a change in protocol resulted in all NOF’s admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. PRN opioids were available for breakthrough pain. NOF’s admitted under the care of other consultants remained on the established protocol. Opioid usage and pain scores (scale 0–10) were measured.

Results: results of 72 patients were collected, 44 in intravenous paracetamol group and 28 in the control group, having regular opiates and oral paracetamol. There is a 65% reduction in opiate usage in the intravenous paracetamol group (P value= 0.015). There is only a 0.5 difference in average pain score between the two groups (P value= 0.173).

Conclusion: The use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. The pain relief within this group was comparable to that in the control group. The side-effects of opioids are dose dependent, a reduction in their usage therefore improves both pre and post-operative morbidity by reducing the side effects. A simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period.

United Kingdom National Institute for Health and Clinical Excellence guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractures of the femoral neck in cognitively intact patients, who were independently mobile prior to the injury. This study aimed to analyse the risk factors associated with revision of the implant and mortality following THR, and to quantify risk. National Joint Registry data recording a THR performed for acute fracture of the femoral neck between 2003 and 2010 were analysed. Cox proportional hazards models were used to investigate the extent to which risk of revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting peri-operative mortality (< 90 days). A total of 4323 procedures were studied. There were 80 patients who had undergone revision surgery at the time of censoring (five-year revision rate 3.25%, 95% confidence interval 2.44 to 4.07) and 137 patients (3.2%) patients died within 90 days. After adjusting for patient and surgeon characteristics, an increased risk of revision was associated with the use of cementless prostheses compared with cemented (hazard ratio (HR) 1.33, p = 0.021). Revision was independent of bearing surface and head size. The risk of mortality within 90 days was significantly increased with higher American Society of Anesthesiologists (ASA) grade (grade 3: odds ratio (OR) 4.04, p < 0.001; grade 4/5: OR 20.26, p < 0.001; both compared with grades 1/2) and older age (≥ 75 years: OR 1.65, p = 0.025), but reduced over the study period (9% relative risk reduction per year). THR is a good option in patients aged < 75 years and with ASA 1/2. Cementation of the femoral component does not adversely affect peri-operative mortality but improves survival of the implant in the mid-term when compared with cementless femoral components. There are no benefits of using head sizes > 28 mm or bearings other than metal-on-polyethylene. More research is required to determine the benefits of THR over hemiarthroplasty in older patients and those with ASA grades > 2

Aims

Patients with femoral neck fractures (FNFs) treated with total hip arthroplasty (THA) have an almost ten-fold increased risk of dislocation compared to patients undergoing elective THA. The surgical approach influences the risk of dislocation. To date, the influence of differing head sizes and dual-mobility components (DMCs) on the risk of dislocation has not been well studied.

National guidelines suggest which investigations should be performed for patients admitted with an acute hip fracture. We have observed practice often deviates from these guidelines. Our study aims to identify the incidence of deviation with regards to blood investigations and review the effect of deviation on management, and the financial burden on the healthcare system. A total of 250 acute hip fracture admissions over 12-months period reviewed retrospectively. Admission blood tests, time of presentation, and time of operation were recorded. The cost of admission blood investigations was calculated. Seventy-nine percent of admissions had one or more non-routine blood investigation tested. Twenty-Nine percent of these tests had abnormal results and these were found to be clinically relevant in 6% of patients. The most commonly requested non-routine investigations were: LFT in 79%, Coagulation screen in 56%, and CRP in 48%. Fifteen percent of patients did not have surgery within the time frame of 36 hours. The total cost of non-routine investigations was £1995.04. Deviation from admission investigations guidelines for hip fractures without clinical indication adds little clinical value, has no effect on management, and can be a potential cause of unnecessary investigations. This in turn leads to further delays and extra costs

Introduction: The role of continuous compartment pressure monitoring to detect compartment syndrome associated with tibia fractures is unclear. Our study aims to assess the impact of continuous compartment pressure monitoring in patients with acute tibial fractures. Method: A randomised controlled trial was performed on 200 consecutive extra-articular tibial shaft fractures presenting to a major metropolitan trauma centre between June 2000 and August 2003. One hundred patients were randomised to continuous compartment pressure monitoring of the anterior compartment for 36 hours. The other group received usual care. The surgical team was alerted if the compartment pressure was within 30mmHg of the diastolic blood pressure. Compartment syndrome was diagnosed on clinical grounds in alert patients. All cases of compartment syndrome were treated with fasciotomy. All patients were followed-up for a minimum of six months. Result: During the study period, three patients presented with acute compartment syndrome and underwent immediate fasciotomy and, consequently, were not entered into the study. In several cases, monitoring revealed pressures within 30 mmHg of diastolic blood pressure, but compartment syndrome was excluded on clinical grounds. The two groups were comparable with regards to age, mechanism of injury and fracture classification. Of the 100 control fractures, there were three cases of compartment syndrome. Each underwent fasciotomy without significant sequelae. Of the 100 monitored fractures, no cases of compartment syndrome were diagnosed. There were no cases of missed compartment syndrome in this study. Continuous compartment pressure monitoring requires regular nurse education and, despite this, in most patients monitoring was not complete. Conclusion: We did not find continuous compartment pressure monitoring useful in diagnosing compartment syndrome in patients with acute tibial fractures or preventing missed compartment syndrome. However, this study is underpowered to detect differences in missed compartment syndrome and it may be subject to trial bias as the level of awareness of compartment syndrome was raised by performing the trial. We no longer perform continuous compartment pressure monitoring at our institution

Introduction. National Institute for Health and Clinical Excellence (NICE) guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractured neck of femur (NOF) in cognitively intact patients who were independently mobile prior to the injury. The National Joint Registry for England and Wales (NJR) has collected data on THRs performed since 2003. This retrospective cohort study explores risk factors independently associated with implant failure and perioperative mortality. Methods. NJR data recording a THR performed for acute fractured NOF between 2003 and 2010 were analysed. Cox proportional hazards models were used to analyse the extent to which risk of implant revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting 90-day perioperative mortality. Significance was taken as p< 0.01. Result. A total of 4495 procedures were analysed, of which 83 (1.9%) underwent revision surgery and 144 (3.2%) patients died within 90 days. Increased risk of implant revision was associated with the use of cementless prostheses (Hazard Ratio [HR]=2.23, p=0.001), but revision risk was independent of age, American Society of Anaesthesiologists (ASA) grade, gender, head size and head material. Risk of mortality within 90 days was significantly associated with high ASA (grade 3: Odds ratio [OR]=7.20, p< 0.001, grade 4/5: OR=38.09, p< 0.001, referenced to grade 1 group) and older age (≥81 years: OR=2.04, p=0.004, referenced to 60–70 years group). Mortality risk was lower in patients who had a hybrid THR (OR=0.51 p=0.004), after risk adjustment. Conclusion. There is considerably greater risk of implant revision when cementless THR is used for managing fractured NOF. Risk of perioperative mortality is greatest in patients over 80 years with ASA grades 3 or above, and lowest with hybrid THR. This information may be used to guide the surgical management of patients with fractured neck of femur

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

Introduction. Continuous compression implants (CCIs) are small memory alloy bone staples that can provide continuous compression across a fracture site, which change shape due to temperature changes. Reviews of CCIs in orthopaedics have documented their use in mainly foot and ankle surgery, with very limited descriptions in trauma. They could be beneficial in the management of complex or open injuries due to their low profile and quick insertion time. The aim of this case series were to clarify the use of CCIs in modern day limb reconstruction practice. Materials & Methods. This was a single centred study looking retrospectively at prospective data for patients who were treated for an acute fracture or non-union with a CCI between September 2019 and May 2023. Primary outcome was to determine the function and indication of the CCI as judged retrospectively and secondary outcomes investigated unplanned returns to theatre for infection or CCI failure. Results. Sixty patients were eligible with a mean age of 44.2 (range 8–89). Fifty-one patients were treated for acute fractures, nine for non-unions; and almost half (27 patients) had open injuries. There were seven different sites for treatment with a CCI, the most common being tibia (25 patients) and humerus (14 patients). Of the 122 CCIs used, 80 were used as adjuncts for fixation in 48 patients. Their indication as an adjunct fell into three distrinct categories – reduction of fracture (39 CCIs), fixation of key fragments (38 CCIs) and compression (3 CCIs). Of these 48 patients, 4 patients had a frame fixation, 19 had a nail fixation, 24 patients had a plate fixation. Forty-two CCIs were used in isolation as definitive fixation, all were for midfoot dislocations expect an open iliac wing fixation from a machete attack and an isolated paediatric medial malleolus fixation. Two patients returned to theatre for infection and two due to CCI failure. Conclusions. This series has demonstrated the versality of CCIs across multiple sites of the body and for a large variety of injuries. It has identified, when not used in isolation, three main indications to support traditional orthopaedic fixations. Given the unpredictability in limb reconstruction surgery, the diversity and potential of CCIs could form part of the staple diet in the modern-day practice