Background. This is an epidemiological study of patients with middle third clavicle fractures presenting to a tertiary hospital. The data is used to formulate a classification system for middle third clavicle fractures based on fracture configuration and displacement. Description of methods. Patients presenting primarily to a referral hospital with middle third clavicle fractures were identified using the PACS radiology system. The radiographs were reviewed to determine the fracture type, displacement, shortening and amount of comminution. The clinical notes of each patient were reviewed to determine the mechanism of injury, soft tissue status, neurovascular status and treatment rendered. A novel classification system was developed to describe the different fracture configurations seen in the group. The interobserver and intraobserver correlation of the classification system as well as the ability of the classification system to predict treatment were tested. Summary of results. Three hundred and three patients were included in the review, 223 males and 80 females. Middle third clavicle fractures were displaced in 69% of cases. Displaced fractures tend to have a significant amount of displacement and shortening in most cases with averages of 19.64mm (Std Dev. 6.901) and 19.15mm (Std Dev. 9.616) respectively. Acceptable interobserver and intraobserver correlation levels were shown for the proposed classification system. Conclusion. The epidemiology of middle third clavicle fractures found in the population studied differs substantially from first world populations. It underlines the high level of road traffic accidents and interpersonal violence seen in South Africa. Surgeons treating clavicle fractures are still divided on the indications for surgery with little correlation found between the fracture type and displacement on radiographs and the type of treatment rendered. The classification system provides guidelines to treating surgeons to the correct treatment modality. MULTIPLE DISCLOSURES

Aims

Systematic reviews of randomized controlled trials (RCTs) are the highest level of evidence used to inform patient care. However, it has been suggested that the quality of randomization in RCTs in orthopaedic surgery may be low. This study aims to describe the quality of randomization in trials included in systematic reviews in orthopaedic surgery.

Primary malignant bone tumours are a scarce entity with limited population-based data from developing countries. The aim of the study is to investigate the frequency and anatomical distribution of primary malignant bone tumours in a local South African population. This will be an epidemiological retrospective study. Data will be used of patients that were diagnosed with primary malignant bone tumours over a period of nine years spanning from 1 January 2014 to 31 December 2022. This data will be received from private and government laboratories. Data to be considered are type of primary malignant bone tumours diagnosed, incidence of primary malignant bone tumours over a period of nine years and the most common anatomical sites of primary malignant bone tumours. The rationale behind our study is to assess the frequency of different primary malignant bone tumours in another geographic area of South Africa and to compare these findings to local and international literature. With a projected increase in diagnosis of primary malignant bone tumours in developing countries it is important to have more available data about primary malignant bone tumours from these areas to have a better understanding of these conditions and to understand the impact of the burden they impose on healthcare systems so that management of these conditions can also be improved. Preliminary results show that 23.83% of primary malignant bone tumours occurred in the age group 0–24 years of age, 49.22% in the 25–59 age group and 26.95% in the 60+ age group. The most common tumour that occurred was chondrosarcoma (49.21%) followed by osteosarcoma (41.80%) then Ewing's sarcoma (4,69%) and lastly chordoma (4.30%). From the 256 samples that met the inclusion criteria the five most common anatomical sites were distal femur (63), proximal tibia (41), proximal humerus (38), pelvis (34) and proximal femur (20)

Aim. Gram negative bacteria (GNB) are emerging pathogens in chronic post-traumatic osteomyelitis. However, data on multi-drug (MDR) and extensively drug resistant (XDR) GNB are sparse. Methods. A multi-centre epidemiological study was performed in 10 countries by members of the ESGIAI (ESCMID Study Group on Implant Associated Infections). Osteosynthesis-associated osteomyelitis (OAO) of the lower extremities and MDR/XDR GNB were defined according to international guidelines. Data from 2000 to 2015 on demographics, clinical features, microbiology, surgical treatment and antimicrobial therapy were retrospectively analyzed. Cure was assessed after the end of treatment as the absence of any sign relevant to OAO. Factors associated with cure were evaluated by regression analysis. Results. A total of 53 infections of OAO of the lower extremities (hip, femur, tibia) were evaluated. Patients were female (n=32, 60.4%), with a mean age (SD) 57(3) years, history of trauma (83%), comorbidities (26.4%). The most frequent GNB were: E.coli (n=15), P.aeruginosa (n=14), Klebsiella spp (n=8), Enterobacter spp (n=8) and Acinetobacter spp (n=5). P.aeruginosa predominated the XDR group than the MDR one (n=6/10 vs n=8/43, p=0.01). Antibiotics were given mostly in combinations (64%) for a median duration of 117 days (SD:31.5). Carbapenems were the most frequently used agents (54.7%), followed by colistin (18.8%) and fluoroquinolones (15%). Surgical treatment included debridement with implant retention (n=22), implant explantation (n=22), new osteosynthesis (n=3), others(n=6). Only failure of the surgical treatment for OAO was associated with lack of cure [OR 8.924 (CI95%: 3.006–26.495), p<0.001] at the end of treatment, for a 12-month follow-up period. Patients' age, gender, comorbidities, history of trauma and surgery, clinical presentation of OAO, type of antimicrobial treatment (use of fluoroquinolones, carbapenems or colistin as monotherapy or in combination) as well as type of surgical intervention (explantation vs implant retention) were not found to significantly influence the patients' outcome. Overall, cure was assessed in 31 patients (58.5%). Death occurred in 7 patients, all older than 60, with failure of surgical treatment (p=0.016). These patients presented with many comorbidities (57%) and without difference in treatment outcome between XDR and MDR infection (p=0.114). Conclusion. Osteosynthesis-associated infections of the lower extremities caused by MDR/XDR GNB are a severe complication in orthopaedic surgery. The role of surgical treatment is independently associated with outcome regardless of the type of intervention (explantation or implant retention) and the type of antimicrobial treatment

Introduction. Epidemiologic studies indicate that isolated patellofemoral (PF) arthritis affects nearly 10% of the population over 40 years of age, with a predilection for females. A small percentage of patients with PF arthritis may require surgical intervention. Surgical options include non-arthroplasty procedures (arthroscopic debridement, tibial tubercle unloading procedures, cartilage restoration, and patellectomy), and patellofemoral or total knee arthroplasty (PFA or TKA). Historically, non-arthroplasty surgical treatment has provided inconsistent results, with short-term success rates of 60–70%, especially in patients with advanced arthritis. Although TKA provides reproducible results in patients with isolated PF arthritis, it may be undesirable for those interested in a more conservative, kinematic-preserving approach, particularly in younger patients, who may account for nearly 50% of patients undergoing surgery for PF arthritis. Due to these limitations, patellofemoral arthroplasty (PFA) has become utilised more frequently over the past two decades. Indications for PFA. The ideal candidate for PFA has isolated, non-inflammatory PF arthritis resulting in “anterior” pain and functional limitations. Pain should be retro- and/or peri-patellar and exacerbated by descending stairs/hills, sitting with the knee flexed, kneeling and standing from a seated position. There should be less pain when walking on level ground. Symptoms should be reproducible during physical examination with squatting and patellar inhibition testing. An abnormal Q-angle or J-sign indicate significant maltracking and/or dysplasia, particularly with a previous history of patellar dislocations. The presence of these findings may necessitate concomitant realignment surgery with PFA. Often, patients with PF arthritis will have significant quadriceps weakness, which should be treated with preoperative physical therapy to prevent prolonged postoperative pain and functional limitations. Tibiofemoral joint pain suggests additional pathology, which may not be amenable to PFA alone. Conclusion. PFA is effective for the treatment of arthritis localised to the PF compartment. Outcomes can be optimised with proper patient selection, meticulous surgical technique, and selection of an onlay-style implant that can be positioned perpendicular to the AP axis of the femur. Minimizing the risk of patellar instability by using onlay-design PFAs has enhanced mid- and long-term results, and leaves progressive tibiofemoral arthritis as the primary failure mechanism beyond 10–15 years

Few epidemiological studies from Asian countries have addressed this issue and reported that FAI is less prevalent in Asian population. The purpose of this study was to determine the prevalence of radiographic hip abnormalities associated with FAI in asymptomatic Korean volunteers. The authors hypothesized that the prevalence of FAI in Korean population would not be less than that in western population. Two hundred asymptomatic volunteers with no prior hip surgery or childhood hip problems underwent three-view plain radiography (pelvis anteroposterior (AP) view, Sugioka view, and 45° Dunn view) of both hips. Cam lesions were defined as the presence of the following signs on each views: pistol-grip deformity, osseous bump at the femoral head-neck junction, flattening of the femoral head-neck offset, or alpha angle >50°. Pincer lesions were determined by radiographic signs, including crossover sign, posterior wall deficient sign, or lateral center-edge (CE) angle >40°. Only positive cases agreed by both observers were defined as true FAI-related deformities. There were 146 male and 254 female hips, with a mean age of 34.7 years. On pelvis AP view, the prevalence of pistol grip deformity, bump, flattening, and alpha angle >50° was 1.3% (male 3.4%, female 0%), 0.8% (male 2.1%, female 0%), 0.8% (male 2.1%, female 0%), and 1.0% (male 2.7%, female 0%), respectively. On Sugioka view, the prevalence of bump, flattening, and alpha angle >50° was 9.8% (male 14.4%, female 7.1%), 13.5% (male 20.5%, female 9.4%), and 14.0% (male 26.7%, female 6.7%), respectively. On 45° Dunn view, the prevalence of bump, flattening, and alpha angle >50° was 8.0% (male 14.4%, female 4.3%), 17.5% (male 27.4%, female 11.8%), and 27.5% (male 44.5%, female 17.7%), respectively. The prevalence of cam lesion which was identified on at least one radiograph was 42.5% (male 62.3%, female 31.1%). The prevalence of cam lesion which was identified on ≥2 radiographs was 19.3% (male 30.8%, female 12.6%). The prevalence of cam type FAI (at least one cam lesion) was 2.0% (male 5.5%, female 0%) on pelvis AP view, 25.8% (male 37.0%, female 19.3%) on Sugioka view, and 35.8% (male 55.5%, female 24.4%) on 45° Dunn view. On pelvis AP view, the prevalence of crossover sign, posterior wall sign, and CE angle >40° was 20.0% (male 23.3%, female 18.1%), 20.8% (male 22.6%, female 19.7%), and 2.0% (male 2.7%, female 1.6%), respectively. The prevalence of pincer type of FAI (at least one pincer lesion) was 23.0% (male 27.4%, female 20.5%). In asymptomatic Korean volunteers, the prevalence of cam type FAI was low on AP pelvis radiographs, whereas the prevalence of cam type FAI on Sugioka and 45° Dunn view was found to be comparable to that previously reported in Western populations. The prevalence of pincer type FAI in asymptomatic Korean volunteers was also comparable that in Western populations and was similar in both gender. Considering the high prevalence of FAI morphologic features on plain radiographs in asymptomatic Korean populations, it is also important to determine whether FAI is a cause of hip pain when considering surgery in Asian patients

There has been an increase in the incidence of bone and joint tuberculosis (BJTB) in The Netherlands and we have carried out an epidemiological study in order to find an explanation for this increase. Data from 1993 to 2000 from The Netherlands Tuberculosis Register (NTR) were used. In 1993 there was a total of 52 patients with BJTB. This figure increased gradually to 80 in 1999 before decreasing to 61 in 2000. There was a total of 12 447 patients with tuberculosis; BJTB was found in 532, accounting for 4.3% of all cases and 10.6% of all extrapulmonary cases. Localisation in the spine occurred in 56%. Certain immigrants, in particular from Somalia, were more likely to have BJTB than other immigrants or the native Dutch population. Increased age and female gender were associated with BJTB. Only 15% of BJTB patients also suffered from pulmonary tuberculosis. The usual long delay in the diagnosis of BJTB may be shortened if physicians are more aware of tuberculosis

Epidemiologic studies project an increase of hip fractures worldwide. They are an important cause of morbidity and mortality in the elderly and represent an increasing burden on a country's health service. The aim of the study was to evaluate the mortality of hip fractures admitted to a regional hospital in Australia and calculate the relative risk ratio of morbidity variables on mortality. This retrospective review included all patients admitted from 2003 to 2008 to a regional Queensland hospital with a hip fracture. The relative risk ratio for the probability of death was calculated for the following variables: previous mobility (independent, home with help, nursing home), type of treatment (hemiarthroplasty, ORIF, DHS/Nail, total hip arthroplasty, conservative), ASA, comorbidities (dementia, hypertension, cardiac, respiratory, renal, previous hip fractures, diabetes), pre-operative haemoglobin, BUN ratio, length of stay, operative time, anaesthetic time and type (general, spinal) and, gender. A total of 211 patients (136 female, 75 male) with an average age of 79.1 years were admitted. Seventy-six patients died during the specified interval. The average 30 day mortality was 6.2% and the average time of survival was 318 days. The relative risk of death was above one for the following variables: female gender 1,16; nursing home 1,11; more than 1 comorbidity 1,38; more than 4 comorbidities 1,78; dementia 1,12; diabetes 1,3; hypertension 1,35, previous fractures 1,43; ASA 4 1,5; operating time more than 120 minutes 7,4; length of stay more than 20 days 2,16, BUN ratio>0.1 1,38 and BUN ration<0.04 1,78. This retrospective project identified a number of variables influencing mortality of hip fractures. These results demonstrate that the relative risk substantially increases with length of surgical time, length of hospital stay in excess of 20 days and more than four associated comorbidities

Low back pain in junior Australian Rules footballers has not been investigated, despite findings that adolescent back pain is a strong predictor for adult back pain. The aim of this study was to determine the prevalence, intensity, quality and frequency of low back pain in junior Australian Rules footballers. A cross-sectional survey of male non-elite junior (n = 60) and elite junior players (n = 102) was conducted along with a convenience sample of non-footballers (school children) (n = 100). Subjects completed a self-reported questionnaire on low back pain incorporating the Quadruple Visual Analogue Scale and McGill Pain Questionnaire (short form), along with additional questions adapted from an Australian epidemiological study. For current, average and best low back pain levels, elite junior players had higher pain levels (p < 0.001), with no difference noted between non-elite juniors and controls for average and best low back pain. For low back pain at worst, there were significant differences in the mean pain cores. The difference between elite juniors and non-elite juniors (p = 0.040) and between elite juniors and controls (p < 0.001) was significant, but not between non-elite juniors and controls. The chance of suffering low back pain increases from 45% for controls, through 55% for non-elite juniors to 66.7% for elite juniors. The chance that a pain sufferer experiences chronic pain is 16% for controls and 41% for non-elite junior and elite junior players. Elite junior players experienced low back pain more frequently (p = 0.002), with no difference in frequency noted between non-elite juniors and controls. Over 25% of elite junior and non-elite junior players reported that back pain impacted their performance some of the time or greater. This study demonstrated that when compared with non-elite junior players and non-footballers of a similar age, elite junior players experience back pain more severely and frequently and have higher prevalence and chronicity rates

INTRODUCTION:. Acetabular retroversion has been implicated as a risk factor for the development of early hip osteoarthritis. In clinical practice standard osseous signs such as the cross-over sign (COS) and the posterior wall sign (PWS) are widely used to establish the diagnosis of acetabular retroversion on plain radiographs. Despite standardized radiological evaluation protocols, an increased pelvic tilt can lead to a misdiagnosis of acetabular retroversion in AP radiographs and 2D MR or CT scans. Previous studies have shown that the elimination of observer bias using a standardized methodology based on 3D-CT models and the anterior pelvic plane (APP) for the assessment of COS and PWS results in greater diagnostic accuracy. Using this method a prevalence of 28% for COS and 24% for PWS has been found in a cohort of patients with symptoms indicative of FAI, however the prevalence of both signs in asymptomatic adults remains unknown. This study therefore sought to establish the prevalence of the COS and PWS in relation to the APP in an asymptomatic population using a reliable and accurate 3 D-CT based assessment. METHODS:. A large pool of consecutive CT scans of the pelvis undertaken in our department for conditions unrelated to disorders of the hip was available for analysis. Scans in subjects with a Harris hip score of less than 90 points were excluded leaving a sample of 100 asymptomatic subjects (200 hips) for this study. A previously established 3D analysis method designed to eliminate errors resulting from variations in the position and orientation of the pelvis during CT imaging was applied to determine in order to assess the prevalence of the COS and PWS in relation to the APP. Here, the acetabuli were defined as retroverted if either the COS, PWS or both were positive. RESULTS:. From the total of 200 hips a positive COS was identified in 24% (48/200) and a positive PWS was detected in 6.5% (13/200) relative to the APP using the CT data. A. In male adults a COS was observed in 25.4% (29/114) and a PWS in 10.5% (12/114). In female adults a COS were observed in 22.1% (19/86) and a PWS in 1.2% (1/86). DISCUSSION:. The high incidence of acetabular retroversion observed using an accurate 3D-CT based methodology shows that this anatomic configuration might not differ in frequency between asymptomatic individuals and patients with symptomatic FAI. Patients presenting with hip pain and evidence of FAI should therefore be subjected to strict diagnostic scrutiny, as the presence of a COS and/or PWS shows a poor correlation with the presence of symptomatic disease. In our collective of asymptomatic adults the COS showed a higher incidence than the PWS. Additionally a deficiency of the posterior acetabular wall was rare in asymptomatic adults compared to FAI patients. Therefore, the question whether an abnormal acetabular version does indeed lead to the development of osteoarthritis in all patients warrants further study. Although an association between osteoarthritis and femuro-acetabular impingement is believed to exist, long-term epidemiological studies are needed to establish the natural history of these anatomical configurations

Aims

The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway.

Aims

To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS).

Aims

This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google.

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital.

There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication.

Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.