Aims. The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip. Patients and Methods. Patients who underwent surgery for a fracture of the hip between 2005 and 2013 were identified from the NSQIP database and the percentage of missing data was noted for demographics, comorbidities and laboratory values. These variables were tested for association with ‘any adverse event’ using multivariate regressions based on common ways of handling missing data. Results. A total of 26 066 patients were identified. The rate of missing data was up to 77.9% for many variables. Multivariate regressions comparing three methods of handling missing data found different risk factors for postoperative adverse events. Only seven of 35 identified risk factors (20%) were common to all three analyses. Conclusion. Missing data is an important issue in national database studies that researchers must consider when evaluating such investigations. Cite this article: Bone Joint J 2018;100-B:226–32

Aims. While use of large national clinical databases for orthopaedic trauma research has increased dramatically, there has been little study of the differences in populations contained therein. In this study we aimed to compare populations of patients with femoral shaft fractures across three commonly used national databases, specifically with regard to age and comorbidities. Patients and Methods. Patients were identified in the Nationwide Inpatient Sample (NIS), National Surgical Quality Improvement Program (NSQIP) and National Trauma Data Bank (NTDB). . Results. The distributions of age and Charleston comorbidity index (CCI) reflected a predominantly older population with more comorbidities in NSQIP (mean age 71.5; . sd. 15.6), mean CCI 4.9; . sd. 1.9) than in the NTDB (mean age 45.2; . sd. 21.4), mean CCI = 2.1; . sd. 2.0). Bimodal distributions in the NIS population showed a more mixed population (mean age 56.9; . sd.  24.9), mean CCI 3.2; . sd. 2.3). Differences in age and CCI were all statistically significant (p <  0.001). . Conclusion. While these databases have been commonly used for orthopaedic trauma research, differences in the populations they represent are not always readily apparent. Care must be taken to understand fully these differences before performing or evaluating database research, as the outcomes they detail can only be analysed in context. Take home message: Researchers and those evaluating research should be aware that orthopaedic trauma populations contained in commonly studied national databases may differ substantially based on sampling methods and inclusion criteria. Cite this article: Bone Joint J 2016;98-B:425–32

Aims. We present an audit comparing our level I major trauma centre’s data for a cohort of patients with hip fractures in the National Hip Fracture Database (NHFD) with locally held data on these patients. Patients and Methods. A total of 2036 records for episodes between July 2009 and June 2014 were reviewed. . Results. The demographics of nine patients were recorded incorrectly. The rate of incorrect data in operation codes was most significant with overall accuracy of 0.637 (95% CI 0.615 to 0.658). The sensitivity of NHFD coding ranged from 0.250 to 1.000 and the specificity 0.879 to 0.999. The recording of cementation had a sensitivity of 0.932 and specificity of 0.713. The recording of total hip arthroplasty had a sensitivity of 0.739 and specificity of 0.983. The overall accuracy of mortality data was 0.942 (95% CI 0.931 to 0.952), with sensitivity of 0.967 and specificity of 0.419. Conclusion. This paper highlights the need for local audit of the integrity of data uploaded to the NHFD. Cite this article: Bone Joint J 2016;98-B:1406–9

The aim of this study was to compare the operating time, length of stay (LOS), adverse events and rate of re-admission for elderly patients with a fracture of the hip treated using either general or spinal anaesthesia. Patients aged ≥ 70 years who underwent surgery for a fracture of the hip between 2010 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of the 9842 patients who met the inclusion criteria, 7253 (73.7%) were treated with general anaesthesia and 2589 (26.3%) with spinal anaesthesia. On propensity-adjusted multivariate analysis, general anaesthesia was associated with slightly increased operating time (+5 minutes, 95% confidence interval (CI) +4 to +6, p < 0.001) and post-operative time in the operating room (+5 minutes, 95% CI +2 to +8, p < 0.001) compared with spinal anaesthesia. General anaesthesia was associated with a shorter LOS (hazard ratio (HR) 1.28, 95% CI 1.22 to 1.34, p < 0.001). Any adverse event (odds ratio (OR) 1.21, 95% CI 1.10 to 1.32, p < 0.001), thromboembolic events (OR 1.90, 95% CI 1.24 to 2.89, p = 0.003), any minor adverse event (OR 1.19, 95% CI 1.09 to 1.32, p < 0.001), and blood transfusion (OR 1.34, 95% CI 1.22 to 1.49, p < 0.001) were associated with general anaesthesia. General anaesthesia was associated with decreased rates of urinary tract infection (OR 0.73, 95% CI 0.62 to 0.87, p < 0.001). There was no clear overall advantage of one type of anaesthesia over the other, and surgeons should be aware of the specific risks and benefits associated with each type. Cite this article: Bone Joint J 2015; 97-B:689–95

Aims. Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. Methods. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. Results. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). Conclusion. We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets. Cite this article: Bone Joint J 2024;106-B(9):994–999

Aims. The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery. Methods. A retrospective cohort study was conducted in Japan using a nationwide multicentre database from April 2010 to March 2018, including 572,181 patients who had received hip fracture surgery. Propensity score matching was performed to compare patients who received additional weekend rehabilitation at the weekend in addition to rehabilitation on weekdays after the surgery (plus-weekends group), as well as those who did not receive additional rehabilitation at the weekend but did receive weekday rehabilitation (weekdays-only group). After the propensity score matching of 259,168 cases, in-hospital mortality as the primary outcome and systemic and surgical complications as the secondary outcomes were compared between the two groups. Results. The plus-weekends group was significantly associated with lower in-hospital mortality rates compared with the weekdays-only group (hazard ratio 0.86; 95% confidence interval 0.8 to 0.92; p < 0.001). Systemic complications such as acute coronary syndrome, heart failure, renal failure, and sepsis were significantly lower in the plus-weekends group, whereas urinary tract infection (UTI) and surgical complications such as surgical site infection and haematoma were significantly higher in the plus-weekends group. Conclusion. Additional weekend rehabilitation was significantly associated with lower in-hospital mortality, as well as acute coronary syndrome, heart failure, renal failure, and sepsis, but was also significantly associated with a higher risk of UTI and surgical complications. This result can facilitate the effective use of the limited rehabilitation resources at the weekend and improve the clinical awareness of specific complications. To establish more robust causal associations between additional rehabilitation over the weekend and clinical outcomes, further prospective studies or randomized controlled trials with larger sample sizes are warranted. Cite this article: Bone Joint J 2023;105-B(8):872–879

Aims. The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods. This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results. We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion. The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications. Cite this article: Bone Joint J 2024;106-B(8):849–857

Aims. This study aimed to describe practice variation in the use of total hip arthroplasty (THA) for older patients with femoral neck fracture and to determine the association between patient, surgeon, and institution factors and treatment with THA. Methods. We performed a cross-sectional analysis of 49,597 patients aged 60 years and older from Ontario, Canada, who underwent hemiarthroplasty or THA for femoral neck fracture between 2002 and 2017. This population-based study used routinely collected healthcare databases linked through ICES (formerly known as the Institute for Clinical Evaluative Sciences). Multilevel logistic regression modelling was used to quantify the association between patient, surgeon, and institution-level variables and whether patients were treated with THA. Variance partition coefficient and median odds ratios were used to estimate the variation attributable to higher-level variables and the magnitude of effect of higher-level variables, respectively. Results. Over the study period, 9.4% of patients (n = 4,638) were treated with THA. Patient factors associated with higher likelihood of treatment by THA included: younger age, male sex, and diagnosis with rheumatoid arthritis. Long-term care residence, use of home care services prior to hip fracture, diagnosis of dementia, higher comorbidity burden, and the most marginalized group were negatively associated with treatment by THA. Treating surgeon and institution accounted for 54.2% and 17.8% of the total variation in treatment with THA, respectively. Surgeon volume of THA procedures in the 365 days prior to surgery was the strongest higher-level predictor of treatment with THA. Specific treating surgeons and institutions still accounted for significant proportions of the variability in treatment with THA (40.3% and 19.5% of total observed variation, respectively) after controlling for available patient, surgeon, and institution-level variables. Conclusion. The strongest predictors for treatment of patients with femoral neck fracture with THA were patient age, treating surgeon, and treating institution. This practice variation highlights differential access to care for patients. Cite this article: Bone Joint J 2023;105-B(2):180–189

Aims. The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty. Methods. This nationwide, retrospective cohort study used data from the Japanese Diagnosis Procedure Combination database. We included older patients (aged ≥ 60 years) who underwent THA or hemiarthroplasty after a femoral neck fracture, between July 2010 and March 2022. A total of 165,123 patients were included. The THA group was younger (mean age 72.6 (SD 8.0) vs 80.7 years (SD 8.1)) and had fewer comorbidities than the hemiarthroplasty group. Patients with dementia or malignancy were excluded because they seldom undergo THA. The primary outcome measures were mortality and complications while in hospital, and secondary outcomes were readmission and reoperation within one and two years after discharge, and the costs of hospitalization. We conducted an instrumental variable analysis (IVA) using differential distance as a variable. Results. The IVA analysis showed that the THA group had a significantly higher rate of complications while in hospital (risk difference 6.3% (95% CI 2.0 to 10.6); p = 0.004) than the hemiarthroplasty group, but there was no significant difference in the rate of mortality while in hospital (risk difference 0.3% (95% CI -1.7 to 2.2); p = 0.774). There was no significant difference in the rate of readmission (within one year: risk difference 1.3% (95% CI -1.9 to 4.5); p = 0.443; within two years: risk difference 0.1% (95% CI -3.2 to 3.4); p = 0.950) and reoperation (within one year: risk difference 0.3% (95% CI -0.6 to 1.1); p = 0.557; within two years: risk difference 0.1% (95% CI -0.4 to 0.7); p = 0.632) after discharge. The costs of hospitalization were significantly higher in the THA group than in the hemiarthroplasty group (difference $2,634 (95% CI $2,496 to $2,772); p < 0.001). Conclusion. Among older patients undergoing surgery for a femoral neck fracture, the risk of early complications was higher after THA than after hemiarthroplasty. Our findings should aid in clinical decision-making in these patients. Cite this article: Bone Joint J 2024;106-B(9):986–993

Aims. To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome. Methods. This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients’ odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates. Results. A total of 563,640 patients were included between 1 April 2011 and 1 October 2020. Of these, 476,469 (85%) had a coded ethnicity for analysis. Non-white patients tended to be younger (mean 81.2 vs 83.0 years), and were more commonly male (34.9% vs 28.5%; p < 0.001). They were less likely to be admitted from institutional care (12.9% vs 21.8%; p < 0.001), to have normal cognition (53.3% vs 62.0%; p < 0.001), and to be free of comorbidities (22.0% vs 26.8%; p < 0.001), but were more likely to be from the most deprived areas (29.4% vs 17.3%; p < 0.001). Non-white patients were more likely to experience delay to surgery for medical reasons (14.8% vs 12.7%; p < 0.001), more likely to be treated with an intramedullary nail or a sliding hip screw (52.5% vs 45.1%; p < 0.001), and less likely to be mobilized by the day after surgery (74.3% vs 79.0%; p < 0.001). Mortality was higher among non-white inpatients (9.2% vs 8.4% for white), but was lower at one year after hip fracture (26.6% vs 30.3%). Conclusion. Our study identified serious problems with the quality of NHS ethnicity data. Despite this, we have shown that there is complex variation in case-mix and hip fracture morphology between ethnic groups. We have also identified variations in care received between ethnic groups, and that disparities in healthcare may contribute to poorer outcome. Inpatient mortality is higher in non-white patients, although this finding reverses after discharge, and one-year mortality is lower. Patients from ethnic minority backgrounds experience disparities in healthcare, however at one year postoperatively non-white patients have a statistically significant lower mortality after controlling for relevant clinical covariates. Cite this article: Bone Joint J 2024;106-B(10):1182–1189

Aims. There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures. Methods. A systematic review of seven databases was performed from the dates of their inception until the end of March 2021 to identify eligible RCTs. Reference lists of the included studies were screened. No language restrictions were applied. The primary outcome was the patient-reported outcome measure of wrist function at 12 months after injury. A meta-analysis was performed for function, pain, range of motion, grip strength, and union. Complications were reported narratively. Results. Seven RCTs were included. There was no significant difference in function between the groups at 12 months (Hedges’ g 0.15 (95% confidence interval -0.02 to 0.32); p = 0.082). The complication rate was higher in the operative group and involved more serious complications. Conclusion. We found no difference in functional outcome at 12 months for fractures of the waist of the scaphoid with ≤ 2 mm displacement treated operatively or nonoperatively. The complication rate was higher with operative treatment. Cite this article: Bone Joint J 2022;104-B(8):953–962

Aims. Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. Methods. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Results. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. Conclusion. COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival. Cite this article: Bone Joint J 2022;104-B(10):1156–1167

Aims. The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures. Methods. This was a retrospective analysis of publicly available audit data obtained from the National Hip Fracture Database (NHFD) 2018 benchmark summary and Facilities Survey. Data extraction was performed using a dedicated proforma to identify relevant hospital-level care process and outcome variables for inclusion. The primary outcome measure was adjusted 30-day mortality rate. A random forest-based multivariate imputation by chained equation (MICE) algorithm was used for missing value imputation. Univariable analysis for each hospital level factor was performed using a combination of Tobit regression, Siegal non-parametric linear regression, and Mann-Whitney U test analyses, dependent on the data type. In all analyses, a p-value < 0.05 denoted statistical significance. Results. Analyses included 176 hospitals, with a median of 366 hip fracture cases per year (interquartile range (IQR) 280 to 457). Aggregated data from 66,578 patients were included. The only identified hospital-level variable associated with the primary outcome of 30-day mortality was hip fracture trial involvement (no trial involvement: median 6.3%; trial involvement: median 5.7%; p = 0.039). Significant key associations were also identified between prompt surgery and presence of dedicated hip fracture sessions; reduced acute length of stay and both a higher number of hip fracture cases per year and more dedicated hip fracture operating lists; Best Practice Tariff attainment and greater number of hip fracture cases per year, more dedicated hip fracture operating lists, presence of a dedicated hip fracture ward, and hip fracture trial involvement. Conclusion. Exploratory analyses have identified that improved outcomes in hip fracture may be associated with hospital-level service characteristics, such as hip fracture research trial involvement, larger hip fracture volumes, and the use of theatre lists dedicated to hip fracture surgery. Further research using patient level data is warranted to corroborate these findings. Cite this article: Bone Joint J 2021;103-B(10):1627–1632

Aims. The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery. Methods. Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability. Results. A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia. Conclusion. Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article: Bone Joint J 2021;103-B(7):1317–1324

Aims. Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Methods. Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Results. Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Conclusion. Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

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Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Aims. The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis. Methods. Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed. Results. A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001). Conclusion. This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483

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The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

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The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.