Trauma

Treating the whole patient with a distal radial fracture

Fixed angle devices for intracapsular fractures?

Further development of pre-operative planning

All good surgeons plan pre-operatively, albeit with varying degrees of formality. Planning is as essential in the unusual - such as complex pelvic and acetabular fractures - as it is in the routine, for example, hip arthroplasty. Planning in arthroplasty is a fairly straightforward affair from a software perspective, although how essential it is can be a little controversial; every surgeon would want a relatively current pre-operative radiograph at least, whereas some would require a CT scan and complex computer planning or custom jigs. Trauma has always been a little different, and with many ways to achieve even the simplest of fixations, planning at some level is a necessity. Nevertheless, the use of planning software has not exactly taken off, partly due to issues with the lack of a suitable planning system. On a day-to-day basis in the operating room there are a range of different approaches, with some surgeons still tracing out the fracture and drawing over the planned fixation using tracing paper and templates, while others complete a similar exercise in their minds only. These authors from Shanghai (China) describe their use of a 3D planning technique to describe the fracture, manoeuvre the fracture fragments and plan the fixation and approach.³ The novelty of the approach is the ability of the software to perform automated segmentation, allowing potentially for a more efficient, computerised planning experience. The authors report the use of this software in six patients with acetabular fractures. The software allows for an automated 3D reduction and planning of virtual fixation. Although the planning exercise required nearly 40 minutes per patient, the authors apparently reported high levels of satisfaction. Clearly still an involved process, the use of auto-segmentation is a massive step forward for the computer planners among us. It may be that this technique will assist some surgeons, but for most of us here at 360 we would regard this as more of a training or interest tool than a useful clinical device in its current form.

Reverse arthroplasty for post-traumatic arthrosis of the humerus

Alendronate and atypical femoral fracture

Tranexamic acid in extracapsular hip surgery

Fixing the back in APC ring injuries improves outcomes

The use of sacroiliac (SI) screws to improve stability in pelvic ring injuries has become almost routine in many centres, while in others — due to the risks of nerve root injury and the relative difficulty of the technique — they are considered an ‘optional extra’ in the less severe injuries. These authors in Nashville, Tennessee (USA) evaluated the requirement for SI screws in moderate anteroposterior compression (APC) pelvic injuries.⁷ The investigators retrospectively report the outcomes of their series of 134 patients, all presenting with anteroposterior compression type-2 (APC-2) pelvic ring injuries. Individual patients were treated with either an anterior symphyseal plate or a symphyseal plate in combination with posterior stabilisation in the form of SI screws. Ninety-two patients (69%) underwent combined anterior and posterior fixation, and 42 patients (31%) were given anterior fixation alone. Anterior plate fixation failed in five patients (5%) in the combined fixation group and in 17 patients (40%) in the anterior-only group. Malunion was identified in one patient (1%) in the combined group and in 15 (36%) in the anterior-only cohort (p < 0.0001). As was perhaps already known in many centres, the authors concluded that supplemental posterior screw for fixation of APC-2 pelvic ring injuries is almost essential and significantly decreases the rate of anterior plate failure and malunion compared with the use of an anterior plate alone. However, the authors note that the potential for selection and detection bias introduced by their retrospective study design limited the strength of this conclusion. We would perhaps venture that it seems more likely the bias would be the other way around. In selected series, surgeons are more likely to provide supplementary fixation to those injuries they feel are more likely to be unstable, and, as such, this conclusion is potentially strengthened by the inherent biases in the study design.

Acetabular fractures

A pair of simple papers shed some light on two different and as yet unresolved aspects of acetabular surgery. The first concerns the outcomes of older patients undergoing open reductions. With widely differing approaches to the older patient with an acetabular fracture, some centres advocate synchronous fixation and arthroplasty, others conservative management and arthroplasty, with the final approach of ‘fix first’ the focus of the current research study. The authors from Cleveland, Ohio (USA)⁸ retrospectively reviewed 193 patients over the age of 60, all of whom presented with acute acetabular fractures to a single centre and were managed with either acute open reduction or conservative management. Overall, 22% developed early complications, with a trend towards a higher rate in patients treated surgically (27% compared with 16%, p = 0.057). Following open reduction internal fixation (ORIF), post-traumatic arthrosis and conversion to total hip arthroplasty occurred in 18% and 14% respectively, compared with 3.8% of patients who had non-operative care. Clearly there are some significant selection biases here, however, it serves to underline the complication rates of conservative treatment of acetabular fractures in the elderly, which were higher than one might expect, and the not insignificant chances of subsequent conversion to a total hip arthroplasty. The second series from Cincinnati, Ohio (USA)⁹ addresses the question, what is the effect of delay on quality of surgery in acetabular fractures? The authors report 650 patients, all treated surgically and included in this retrospective series. The authors set out to correlate the quality of fracture reduction to time interval from injury to ORIF. In their series, 85% of patients were classified as achieving an anatomic reduction. In the 11% of cases in which imperfect or poor reductions were achieved, these patients waited longer for their surgery, with a median of 4.5 days compared with three days for the anatomic group. Earlier intervention improves the probability of achieving an anatomic reduction with an odds ratio of 0.12 per additional day waiting for surgery.

A unified theory of bone healing and nonunion

We would finally recommend to our readers a thought-provoking article from Nottingham (UK) which presents a unified clinical theory that links established facts about the physiology of bone and homeostasis¹⁰ with those involved in the healing of fractures and the development of nonunion.