Ilizarov fixators are reliant on tensioned fine wires for stability. The tension in the wires is generated using specific tensioning devices. Loss of wire tension over time may lead of loss a stability and complications. A series of in vitro experiments were undertaken to explore wire tensioner accuracy, the impact of fixation bolt torque and initial tension on loss of tension in ilizarov constructs under static and dynamic loads. Medical grade materials were applied to a synthetic bone analogue using surgical instruments in all experiments. Bolt torque was fixed at 6, 10 or 14 Nm using a torque limiting wrench. Wire tension was assessed using a strain measurement bridge. Wires were tensioned to 90, 110 and 130kg as measured by a commercial dynamometric tensioner. Static and dynamic testing was undertaken using an instron testing machine. Cyclical loads from 50–750N were applied for 5000 cycles.Introduction
Materials & Methods
Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions. This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements.Introduction
Materials & Methods
Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates. Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome.Introduction
Materials & Methods
To determine if force measured using a strain gauge in circular external fixation frames is different for 1) different simulated stages of bone healing, and for 2) fractures clinically deemed either united or un-united. In a laboratory study, 3 similar Ilizarov frame constructs were assembled using a Perspex bone analogue. Constructs were tested in 10 different clinical situations simulating different stages of bone healing including with the bone analogue intact, with 1,3 and 50mm gaps, and with 6 materials of varying stiffness's within the 50mm gap. A Bluetooth strain gauge was inserted across the simulated fracture focus, replacing one of the 4 threaded rods used to construct the frame. Constructs were loaded to 700N using an Instron testing machine and maximum force during loading was measured by the strain gauge. Testing was repeated with the strain gauge replacing each of the 4 threaded rods in turn, with measurements being repeated 3 times, across all 3 frame constructs for all 10 simulated clinical situations (n=360). Force measurements between the situations were compared using a Kruskal-Wallis test (KW) and a post-hoc Steel test was used for multiple comparison against control (intact bone model). Additionally, a pilot study has been initiated to assess clinical efficacy of the strain gauge measurement in patients with circular frames. The strain gauge replaced the anterior rod across the fracture focus for each patient. Patients were asked to step on a weighing scale with their affected limb, and maximum weight transfer through the limb and maximal force measured in the frame were recorded. This was repeated 3 times and a mean ratio of force to weight through affected limb was calculated for each patient. The clinical situation at each measurement was designated as united or un-united by one of the senior authors for analysis. Force measurements between the situations were compared using a Wilcoxon-Mann-Whitney test.Abstract
OBJECTIVES
METHODS
Multiple biochemical biomarkers have been previously investigated for the diagnosis, prognosis and response to treatment of articular cartilage damage, including osteoarthritis (OA). Synovial fluid (SF) biomarker measurement is a potential method to predict treatment response and effectiveness. However, the significance of different biomarkers and their correlation to clinical outcomes remains unclear. This systematic review evaluated current SF biomarkers used in investigation of cartilage degeneration or regeneration in the knee joint and correlated these biomarkers with clinical outcomes following cartilage repair or regeneration interventions. PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials, and Embase databases were searched. Studies evaluating SF biomarkers and clinical outcomes following cartilage repair intervention were included. Two researchers independently performed data extraction and QUADAS-2 analysis. Biomarker inclusion, change following intervention and correlation with clinical outcome was compared. 9 studies were included. Study heterogeneity precluded meta-analysis. There was significant variation in sampling and analysis. 33 biomarkers were evaluated in addition to microRNA and catabolic/anabolic ratios. Five studies reported on correlation of biomarkers with six biomarkers significantly correlated with clinical outcomes following intervention. However, correlation was only demonstrated in isolated studies. This review demonstrates significant difficulties in drawing conclusions regarding the importance of SF biomarkers based on the available literature. Improved standardisation for collection and analysis of SF samples is required. Future publications should also focus on clinical outcome scores and seek to correlate biomarkers with progression to further understand the significance of identified markers in a clinical context.
Routine radiographs in the follow-up of circular frames is commonplace, however the effect on clinical decision making is unclear. Previous work locally has suggested that >95% of radiographs, particularly at early time points, do not affect clinical management. This study was conducted to assess the impact of a transition to early remote follow-up on circular frame patients with limited radiographic assessment. Patients were identified from a prospective limb reconstruction database. Data were collected including the number of clinic appointments, type of clinic appointment, number of radiographs performed, and impact this had on clinical management. This was compared to our previous cohort of 85 patients undergoing standard follow-up.Introduction
Materials and Methods
Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame. Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system.Aims
Methods
Introduction of the National Hip fracture database, best practice tariff and NICE guidelines has brought uniformity of care to hip fracture patients & consequently improved outcomes. Low energy femoral shaft fractures of the elderly are not within these guidelines, but represent a similar though significantly smaller patient cohort. A retrospective review was performed at Huddersfield Royal Infirmary using theatre, coding & hip fracture databases. Data was filtered to include patients ≥75, excluding non-femoral injuries. Imaging & notes were then reviewed confirming femoral shaft fractures; excluding open, peri-prosthetic & high energy fractures. Between September 2008 and July 2016 24 patients were identified and split into two equal cohorts, before June 2011 NICE Guidelines and after. The groups were equal in terms of age (Mean: 85.25:84.67, P=0.) & sex (12 females Pre-NICE, 9 Post-Nice, P= 0.22). Our main outcome measures of length of stay were 31.89 days:26 days (p=0.38), time to surgery was 29.8hours: 28.4 hours (p=0.8) and 1-year survival rate conditional odds ratio of 1.48 (p=1.00). A secondary measure demonstrated a significantly higher proportion of post-NICE patients receiving surgery after midday 5/12:11/12 (P= 0.03). The infrequency of low energy femoral shaft fractures makes them difficult to study and production of an adequately powered study in a single centre impossible. The authors hope this work can inspire discussion and a coordinated multicentre approach to answer this question. These patients could easily be treated with the same level of enthusiasm as hip fractures.
To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results. Adult patients treated using an Ilizarov frame prior to soft tissue management were identified from our Ilizarov database. This data was supplemented by medical record review.Background
Methods
To compare quality of life during treatment in children and adolescents with tibial fracture treated with either a definitive cast or Ilizarov frame. A prospective, longitudinal cohort study was undertaken. Patients aged between 5 and 17 years with tibial fractures treated with a cast or Ilizarov frame were recruited. Health-related quality of life was measured during treatment using the Paediatric Quality of Life Inventory. Results were analysed based on time from injury. Statistical analysis was undertaken using a Kruksal-Wallis test.Background
Methods
To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates.Purpose
Method
The aim of this study was to report the clinical, functional
and radiological outcomes of children and adolescents with tibial
fractures treated using the Ilizarov method. Between 2013 and 2016 a total of 74 children with 75 tibial fractures
underwent treatment at our major trauma centre using an Ilizarov
frame. Demographic and clinical information from a prospective database
was supplemented by routine functional and psychological assessment
and a retrospective review of the notes and radiographs.Aims
Patients and Methods
With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre. Patients were identified via prospectively collected national and departmental databases. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long term outcomes.Background
Methods
Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation. Between September 2012 and January 2016, more than 120 patients with open tibial fractures were admitted to our unit. Patients were identified through prospective databases. Data collected included patient demographics, injury details, orthopaedic and plastic surgery procedures. Major complications were recorded. Paediatric cases were excluded and one patient was lost to follow up.Introduction
Methods
We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)
Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications. 142 patients with 143 fractures were identified, 40 (28%) were open, 94 (66%) were intra-articular, 85 (59%) were tertiary referrals. 32% were type 1, 28%, type 2 and 40% type 3 AO/OTA severity. 139 (97%) of the fractures united (2 non-unions, 1 amputation and 2 delayed unions who remain in frames), at a median of 165 days (range 104 to 429, IQR 136 to 201). 62% united by 6 months, 87% by 9 months and 94% by 1 year. Both non-unions have united with further treatment. Closed fractures united more rapidly than open (median 157 vs 185 days; p=0.003) and true Pilon (43C3) fractures took longer to unite other fractures (median 156 vs 190 days; p<0.001). 34% of patients encountered a problem, 12% an obstacle and 10% a complication. Of the complications, 6 (4%) were minor, 5 (3.5%) major not interfering with the goals of treatment and 4 (3%) major interfering with treatment goals (including the 2 patients with non-union and 1 who underwent amputation as well as 1 significant mal-union). This will increase to 4% if the 2 delayed unions fail to unite. Overall 56% reported good or excellent ankle scores at last report, 28% fair and 16% poor. Closed, extra-articular and non-43C3 fractures had better functional outcome scores than open, intra-articular and 43C3 fractures respectively.Introduction
Results
Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from March 2011 until Nov 2014. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient. The median time of treatment in the frame was 169 days (range 105 – 368 days). Patients underwent a median of 13 sets of plain radiographs; at least one intra operative exposure and 16 patients underwent CT scanning. The median total effective dose per patient from time of injury to discharge was 0.025 mSv (interquartile range 0.013 – 0.162 and minimum to maximum 0.01–0.53). CT scanning is the only variable shown to be an independent predictor of cumulative radiation dose on multivariate analysis, with a 13 fold increase in overall exposure.Methods:
Results:
Intramedullary infection in long bones represents
a complex clinical challenge, with an increasing incidence due to the
increasing use of intramedullary fixation. We report a prospective
case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator
(RIA) system, in association with antibiotic cement rods for the
treatment of lower limb long bone infections. A total of 24 such
patients, 16 men and eight women, with a mean age of 44.5 years
(17 to 75), 14 with femoral and 10 with tibial infection, were treated
in a staged manner over a period of 2.5 years in a single referral
centre. Of these, 21 patients had had previous surgery, usually
for fixation of a fracture (seven had sustained an open fracture
originally and one had undergone fasciotomies). According to the
Cierny–Mader classification system, 18 patients were classified
as type 1A, four as 3A (discharging sinus tract), one as type 4A
and one as type 1B. Cite this article:
Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario. Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported.Introduction
Materials and methods
The effect of head injury on systemic physiology, including bone healing is still a topic of vivid discussion. We aimed to investigate whether in patients with long bone fractures the presence of head injury is associated with excessive callus formation. Data on patients with head injury and femoral diaphyseal fracture admitted to our trauma unit between 1997- 2002 were collected and analysed. Patients with factors that could influence bone healing such as smoking, NSAIDs and hormonal disorders were excluded. The severity of head injury was quantified using GCS, AIS and CT scan reports. Patients matched for age, sex and ISS with femoral shaft fractures and no head injury formed the control group of the study. All the fractures were stabilised with reamed femoral nail. The quantification of fracture healing response was estimated by taking the radiological ratio of the largest diameter of callus formed into two planes and the adjacent normal diameter of femoral canal. The minimum follow-up of the patients was 12 months. In total 42 patients were studied, 17 with head injury and femoral fracture and 25 with an isolated femoral fracture, (control group). Both groups were comparable in terms of age, sex, ISS. The difference between the mean callus to diaphyseal ratio was statistically significant for both the AP and Lateral projections (AP – mean difference 0.462, 95% CI 0.312 to 0.602, p<0.0001, LAT – mean difference 0.289, 95% CI 0.142 to 0.436, p<0.001) with the head injured patients having more florid callus compared to the control group. This study supports the view that head injury leads to exuberant callus formation in patients with long bone fractures. The mechanisms of this response could be both central and local. Research is ongoing to elucidate the pathways involved in this biological phenomenon.
We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion.Conclusion/Significance
Guidelines on the care of the seriously injured have led to widespread changes in clinical practice. The ‘hub and spoke’ model of trauma care means increasing numbers of patients with complex problems are concentrated into regional centres. Though providing the highest standards of treatment, this has cost implications for the receiving unit, particularly given the Department of Health's move towards a ‘Payment by Results’ model of health provision. We undertook an economic evaluation of complex limb reconstruction within our tertiary referral unit. Patients referred to the complex trauma service were identified. Patients were assigned to either a ‘complicated’ or ‘straightforward’ group by two consultant surgeons, based on the nature of their treatment. 5 cases from each group were randomly selected for further analysis. Data pertaining to the direct healthcare costs for these patients was analysed. Costs per investigation/intervention were obtained relating to hospital stay, outpatient care, operative interventions and investigations. Overall 26 patients were referred to our complex trauma service from other units over 6 months. A mean of £8,375 (6,163) per patient was recouped using current Service Level Agreements. This amounts to a £26,587 deficit per patient, or £1,394,905 per year assuming current referral rates. Those planning a service treating complex trauma must allow for the considerable costs involved and make provisions to recoup this from the referring Primary Care Trust.
We aimed to quantify the health related quality of life in a series of patients suffering a variety of different tibial injuries. Patients with previous tibial injury, randomly selected from our trauma database, who successfully completed their entire course of treatment at our institution, were recalled for final assessment. Mean time to final follow-up was 37.4 months. Statistical analysis was performed using SPSS computer software. Overall, 130 patients were evaluated. There was no significant difference in the self-care dimension between the groups. Psychological problems were common in patients with IIIb and IIIc fractures, as well as amputees, with the highest incidence in those with IIIc fractures. Patients who had undergone amputation and those with IIIb open fractures reported problems with mobility significantly more frequently than those who had IIIc type injuries. However, this could be partially attributed to the significant difference in mean age between groups, with patients sustaining IIIc injuries being younger (31.9 vs 46.9). Patients with IIIb and IIIc type fractures reported significantly more problems with pain compared with those who had undergone amputation. Interestingly, patients who had undergone fasciotomy reported pain as frequently as amputees. Regarding the VAS, only patients with closed fractures reported significantly different scores from the mean of all the other groups. These data represent the health related quality of life of patients having suffered the full spectrum of tibial injury and should be considered when determining the treatment options for these patients.
Surgical options in the treatment of acute acromio-clavicular joint (Rockwood Type III and IV) dislocations are many and controversial. We evaluated our technique using TIGHTROPE connecting the base of the coracoid to the proximal fragment of the clavicle. Between March 2006 and December 2006, ten young and active adult patients with acute ACJ dislocations were treated with arthroscopically assisted ARTHREX TIGHTROPE fixation. The dislocation was reduced with traction and manual reduction with the patient in beach-chair position. The base of the coracoid was identified and isolated using a radiofrequency ablator placed through the anterior portal while visualizing through the lateral portal. An ACL guide was placed percutaneously supero-medial to the coracoid over the distal with the inferior end of the ACL guide placed through a posterior portal, approximated against the prepared base of the coracoid. The Arthrex Tightrope braided fibre-wire was introduced through the pre-drilled distal clavicle passed to the base of the coracoid and manually tensioned to achieve stable reduction. Standard rehabilitation protocol was utilised as for internal fixation of distal clavicular fractures. Patients were evaluated clinically using Constant Score, which ranged from 75 to 83 and radiologically at 6 weeks and 3 months. We present the functional results and the technical difficulties faced highlighting on the probable reasons for failure of fixation in two of our early patients who had revision fixations. We also describe the additional intra-operative techniques used in the last few patients to prevent such complications and achieve a secure reduction. We conclude that Arthroscopic Reconstruction of dislocated Acromio-Clavicular joint using TIGHTROPE may require additional repair of the ligaments in carefully selected patients to prevent failure of fixation.
A previously validated patient satisfaction questionnaire was completed by each patient. This investigates satisfaction with admission, environment, healthcare professionals, treatment, leaving hospital and overall care. Fisher exact test used to compare groups for significant differences in responses, significance was assumed at p<
0.05 level.
Patients were followed to discharge in outpatient clinics until bony union.
In total 17 patients (14 male, 3 female) mean age 29.4(14–53) open fractures 2 Mean AIS 3.2 (2–5) Fracture treatment was reamed femoral nail Bony union 10.5(6–22)weeks Group 2 ( Patients without head injury) Intotal 25 patients(19 male, 6 female) Mean age 32(16–81) Open fractures 2 Fracture treatment was reamed femoral nail Bony union 20.5(14–32)weeks Group 3 ( Patients without head injury) In total 24 patients(18 male, 6 female) Mean age 47(17–83) Open fractures 2 Fracture treatment was unreamed femoral nail Bony union 26.9 (21–32) weeks
For femoral shaft fracture, damage control orthopaedics entails primary external fixation and subsequent conversion to an intramedullary device (IMN). Sub-clinical contamination of external fixator pin sites is common and it is argued that such an approach risks subsequent local infective complications. We aimed to determine the rate of wound infection following DCO procedures and primary IMN for femoral fracture stabilisation. Retrospective analysis of a prospectively assembled adult patient database was carried out. Inclusion criteria were femoral #, New Injury Severity Score (NISS) above 20 and survival more than 2 weeks. Two groups, damage control (DCO) and early total care (ETC) (Primary Nail), were formed. Contamination was positive culture from the wound or fixator pin-sites without clinical infection. Superficial infection was a combination of positive bacterial swabs and local or systemic signs of infection. Deep infection was any case requiring surgical intervention with a sub-group requiring removal of femoral metal work (ROMW) also defined. 173 patients met the criteria for inclusion, with 192 fractures (19 bilateral). The mean follow up was 19 months. Patients in the damage control group were more severely injured than those undergoing primary intramedullary nailing (NISS 36 vs 25, p 0.001). There were also more severe (Grade 3 A,B or C) local soft tissue injuries in this group (p 0.05). 98 of the 111 DCO patients underwent subsequent IMN. Others either died without conversion being appropriate, or it was elected to complete treatment with external fixation. The mean time of exchange an ex/fix to a nail was 14.1 days. Though contamination rates were higher in the DCO group (12.6% vs 3.7%, p 0.05), there was no excess of infective complications (11.1% vs 10.8%). Contamination increased significantly in patients who underwent conversion to IMN after 14 days. Grade 3 open injury was significantly associated with infection irrespective of treatment. This study demonstrates that infection rates following DCO for femoral fractures are not significantly different to those observed following primary intramedullary nailing. Whilst the overall risk of deep infection in the DCO group did not show any correlation with the timing of converting the external fixator to a nail, the risk of contamination was higher in patients where the exchange nailing was performed after a period of 2 weeks.
The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p <
0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.
We report a retrospective study over five years to determine the incidence of infection and nonunion after intramedullary nailing in fractures of 214 long bones; 122 femoral, 75 tibial and 17 humeral. The indications for nailing were trauma (n = 161), pathological fracture (n = 30) and nonunion (n = 23). There were 30 open fractures. The overall rates of deep infection and nonunion were 3.8% and 14.2%, respectively. Using multiple logistic regression analysis, we determined the relationships between deep infection and nonunion and the pre- and peri-operative factors of age, ASA score, indication for nailing, the use of reaming, the use of antibiotics, whether the fracture was open and the operating time. Open fractures were found to be significantly associated with deep infection. The length of the operation may also affect the outcome. Opening of the fracture at the time of surgery and the ASA score were found to be significantly associated with the development of nonunion after intramedullary nailing. We have compared our findings with previously published data from large teaching hospital units.