Introduction

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.

Introduction

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.

Introduction

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.

Abstract

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.

Introduction

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.

Aims

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.

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.

Background

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.

Background

To compare quality of life during treatment in children and adolescents with tibial fracture treated with either a definitive cast or Ilizarov frame.

Purpose

To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

Aims

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.

Background

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.

Introduction

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.

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)

Introduction

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.

Methods:

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.

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. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

Introduction

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.

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).

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.

Purpose of Study: This study was done to assess the efficacy of EQ5D (EuroQol), a simple quality of life (QOL) score. The study was designed to test the feasibility and reliability of using this simple QOL score alongside Constant score following arthroscopic shoulder surgery. Though Constant score gives a shoulder related outcome it does not provide a patient perspective of outcome in relation to their quality of life.

Methodology: A prospective cohort study of 100 consecutive patients listed for arthroscopic shoulder surgery between May and December 2005 were recruited. Assessments were undertaken both preoperatively and at 6 months post operatively. EuroQol is a simple 5 question self administered questionnaire and the Constant score was recorded by the treating physician who was blinded to the result of the EuroQol. Data was assessed for normality and non parametric tests were used. Statistical significance was assumed at the p< 0.05 level.

Results: The median age of 54 years (32 to 79). 60% were male. The median pre operative EuroQol score was 0.26 with a median post operative score of 0.71. Preoperatively, the median constant score was 31.0 with a postoperative score of 72.0 The difference between pre and post operative scores in both the EuroQol and Constant scores was shown to be statistically significant (p< 0.0001 in each group). In the 200 paired observations the two scores were also shown to be closely correlated RS statistic 0.71 (p< 0.0001).

Conclusion: EQ5D is easily completed by the patient by a self administered questionnaire and reflects the quality of life improvement attained after shoulder surgery. It is very easy to use compared to other available QOL scores like SF12, SF36. We recommend its routine usage along with Constant Shoulder score as there is a strong positive correlation.

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.

Introduction: Increasing numbers of patients are being treated outside traditional NHS hospitals as part of GSup (General supplemental funding) projects and other initiatives to reduce waiting lists. Concerns regarding these arrangements include case mix at NHS hospitals, quality of clinical care and patient satisfaction.

Null Hypothesis: There is no difference between overall patient satisfaction following treatment within the NHS, as part of GSup or as an independent private patient.

Methods: Patients undergoing total hip arthroplasty by a single consultant were contacted 6 to 18 months postop. 3 groups were formed; those treated in the local NHS hospital, patients treated as part of GSup and private patients independently financed.

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.

Results: 144 of 202 patients responded. Though generally high overall levels of satisfaction were reported, areas of concern were identified, particularly regarding cleanliness of hospital, the availability of nursing staff, maintenance of patient confidentiality and communication with patients. In all cases the GSup patients reported significantly higher levels of satisfaction compared with the NHS patients. 12% of NHS patients felt their overall care fell below “very good” compared with 0% of the GSup patients (p< 0.05).

Discussion: Significant differences are identified between NHS and GSup patient satisfaction regarding hospital environment, healthcare professionals and overall standards of care. There were few differences between GSup and private patients treated in the same environment but where they did occur they were universally more positive for the GSup patients.

Conclusions: Concerns that GSup patients may be less satisfied with their care appear unfounded; in general they were better satisfied than NHS patients.

Hypothesis: In severely the injured, there has been a move away from early total care to staged physiological and anatomic reconstruction, damage control orthopaedics (DCO). This seeks to limit the magnitude of the second hit insult resulting from operative treatment after trauma, deferring complex reconstructive work until a later stage. For femoral shaft fracture, this entails initial external fixation, to provide early skeletal stabilisation, and subsequent conversion to an intramedullary nail (IMN).

Materials and Methods: Patients with femoral shaft fracture, who underwent primary IMN or DCO between 1996 and 2002 were identified from our database. Those with New Injury Severity Score (NISS) < 20 were excluded. The systemic inflammatory response (SIRS) and Marshall multi-organ failure scores (MMOFS) were calculated every 12h for 4 days. These systems have been previously correlated with outcome and complications in critical care.

Results: 174 patients were included. The mean SIRS score was higher at each time period post operatively in the IMN group (p < 0.01). The MMOFS was slightly higher at each point in the DCO group, (only sig. at 48h). There was a higher incidence of pneumonia and mortality (significant p < 0.02), ARDS and MOF (both n.s.) in the DCO group, this being attributable to the higher incidence of head and thoracic injury (AIS severity 2 or more). The mean peak post-operative SIRS score was significantly higher in the IMN group than in the DCO group, both at primary procedure and conversion, as was the time with SIRS score above 1. The pre-op and peak post-op SIRS score correlated with the peak post op MMOFS score (p 0.0002). The conversion pre-op SIRS score correlated with post-operative peak SIRS score and MMOFS score (p 0.0001). On average, a significant rise in the MMOFS score did not occur following the conversion procedure.

Conclusion: It would appear that despite having significantly more severe injuries, patients in the DCO group had a smaller, shorter postoperative systemic inflammatory response and suffered only slightly more pronounced organ failure than the IMN group. They did suffer more complications, but this was only significant for pneumonia. DCO patients undergoing conversion whilst their SIRS score was raised suffered the most pronounced subsequent inflammatory response and rise in organ failure score.

Objectives The objective of this study was to investigate accelerated bone healing in patients with femoral shaft fractures.

Methods Data on patients with diaphyseal femoral fractures admitted to our trauma unit between 1997 and 2002 was collected and analysed. Patients were categorised into three groups by the presence or absence of head injury, and the reamed or undreamed nailing technique used. Severity of head injury was quantified using abbreviated injury score (AIS) and Glasgow Coma Scale (GCS). Time to bony union was assessed from serial of x-rays and clinical examination.

Patients were followed to discharge in outpatient clinics until bony union.

Results Group 1 ( Patients with head injury)

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

Conclusion This study supports rapid bone union in the presence of head injury. Further research is indicated to provide a definate answer, specially mesenchymal cell and their control pathways which could allow further development of their potential therapeutic uses.

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.

Background /Methods: Abbreviated Injury Scale based systems; the ISS, NISS, and AISmax, are used to assess trauma patients. The merits of each in predicting outcome are controversial. A large prospective database was used to assess their predictive capacity using receiver operator characteristic curves.

Results: 13,301 adult patients met the inclusion criteria. All systems were significant outcome predictors for sepsis, multiple organ failure (MOF), length of hospital stay, length of ICU admission and mortality (p 0.0001). NISS was a significantly better predictor than the ISS for mortality (p 0.0001). NISS was equivalent to the AISmax for mortality prediction and superior in patients with orthopaedic injuries. NISS was significantly better for sepsis, MOF, ICU stay and total hospital stay (p 0.0001). Analysis of the ROC curves revealed that the traditional ISS cut-offs for severity of 16, 25 and 50 should be increased to 20, 30 and 55 to provide patients with equivalent outcome.

Conclusions: NISS is superior or equivalent to the ISS and AISmax for prediction of all investigated outcomes in a population of blunt trauma patients. As NISS is easier to calculate, its use is recommended to stratify patients for clinical and research purposes.

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.