Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

Aims

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

Aims

Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise.

Aims

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.

Aims

The aim of this study was to report the outcome following primary fixation or a staged protocol for type C fractures of the tibial plafond.

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer.

The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis.

Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score.

Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437).

Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable.

Cite this article: Bone Joint J 2015;97-B:532–8.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

This brief annotation summarises the particular contributions made by the annual Edinburgh International Trauma Symposium in various areas of research into aspects of orthopaedic trauma and the management of acutely injured patients, during the 25 years since its establishment.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

The stress response to trauma is the summation of the physiological response to the injury (the ‘first hit’) and by the response to any on-going physiological disturbance or subsequent trauma surgery (the ‘second hit’).

Our animal model was developed in order to allow the study of each of these components of the stress response to major trauma. High-energy, comminuted fracture of the long bones and severe soft-tissue injuries in this model resulted in a significant tropotropic (depressor) cardiovascular response, transcardiac embolism of medullary contents and activation of the coagulation system. Subsequent stabilisation of the fractures using intramedullary nails did not significantly exacerbate any of these responses.

The identification of high-risk factors in patients with fractures of the pelvis at the time of presentation would facilitate investigation and management. In a series of 174 consecutive patients with unstable fractures of the pelvic ring, clinical data were used to calculate the injury severity score (ISS), the triage-revised trauma score (T-RTS), and the Glasgow coma scale (GCS). The morphology of the fracture was classified according to the AO system and that of Burgess et al. The data were analysed using univariate and multivariate methods in order to determine which presenting features were identified with high risk.

Univariate analysis showed an association between mortality and an ISS over 25, a T-RTS below eight, age over 65 years, systolic blood pressure under 100 mmHg, a GCS of less than 8, blood transfusion of more than ten units in the first 24 hours and colloid infusion of more than six litres in the first 24 hours. Multivariate analysis showed that age, T-RTS and ISS were independent determinants of mortality. A T-RTS of eight or less identified the cohort of patients at greatest risk (65%). The morphology of the fracture was not predictive of mortality. We recommend the use of the T-RTS in the acute situation in order to identify patients at high risk.

Discrepancy in leg length after total hip replacement has been associated with patient dissatisfaction. We prospectively studied 200 consecutive patients undergoing unilateral Charnley hip replacements to identify whether there is a demonstrable association between such disparity and postoperative function. Radiological measurements between defined points on the pelvis and femur of the operated hip were compared with the same points on the contralateral joint. A lengthening index was derived and statistical analysis used to compare this with validated functional outcome scores (Harris hip score and the SF36 Health Survey) and patient satisfaction.

Our results showed no statistical association between leg-length discrepancy after hip arthroplasty and functional outcome or patient satisfaction.