Posterior tilt in nondisplaced femoral neck fractures increases the risk of reoperations after osteosynthesis. A systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review on the effect of posterior tilt on reoperations, patient reported outcome measures (PROM) and functional outcome following osteosynthesis of undisplaced FNFs (uFNF). MATERIAL AND METHODS: A search string was developed with the aid of a scientific librarian and the search was performed in PubMed, CINAHL and Embase. The studies were screened independently by two authors using Covidence. Data were extracted by two authors and quality assessment was performed using Robins-I tool. The meta-analyses were performed in STATA IC 16 using Risk Ratio as the primary effect estimate. RESULTS: In total, 617 studies were screened and ten studies were included with a total of 3,131 patients. The mean age ranged from 68.3 to 85.0 years and the prevalence of posterior tilt ≥20° in the studies ranged from 4.5% to 27.6%. There were 10.3% reoperations when posterior tilt was <20° whereas there were 24.5% when posterior tilt was ≥20° The meta-analysis therefore demonstrated an overall risk ratio of 0.11 (95% confidence interval; 0.04-0.18). Only one study investigated functional outcome, using ADL as measurement, but found no significant difference. No studies investigated PROM. In general, the studies were assessed to be of poor quality mainly due possible bias and confounding. CONCLUSION: A posterior tilt ≥20° leads to a higher risk of reoperations in uFNF. Even though the studies were of poor quality, the results suggest that we should include the measurement of posterior tilt in national guidelines.

Management of proximal femur fractures in the elderly: current concepts and treatment options.

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Total hip replacement in patient with residual poliomyelitis with neglected femoral neck fracture.

A 71-year-old man with residual poliomyelitis was referred to the orthopaedic surgeons with a neglected left femoral neck fracture of the paralytic limb. He had presented at another hospital with left groin pain and inability to weight bear 4 weeks earlier after a fall from standing height, but had delayed treatment due to his insistence on waiting until he returned to his home country.Successful treatment of residual poliomyelitis fractures requires early union as well as early mobilisation and rehabilitation. This patient presented to the orthopaedic surgeons with a challenging case due to the delay in treatment and the fact that the fracture was basicervical which results in an unstable fracture. Surgical expertise was required to decide on the optimum surgical option and a total hip arthroplasty was performed. The patient made a good recovery following physiotherapy as evidenced clinically and radiologically.

The hidden dangers of staying home: a London trauma unit experience of lockdown during the COVID-19 virus pandemic.

INTRODUCTION: The COVID-19 pandemic resulted in reconfiguration of the NHS. Elective services were stopped and trauma services focused on decreasing patient-clinician interactions and managing injuries nonoperatively wherever possible. The everyday life of the general public changed dramatically with the introduction of a national lockdown to prevent the spread of COVID-19. This paper looks at the experience of a South West London trauma unit. MATERIALS AND METHODS: All patients reviewed in fracture clinic and by the orthopaedic on-call team between 23 March to 23 April 2020 were included. Data on the mechanism of injury and whether this was a usual activity, the injury sustained and its management were collected. RESULTS: A total of 167 trauma injuries were seen, compared with 735 new patients with injuries in the previous month. The number of trauma operations completed decreased by 38%; 55% of injuries occurred inside the home and 44% outside the home during daily exercise. Some 31% of injuries were secondary to a new activity taken up during lockdown. Three open fractures and two polytrauma cases were seen that would have normally been managed at the local major trauma centre. CONCLUSION: Overall, both the number of injuries seen and trauma operations completed during the enforced lockdown decreased. This is probably due to a change in the way the general public are living their lives, and the reconfigurations within the NHS in response to the COVID-19 pandemic. This is an interesting time within trauma and orthopaedic departments, as they continue to adapt to the changing injuries and working environment.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Protection of Surgical Team from COVID-19 during Bipolar Hemiarthroplasty in an Infected Elderly Patient.

The novel coronavirus disease 2019 (COVID-19), which began in Wuhan, China, has rapidly flared up all over the world, evolving into a pandemic. During these critical times, we should give emphasis on infection prevention for the health care staff as well as appropriate patient management in order to maintain the health care system. We report our experience in protecting a surgical team from COVID-19 infection during a bipolar hemiarthroplasty in an infected patient. This case highlights the importance of appropriate protection of the health care staff and education in minimizing the risk of transmission of the infection and maintaining the health care system.