A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component.

AIMS: The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). METHODS: Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. RESULTS: A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). CONCLUSION: Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable.Cite this article: Bone Joint J 2023;105-B(2):124-134.

What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

INTRODUCTION: The Trauma network was established in April 2012 in England to improve the care of patients with trauma. The care of major trauma was centralised to major trauma centres. This article aims to survey trauma team members (TTM) to compare perceptions of trauma care delivery in major trauma centres (MTC) and trauma units (TU) from where major trauma care has been diverted. METHODS: Trauma team members (TTM) from six hospitals were interviewed between June and July 2016. This included three MTCs and their neighbouring TU. Data were also gathered to determine appropriate trauma qualifications of TTMs. RESULTS: TTMs in MTCs perceived the standard of trauma service improved (90% increased, 10% same) since April 2012 in comparison to TUs (10% increased, 63% same, 27% decreased) (p ≤ 0.001). In MTCs, TTMs felt their skills improved more (66% improved, 34% unchanged) compared to TU's (24% improved, 64% unchanged, 12% regressed) (p ≤ 0.001). TTM's in MTCs were more satisfied with their trauma teams training (p ≤ 0.001), leader's communication (p ≤ 0.001) and handover process (p ≤ 0.01) in comparison to TTMs in TUs. 69% of doctors in MTCs held valid trauma qualifications as compared to only 37% in TUs (p ≤ 0.001). CONCLUSION: The centralisation of major trauma care to MTCs allows care for severely injured patients in specialised hospitals with allocated resources. This survey shows the effect of this reorganisation where diversion of major trauma from TUs may have led to their TTMs perceiving their standard of care to be less than TTMs in MTCs. This study recommends training support for TUs using modalities such as simulation-based training and regular audits to ensure improved perceptions and adequate qualifications. Multidisciplinary meetings between MTCs and TUs can allow information to be exchanged and shared to ensure reciprocal support and engagement to improve perception of trauma care delivery.

Improving patient and staff safety by minimising radiation exposure during trauma surgery: A simple and validated predictive model.

INTRODUCTION: Minimising radiation exposure, from fluoroscopic equipment during trauma surgery is crucial to safe-guarding patients and staff. This aim of this study was to identify variables associated with increased radiation exposure for 3 of the most common trauma procedures. Secondly, we aimed to derive an internally and externally validated mathematical model for predicting radiation exposure for these procedures. MATERIALS AND METHODS: We prospectively recorded radiation exposure from 270 sliding hip screw (SHS), ankle and wrist fixation procedures. Patient demographics, fracture severity, surgeon and radiographer grade were assessed using univariate and multivariate analyses. A mathematical model was then created and externally assessed for validity from another unit. RESULTS: With regards to the analysis of radiation exposure when fixing wrist fractures, a significant regression equation was found (F (3, 86) = 62.2, p < 0.001), with an adjusted R2 of 0.69. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 81.916(Fracture severity) + 43.426(Surgical grade) + 23.490 (radiographer grade)-203.89.With regards to the analysis of radiation exposure when fixing ankle fractures, a significant regression equation was found, (F (3, 83) = 15.49, p < 0.001), with an adjusted R2 of 0.34. Patients' predicted radiation exposure (cGY/cm2) was therefore equal to the positive result of: 39.541(Fracture severity) + 51.937(Surgical grade) + 37.702 (radiographer grade)-124.558 SHS (F (3, 89) = 25.29, p < 0.001), R2 of 0.44.61.338(Fracture severity) + 60.945(Surgical grade) + 35.491 (radiographer grade)-105.501. These predictive models were successfully externally validated. CONCLUSION: This study has demonstrated a workable and externally validated model for accurately predicting the likely radiation exposure using common and easily collectable variables. These models could be used to modify practuce and minimise the radiation exposure to patients and staff.

Templating Hip Arthroplasty.

BACKGROUND: Different methods have been developed and employed with variable degrees of success in pre-operative templating for total hip arthroplasty. Preoperative templating, especially digital templating, has been claimed to have increased the effectiveness of total hip arthroplasty by improving the precision of prediction of prosthetic implant size. AIMS: The overall aim of this systematic review is to identify whether the use of pre-operative templating in total hip arthroplasty procedures has resulted in increased accuracy, reliability and precision of the procedure. Various methods of templating, like traditional acetate overlay and digital method of templating that includes a single radiographic marker and double radiographic marker methods, have been compared to establish the most reliable method of templating. METHODS: We searched the PubMed, Google Scholar Cochrane Central Register of Controlled Trials (CENTRAL), and MEDLINE (1966 to present), EMBASE (1980 to present), CINAHL (1982 to present), Psych INFO (1967 to present) and Clinical Trials Gov. CONCLUSION: The results of this systemic review suggest that preoperative templating is resulting in an enormous increase in the accuracy of total hip arthroplasty and among various methods, King Mark is the most reliable method.

Predictors of Intraoperative Fractures during Hemiarthroplasty for the Treatment of Fragility Hip Fractures.

BACKGROUND: The aim of our study was to determine the rate and preoperative predictors of intraoperative fracture (IOF) during hip hemiarthroplasty (HA) in patients who have sustained a fragility hip fracture injury. METHODS: We reviewed 626 patients who underwent HA at our institution using the National Hip Fracture Database. Various patient- and surgery-related data including demographic information, cement usage, surgeon grade, time to surgery, and operative duration were collected. The metaphyseal diaphyseal index and modified canal bone ratio were measured on preoperative radiographs. We compared patients with and without IOF with respect to all variables collected. Multivariate regression modeling was used to identify significant preoperative risk factors for IOF. RESULTS: There was a 7% incidence of IOF in our cohort exclusively comprising of Vancouver A fractures. The majority of these complications were treated nonoperatively (52%). There was no statistically significant difference with respect to cement usage, surgeon grade, operative duration, time to surgery, and radiographic parameters collected. Increasing age was found to be the most significant preoperative risk factor for predicting IOF (p = 0.024, overall relative risk = 1.06). CONCLUSIONS: Our identified predictor of increasing age is nonmodifiable and illustrates the importance of meticulous surgical technique in older patients. Furthermore, its independence from fixation methods or prosthesis design as a predictor of IOF may support using an uncemented prosthesis in patients at risk from cement implantation.

Osteochondral avulsion fracture of the femoral origin of the anterior cruciate ligament in an 11-year-old child.

Although tibial end avulsions of the anterior cruciate ligament are relatively common in clinical practice, avulsions of the femoral end of this ligament are by comparison rare. We present the case of an 11-year-old boy with a bony avulsion injury, which was presumed to have arisen from the tibial insertion of the anterior cruciate ligament but turned out instead to be an osteochondral avulsion fracture of the femoral origin. This unexpected finding that was not detected during preoperative workup resulted in the first attempt at surgical fixation being aborted. The need for a second planned definitive fixation procedure emphasises the importance of combining a thorough history and examination in association with appropriate imaging in the patient workup. The patient's definitive operative treatment and outcome are described. Although rare, surgeons (and emergency room doctors) treating such patients should include femoral end avulsion injuries of the anterior cruciate ligament in the differential diagnosis of a child presenting with an acute haemarthrosis of the knee. Furthermore, once diagnosed, early onward referral to an experienced knee surgeon is advocated.

Biological therapy of bone defects: the immunology of bone allo-transplantation.

IMPORTANCE OF THE FIELD: Bone is one of the most transplanted tissues worldwide. Autograft is the ideal bone graft but is not widely used because of donor site morbidity and restricted availability. Allograft is easily accessible but can transmit infections and elicit an immune response. AREAS COVERED IN THIS REVIEW: This review identifies all in vitro and in vivo evidence of immune responses following bone transplantation and highlights methods of improving host tolerance to bone allotransplantation. WHAT THE READER WILL GAIN: In humans, the presence of anti-HLA specific antibodies against freeze-dried and fresh-frozen bone allografts has been demonstrated. Fresh-frozen bone allograft can still generate immune reactions whilst freeze-dried bone allografts present with less immunogenicity but have less structural integrity. This immune response can have an adverse effect on the graft's incorporation and increase the incidence of rejection. Decreasing the immune reaction against the allograft by lowering the immunogenic load of the graft or lowering the host immune response, would result in improved bone incorporation. TAKE HOME MESSAGE: It is essential that the complex biological processes related to bone immunogenicity are understood, since this may allow the development of safer and more successful ways of controlling the outcome of bone allografting.