Hip and knee arthroplasty implants contraindicated in obesity.

INTRODUCTION: High patient weight is a risk factor for mechanical implant failure and some manufacturers list obesity as a contraindication for implant use. We reviewed data from the 2012-2013 UK National Joint Registry to determine whether surgical practice reflects these manufacturer recommendations. METHODS: The product literature for the most commonly used hip and knee implants was reviewed for recommendations against use in obese patients (body mass index [BMI] ≥ 30kg/m(2)). The total number of obese patients undergoing hip and knee arthroplasty was calculated, as was the proportion receiving implants against manufacturer recommendations. RESULTS: Out of 200,054 patient records, 147,691 (74%) had a recorded BMI. The mean BMI for patients undergoing primary total hip arthroplasty was 29kg/m(2), compared with 31kg/m(2) for total knee arthroplasty. Of the 25 components reviewed, 5 listed obesity as a contraindication or recommended against implant use in obese patients. A total of 10,745 patients (16% of all obese patients) received implants against manufacturer recommendations. CONCLUSIONS: A high proportion of patients are receiving implants against manufacturer recommendations. However, there are limitations to using BMI for stratifying risk of implant fatigue failure and manufacturers should therefore provide more detailed guidelines on size specific implant load limits to facilitate surgical decisions.

The ongoing relevance of acetabular fracture classification.

The most widely used classification system for acetabular fractures was developed by Judet, Judet and Letournel over 50 years ago primarily to aid surgical planning. As population demographics and injury mechanisms have altered over time, the fracture patterns also appear to be changing. We conducted a retrospective review of the imaging of 100 patients with a mean age of 54.9 years (19 to 94) and a male to female ratio of 69:31 seen between 2010 and 2013 with acetabular fractures in order to determine whether the current spectrum of injury patterns can be reliably classified using the original system. Three consultant pelvic and acetabular surgeons and one senior fellow analysed anonymous imaging. Inter-observer agreement for the classification of fractures that fitted into defined categories was substantial, (κ = 0.65, 95% confidence interval (CI) 0.51 to 0.76) with improvement to near perfect on inclusion of CT imaging (κ = 0.80, 95% CI 0.69 to 0.91). However, a high proportion of injuries (46%) were felt to be unclassifiable by more than one surgeon; there was moderate agreement on which these were (κ = 0.42 95% CI 0.31 to 0.54). Further review of the unclassifiable fractures in this cohort of 100 patients showed that they tended to occur in an older population (mean age 59.1 years; 22 to 94 vs 47.2 years; 19 to 94; p = 0.003) and within this group, there was a recurring pattern of anterior column and quadrilateral plate involvement, with or without an incomplete posterior element injury.

Low energy fractures of the acetabulum.

INTRODUCTION: Acetabular fractures due to high energy injuries are common and well documented; those secondary to low energy mechanisms are less well described. We undertook a retrospective study of the acetabular fracture referrals to our unit to evaluate the proportion of injuries resulting from a low energy mechanism. METHODS: A total of 573 acetabular fractures were evaluated from 1 January 2005 to 31 December 2008. The plain radiography and computed tomography of those sustaining a low energy fracture were assessed and the fracture patterns classified. RESULTS: Of the 573 acetabular fractures, 71 (12.4%) were recorded as being a result of a low energy mechanism. The male-to-female ratio was 2.4:1 and the mean patient age was 67.0 years (standard deviation: 19.1 years). There was a significantly higher number of fractures (p<0.001) involving the anterior column (with or without a posterior hemitransverse component) than in a number of previously conducted large acetabular fracture studies. CONCLUSIONS: Our results demonstrate that low energy fractures make up a considerable proportion of acetabular fractures with a distinctly different fracture pattern distribution. With the continued predicted rise in the incidence of osteoporosis, life expectancy and an aging population, it is likely that this type of fracture will become increasingly more common, posing difficult management decisions and leading to procedures that are technically more challenging.

Acetabular fractures in patients aged > 55 years: a systematic review of the literature.

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes.

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Fractures of the pelvis.

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.

Medical negligence in orthopaedic surgery: a review of 130 consecutive medical negligence reports.

Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce. We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants' solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from pound 4500 to pound 2.7 million, the median settlement being pound 45,000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.

Crescent fracture-dislocation of the sacroiliac joint: a functional classification.

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma.

The hormonal and inflammatory responses to pelvic reconstructive surgery following major trauma.

Patients undergoing trauma sustain an initial injury followed by further physiological challenges during surgery. Plasma osteocalcin (OC), a marker of osteoblastic activity, declines after major surgery. Increased cortisol secretion, and other components of the perioperative stress response, may play a role in mediating this response. We have examined the osteocalcin, hormonal and cytokine responses in twenty patients undergoing post-traumatic pelvic reconstruction surgery. We measured plasma osteocalcin, serum cortisol, bone specific alkaline phosphatase (BSAP), IL-6, IL-8, IL-10, plasma epinephrine and norepinephrine concentrations for up to 3 days after surgery. We recorded an increase in IL-6, IL-10 and epinephrine concentrations perioperatively and a fall in OC and BSAP concentrations. There were no significant changes in cortisol or IL-8 concentrations. Patients undergoing pelvic reconstruction surgery following trauma have a preserved inflammatory and catecholamine response but the cortisol response may be obtunded. Osteocalcin concentrations are affected by factors other than glucocorticoids.

Pelvic floor dysfunction in women after pelvic trauma.

The aim was to assess symptoms of pelvic floor dysfunction in women following pelvic trauma. A retrospective questionnaire survey of 24 consecutive women was performed in a tertiary referral orthopaedic centre and urogynaecology unit. Sixteen women had a type B and eight a type C pelvic fracture (Association Osteosynthesis manual classification). The median age was 24 years (11-92). Twenty-one women were nulliparous. Sixteen women reported de novo pelvic floor dysfunction. Bladder symptoms occurred in 12, bowel problems in 11 and sexual dysfunction in 7 of 17 sexually active women. Pelvic fracture seems to be a risk factor for pelvic floor dysfunction.

Pelvic and acetabular fractures in the United Kingdom: a continued public health emergency.

In 1996 the quality of the early management of 100 consecutive patients referred to the SW Thames regional pelvic and acetabular unit between 1989 and 1992 was studied. The management of these patients was assessed in four specific areas, and guidelines were laid down. It was found that in 56% of patients the early management did not meet these suggested standards, with 34% having deficiencies in more than one area. These results were presented and published. Five years later, the early management of a further 100 consecutive referrals was assessed using these same guidelines, in order to close the audit loop. The treatment of 57% of patients still did not reach the guideline standards, but the number with problems in more than one area fell to 20%. There has been improvement in the early management of pelvic and acetabular injuries. The use of external fixation in cases of severe haemorrhage increased, but frames were often poorly applied. Early communication with the specialist centre was encouraged but unfortunately there was still an unacceptable delay in referral. The frequency of delayed referral actually increased during the 5 years between study groups.

Volume changes within the true pelvis during disruption of the pelvic ring--where does the haemorrhage go?

Fractures of the pelvis are not only common but are very varied in their complexity. They represent 3% of all fractures (1), they account for 1 in every 1000 surgical admissions and are the third most commonly encountered injury in motor vehicle accident fatalities (2). However, only a small percentage of all pelvic fractures are associated with major disruption of the pelvic ring (3). Life threatening haemorrhage is a frequent complication of major pelvic fractures (1, 4) and haemorrhage is the leading cause of death in these patients (5, 6). It was believed that fracture and subsequent displacement of the ring greatly increased pelvic volume. However, clinical practice seemed to indicate that this might not be true. This study aimed to assess the change in pelvic volume which occurs in severely displaced pelvic fractures. A model of the bony pelvis was designed to permit extreme displacements of the symphyseal and sacroiliac joints. The volume of a polythene balloon placed within the true pelvis was measured as an indication of true pelvic volume. Our finding was that the increase in the volume of the true pelvis which occurs in a fracture with massive diastasis is much smaller than previously assumed.

The early management of pelvic and acetabular fractures.

One hundred consecutive referrals with pelvic and acetabular fractures treated over a three year period were reviewed with regard to their early management. Early management was subdivided into four areas: 1. initial assessment and treatment; 2. imaging; 3. referral; 4. management of associated injuries. The cases comprised 26 pelvic fractures (18 treated operatively), 69 acetabular fractures (50 treated operatively), and 5 combination fractures (3 treated operatively). Guidelines were laid down in each of the four areas of management and each patient's management was compared with this ideal. 56% of cases had deficient management by our criteria. There were important failures in diagnosis and early treatment of these complex injuries. A set of simple guidelines is offered to help improve the situation.

Indications and techniques of external fixation of the injured pelvis.

High energy pelvic ring disruption represents a serious clinical problem with an overall reported mortality rate of approximately 10% (1). However, the mortality for open pelvic fractures approaches 50% (2). This alarmingly high rate has two major components. The first is death due to uncontrollable haemorrhage, often associated with terminal diffuse intravascular coagulation. The second is linked with the serious associated injuries. Improved resuscitation techniques have a direct bearing on both these components and should reduce morbidity and mortality (3,4). The external fixator has a major role to play during resuscitation and, in particular, in the control of bleeding. However, this primary function must not be confused with the more limited secondary role for the external fixator as a definitive form of treatment for certain pelvic fractures. This paper gives clear guidelines on the indications for the use of the external skeletal fixator with pelvic fractures and goes on to discuss pin placement and frame configuration in relation to the biomechanics and biology of the injury.