Epidemiology and outcomes of tibial plateau fractures in adults aged 60 and over treated in the United Kingdom.

BACKGROUND: Tibial plateau fractures are common in older adults, often resulting from low-energy falls. Although lower limb fragility fracture care has evolved, the management of tibial plateau fractures in older patients remains poorly researched. This study aimed to define the epidemiology, treatment and outcomes of tibial plateau fractures in patients aged over 60 years. METHODOLOGY: Patients aged 60 years or older with a tibial plateau fracture who presented to a single trauma center between January 2008 and December 2018 were identified. Incomplete records were excluded. Epidemiological data, fracture classification, injury management, radiological outcomes, complications, and mortality were assessed via retrospective case note and radiograph review. Local ethics approval was obtained. RESULTS: Two-hundred and twenty patients with a mean age of 74 years (range 60-100) were included. 73% were female and 71% of injuries were sustained following low-energy falls. Median follow up was three months. 50% of fractures involved the lateral plateau. 60% of injuries were treated non-operatively. 76% of patients had their weight-bearing restricted for the first six weeks, with little difference between operatively and non-operatively managed patients. 8% of all patients required subsequent knee replacement. All-cause mortality at 30-days and one-year were 2% and 5% respectively. CONCLUSION: The majority of tibial plateau fractures in the over 60s are sustained from low-energy trauma. Management is relatively conservative when compared with younger cohorts. The data reported brings up questions of whether surgical treatment is beneficial to this patient group, or whether restricted weight bearing is either possible or beneficial. Prospective, multi-center comparative trials are needed to determine whether increased operative intervention or different rehabilitation strategies purveys any patient benefit.

Reducing unnecessary fixation of midshaft clavicle fractures.

PURPOSE: Displaced midshaft clavicle fractures have a non-union rate of 10-20%. Those who unite with conservative treatment have similar outcomes to those who undergo operative treatment; therefore, protocols to identify potential non-unions are important to avoid unnecessary surgery. The aim of this study is to report one such protocol. METHODS: A protocol was introduced, where all isolated closed displaced midshaft clavicle fractures were initially managed non-operatively in a sling. At 2 weeks patients were assessed clinically and those who were struggling with their symptoms were offered surgery, with the remainder mobilised as comfortable. All cases treated at one centre over a three-year period, with a minimum follow-up of one-year underwent case note review. RESULTS: Between 2015 and 2017 613 clavicle fractures were managed through clinic. 347 were middle third (56%), 75% were male, mean age 41(range16-97). Forty-one middle third clavicle fracture patients underwent early fixation. Eleven patients required late fixation for symptomatic delayed, non- or malunion, 6 for symptomatic non-unions and 1 was a symptomatic malunion. For displaced fractures the early operative rate was 17.8%, and symptomatic non/malunion rate was 3.2%. This led to a total operative rate of 21%. CONCLUSION: A protocol for managing clavicle fractures has demonstrated an effective management of these injuries. It is cost-effective reducing the number of patients with displaced fractures requiring fixation with a fixation rate of 21% whilst reducing the rate of symptomatic non- and malunion (3.2%). The management pathway is simple and could be introduced into any orthopaedic outpatient department with ease.

International trauma care: initial European approaches during the COVID 19 pandemic.

The world was not prepared for the global of pandemic in early 2020 with the arrival of COVID 19. Europe has some of the most developed health care systems in the world and this article explains the initial response to the pandemic from an orthopaedic and trauma viewpoint from 8 nations. Italy reported the first cluster in February, which then rapidly spread around the continent, requiring a rapid reorganization of services. The reports highlight how elective surgery was universally stopped, surgical services were reconfigured, and new practices, such as the widespread use of telemedicine, may well become permanent. It also emphasizes how the pandemic has re-educated us on the importance of a consistent and central approach to deal with a global health crisis, and how medical services need to remain flexible and responsive to new ways of working.

Hip fracture systems-European experience.

European countries have established health care systems but are struggling with the increasing rise of fragility fractures in their aging population. In trying to address this significant burden, countries are establishing national guidelines and standards, focusing on hip fractures, which represent the significant cost for this patient group. This has evolved with the establishment of national audits and guidelines. Reports from 4 European countries (England, Italy, Netherlands, and Spain) are presented. All nations have identified both deficiencies in their systems, and protocols to improve these deficiences. When standards are introduced, there has been evidence of improved results. Significantly more work is needed to understand the key components of the systems and pathways, and efforts to study and standardize care are ongoing.

The value of 'binder-off' imaging to identify occult and unexpected pelvic ring injuries.

AIMS: To determine the effectiveness of 'binder-off' plain pelvic radiographs in the assessment of pelvic ring injuries. PATIENTS AND METHODS: All patients requiring operative intervention at our tertiary referral pelvic unit/major trauma centre for high-energy pelvic injuries between April 2012 and December 2014 were retrospectively identified. Pre-operative pelvic imaging with and without pelvic binder was reviewed with respect to fracture pattern and pelvic stability. The frequency with which the imaging without pelvic binder changed the opinion of the pelvic stability and need for operative intervention, when compared with the computed tomography (CT) scans and anteroposterior (AP) radiographs with the binder on, was assessed. RESULTS: Seventy-three percent (71 of 97) of patients had initial imaging with a pelvic binder in situ. Of these, 76% (54 of 71) went on to have 'binder-off' imaging. Seven percent (4 of 54) of patients had unexpected unstable pelvic ring injuries identified on 'binder-off' imaging that were not identified on CT imaging in binder. CONCLUSIONS: Trauma CT imaging of the pelvis with a pelvic binder in place is inadequate at excluding unstable pelvic ring injuries, and, based on the original findings in this paper, we recommend additional plain film 'binder-off' radiographs, when there is any clinical concern.

Early complications following cemented modular hip hemiarthroplasty.

INTRODUCTION: Hemiarthroplasty is the recommended treatment for displaced, intracapsular, femoral neck fractures. This study aimed to evaluate the early complications following insertion of the JRI Furlong cemented hemiarthroplasty, a contemporary, modular, double tapered, polished prosthesis. METHOD: A series of 459 consecutive patients (May 2006 - June 2009) treated with a JRI hemiarthroplasty with a minimum of one-year (1-4years) follow-up were evaluated. Data collected retrospectively from clinical records and hospital databases included patient demographics, mortality, deep infection, dislocation, periprosthetic fracture, and any requirement for revision or complications related to the prosthesis. RESULTS: Full data were available for 429 of 459 (93%), partial data for 30 (7%). Average age was 83 years (52-100), 76% were female. One-year mortality was 24%. Intraoperative fractures occurred in 17 patients (3.7%). There were two intraoperative deaths. There were nine early deep wound infections (2%). There were two revisions to total hip replacement (THR), four patients required conversion to THR and one underwent an excision arthroplasty procedure. DISCUSSION: Early surgical outcomes for the JRI hemiarthroplasty prosthesis are equivalent or superior to other major hemiarthroplasty prostheses previously reported however, there was a high intraoperative fracture rate of 3.7%. We recommend using a stem one size smaller than the final broach in fragile, osteoporotic bone. No patients re-presented with aseptic loosening or stem failure.

The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome.

OBJECTIVES: Traditionally, the anterior surgical approach of choice for acetabular reconstruction was ilioinguinal. There has been an increasing usage of the midline "Stoppa" or "anterior intrapelvic approach." The aim is to report the techniques, early results (minimum 1 year), and complications of anterior approaches for acetabular reconstruction. DESIGN: Retrospective case-note review. SETTING: Pelvic and acetabular tertiary center. PATIENTS: A consecutive series of acetabular fractures treated at 1 tertiary specialist unit were retrospectively reviewed. The fracture patterns, incisions used, intraoperative and postoperative complications, reduction achieved (measured on postoperative radiographs and computed tomography scans), and early postoperative results (minimum 1-year follow-up), were recorded. MAIN OUTCOME MEASUREMENTS: Postoperative reduction (measured by postoperative plain radiographs and computed tomography). RESULTS: Of 160 consecutive patients who underwent acetabular reconstruction, 56 (mean age, 44 years) underwent reconstruction using only anterior approaches (mean of 7 days after injury). Iatrogenic complications, postoperative infection, arthritis, and avascular necrosis rates are comparable with the literature. Overall, anatomic reduction was seen in 71% of cases and concentric reconstruction of the dome in over 90%. Thirty-six of the 56 patients (64%) were symptom-free at the latest follow-up and 34 (61%) had returned to work. CONCLUSIONS: The results reported suggest the use of dual approaches using the lateral 2 windows, and/or a midline anterior intrapelvic approach in anterior acetabular reconstructions has a relatively low complication rate and can lead to anatomic reconstructions in 71%. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Is fixation failure after plate fixation of the symphysis pubis clinically important?

BACKGROUND: Plate fixation is a recognized treatment for pelvic ring injuries involving disruption of the pubic symphysis. Although fixation failure is well known, it is unclear whether early or late fixation failure is clinically important. QUESTIONS/PURPOSES: We therefore determined (1) the incidence and mode of failure of anterior plate fixation for traumatic pubic symphysis disruption; (2) whether failure of fixation was associated with the types of pelvic ring injury or pelvic fixation used; (3) the complications, including the requirement for reoperation or hardware removal; and (4) whether radiographic followup of greater than 1 year alters subsequent management. METHODS: We retrospectively reviewed 148 of 178 (83%) patients with traumatic symphysis pubis diastasis treated by plate fixation between 1994 and 2008. Routine radiographic review, pelvic fracture classification, method of fixation, incidence of fixation failure, timing and mode of failure, and the complications were recorded after a minimum followup of 12 months (mean, 45 months; range, 1-14 years). RESULTS: Hardware breakage occurred in 63 patients (43%), of which 61 were asymptomatic. Breakage was not related to type of plate, fracture classification, or posterior pelvic fixation. Five patients (3%) required revision surgery for failure of fixation or symptomatic instability of the symphysis pubis, and seven patients (5%) had removal of hardware for other reasons, including late deep infection in three (2%). Routine radiographic screening as part of annual followup after 1 year did not alter management. CONCLUSIONS: Our observations suggest the high rate of late fixation failure after plate fixation of the symphysis pubis is not clinically important.