Is it possible to predict which patients are most likely to benefit from intra-articular corticosteroid injections? A systematic review.

AIM: Intra-articular corticosteroid injections (IACIs) can reduce osteoarthritis-related pain, with differing levels of response across patient groups. This systematic review investigates what is known about the positive and negative predictors of outcomes in patients with osteoarthritis who undergo IACIs. METHODS: We systematically searched the Medline, Embase, and Cochrane databases to May 2023 for studies that evaluated patients undergoing IACIs for osteoarthritis and reported on predictors of outcomes in these patients. RESULTS: Eight studies were included. Two were placebo-controlled trials, six were observational studies. Due to the heterogeneity of outcomes and variables between the studies, it was not possible to pool the results for formal meta-analysis. Higher baseline pain, older age, higher BMI, lower range of movement, higher Kellgren-Lawrence radiographic score, joint effusion, and aspiration were shown to be predictors of a positive response to IACIs in some of the included studies. However, other studies showed no difference in response with these variables, or a negative correlation with response. Sex, smoking, mental health status, hypertension/ischaemic heart disease, diabetes mellitus, duration of symptoms, and socioeconomic status did not demonstrate any correlation with the prediction of positive or negative outcomes after IACIs. CONCLUSION: Several patient features have been identified as positive predictors of outcomes following IACIs. However, this systematic review has identified inconsistent and variable findings across the existing literature. Further research with standardization of IACI administration and outcome measures is required to facilitate further analysis of the reliability and significance of predictive factors for response to IACIs.

Have outcomes of trauma in centenarians changed in the last 15 years?

BACKGROUND: Centenarians are an often forgotten and under-reported group. Trauma in this population is a substantial cause of morbidity and mortality. 15 years ago, a small observational study examined the outcomes of trauma in centenarians in a single trauma unit, concluding that age alone should not be a determinant of treatment. Following implementation of national standards of care for trauma patients in older adults, this study re-examined outcomes in centenarians admitted secondary to trauma to assess if outcomes have changed. MATERIALS AND METHODS: We performed a retrospective cohort study examining patients aged over 100 years who had been admitted with trauma to an acute district general hospital and trauma unit. Patients were admitted from January 2020 to January 2022. Outcomes investigated included duration of hospital stay, complications, and mortality at three timepoints (inpatient, 30 days, 12 months). We compared this cohort to the cohort 15 years ago to assess for changes in outcomes. RESULTS: 29 patients met our eligibility criteria in this cohort. Common presenting injuries included hip fracture (13), pelvic ring fractures (8) and head injuries (8). There was significantly higher inpatient mortality within our cohort between patients who underwent operative versus non-operative treatment, but no significant difference in duration of hospital stay. There was no significant change in duration of hospital stay, inpatient mortality, or mortality at 30 days and 12 months between this cohort and 15 years ago. CONCLUSIONS: Outcomes of centenarians admitted secondary to trauma have been maintained but not improved in the last 15 years in our centre. Following this we must consider if more must be done to improve outcomes in this underreported but growing patient demographic.

A Meta-Analysis of the Incidence and Temporal Trends of Postoperative Dislocation in Revision Total Hip Arthroplasty Utilizing Constrained Acetabular Components or Dual Mobility Implants.

BACKGROUND: The incidence of dislocation after revision total hip arthroplasty (rTHA) is reported to be up to 25% and remains a common source of failure. Constrained acetabular components and dual mobility implants are two implant classes being utilized to alleviate this burden in patients who have recurrent instability or major intraoperative instability. This meta-analysis evaluated the incidence and temporal trends of dislocation after implantation with constrained acetabular components and dual mobility implants in rTHA. METHODS: Longitudinal studies reporting dislocation after the use of constrained acetabular components or dual mobility implants in rTHA were sought from Medline and Embase to October 2022. Secondary outcomes included re-revision surgery for dislocation and all causes. A total of 75 relevant citations were identified comprising 36 datasets of 3,784 constrained acetabular components and 47 datasets of 10,216 dual mobility implants. RESULTS: For constrained acetabular components, the pooled incidence of dislocation was 9% (95% confidence interval: 7.2, 11.7) (range 0.0%-35.3%) over a weighted mean follow-up of 6 years, in contrast to 3% (95% confidence interval: 2.2, 4.4) (range 0.0%-21.4%) over 5 years for dual mobility implants. Re-revision rates for dislocation after using constrained acetabular components were around 9%, in contrast to 2% for dual mobility implants. Re-revision rates for all causes after using constrained acetabular components were around 19%, in contrast to 8% for dual mobility implants. CONCLUSION: Dual mobility implants in the context of rTHA demonstrate lower incidences of dislocation (3% versus 9%), re-revision for dislocation (2% versus 9%), and rer-evision for any cause (8% versus 19%) in contrast to constrained acetabular components. This must be considered by surgeons when implanting such devices, often selected to treat instability.

Research priorities for intra-articular corticosteroid injections for osteoarthritis: A Delphi study.

Objective: To identify research priorities for intra-articular corticosteroid injections for osteoarthritis using a Delphi study. Design: In the Round 1 questionnaire, participants generated up to five potential research topics related to corticosteroid injections for osteoarthritis. These responses were collated and grouped to develop candidate research questions. Literature searches were conducted and questions with a lack of evidence were included in the next round. In Round 2, importance ratings (1-9; not important to very important) were assigned to each question. Those questions given an importance rating of 7-9 by ≥ 70% of participants were carried forward. In Round 3, participants were provided with the group ratings and the rating process was repeated to develop the final research priority list. Results: All three Delphi rounds were completed by 75 participants (82%; 34 patients, 21 healthcare professionals and 20 academics). A total of 310 research topics were generated in Round 1, from which 26 research questions were developed. None had been robustly answered by research and therefore all were included in the Round 2 questionnaire. In Round 2, 14 research questions were retained; all 14 were prioritised in Round 3 and included in the final research priority list. The questions covered long-term effects, clinical and cost-effectiveness, measurement of outcomes, comparison to other treatments, provision, safety, identifying responders, maximising benefits, patient experience, delaying the need for joint replacement, and dosage. Conclusion: Using a robust consensus technique with key stakeholders, we have developed a research priority list to guide future research into corticosteroid injections for osteoarthritis.

Surgical Versus Non-surgical Treatment of Unstable Lateral Compression Type I (LC1) Injuries of the Pelvis With Complete Sacral Fractures in Non-fragility Fracture Patients: A Systematic Review.

Lateral compression type 1 (LC1) injuries comprise two-thirds of pelvic fractures. Approximately one-third of LC1 fractures are unstable and may benefit from surgical fixation to improve stability but it is not clear if this leads to better clinical or cost-effectiveness outcomes. This study explores differences in patient-reported outcomes, complications, time-to-mobilisation, cost-effectiveness, and length of hospital stay between surgically and non-surgically treated unstable LC1 non-fragility fractures. We performed a systematic review to determine whether surgical or non-surgical treatment yielded better clinical and cost-effectiveness outcomes for the treatment of unstable LC1 pelvic injuries with complete sacral fractures, excluding fragility fractures. We searched Medline, Embase and Cochrane databases from inception to June 2022, as well as clinical trial registries. A formal meta-analysis was not possible due to available study designs and heterogeneity. Therefore, a narrative review of the findings has been provided. Five observational studies met the inclusion criteria. A total of 183 patients were treated surgically, and 314 patients were treated non-surgically. Patients treated surgically had lower pain levels (Visual Analogue Scale) and fewer days to mobilisation. Quality of life (EuroQol-5 domains and 36-Item Short Form questionnaires) was better in the surgical group, but not statistically significant. No statistical differences in the length of hospital stay or complication rates were found. This review highlights the low quantity and quality of existing data on patients with unstable LC1 pelvic fractures and the need for a definitive randomised controlled trial to determine whether surgical or non-surgical care should be the preferred treatment concerning clinical and cost-effective care.

Affordable Artificial Intelligence-Assisted Machine Supervision System for the Small and Medium-Sized Manufacturers.

With the rapid concurrent advance of artificial intelligence (AI) and Internet of Things (IoT) technology, manufacturing environments are being upgraded or equipped with a smart and connected infrastructure that empowers workers and supervisors to optimize manufacturing workflow and processes for improved energy efficiency, equipment reliability, quality, safety, and productivity. This challenges capital cost and complexity for many small and medium-sized manufacturers (SMMs) who heavily rely on people to supervise manufacturing processes and facilities. This research aims to create an affordable, scalable, accessible, and portable (ASAP) solution to automate the supervision of manufacturing processes. The proposed approach seeks to reduce the cost and complexity of smart manufacturing deployment for SMMs through the deployment of consumer-grade electronics and a novel AI development methodology. The proposed system, AI-assisted Machine Supervision (AIMS), provides SMMs with two major subsystems: direct machine monitoring (DMM) and human-machine interaction monitoring (HIM). The AIMS system was evaluated and validated with a case study in 3D printing through the affordable AI accelerator solution of the vision processing unit (VPU).

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.

The Incidence and Temporal Trends of Dislocation After the Use of Constrained Acetabular Components and Dual Mobility Implants in Primary Total Hip Replacements: A Systematic Review and Meta-Analysis of Longitudinal Observational Studies.

BACKGROUND: Dislocation after a primary total hip replacement (pTHR) remains a common cause of treatment failure. Constrained acetabular components (CACs) and dual mobility implants (DMIs) may mitigate this in patients at high risk of dislocation or with significant intraoperative instability. This meta-analysis evaluated the incidence and temporal trends of dislocation after implantation with CACs and DMIs in pTHR. METHODS: Longitudinal studies reporting dislocation after the use of CACs or DMIs in pTHR were sought from Medline and Embase to September 2020. Secondary outcomes included revision surgery for dislocation and for all causes. RESULTS: A total of 46 studies (3 CAC and 43 DMI) comprising 582 CACs and 18,748 DMIs were included. The pooled incidence of dislocation was 1.08% (95% confidence interval [CI]: 0.00-3.72; range 0.27%-2.60%) over a weighted mean follow-up of 4.1 years for CACs, compared with 0.25% (95% CI: 0.08-0.46; range 0.00%-4.72%) over 6.2 years for DMIs. For DMIs, there was a temporal decline in dislocations from the 1980s onward, and dislocation rates remained low (<1%) until 15 years postoperatively. There were insufficient data for similar analysis of CACs. All studies were at high risk of bias. The incidence of revision for dislocation after CACs was 0.3% vs 0.1% for DMIs, and the incidence of revision for all causes after CACs was 4.8% vs 2.7% for DMIs. CONCLUSION: DMIs demonstrated a lower incidence of dislocation compared with CACs; however, there was a relative absence of CACs used in the context of pTHR in the literature. Temporal trends in dislocation have improved over time for DMIs.

Risk of complications following surgical fixation of femoral diaphyseal fractures in children aged 4 to 12 years: A systematic review and meta-analysis.

INTRODUCTION: There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. METHODS: We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications. RESULTS: Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n = 161), two analysed plates (n = 51) and five analysed EF (n = 168). Within the observational studies, 13 analysed FIN (n = 610), seven analysed plates (n = 214) and six analysed EF (n = 153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p = 0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p = 0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p = 0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). CONCLUSION: Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior.

Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence.

OBJECTIVE: To determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. DESIGN: Umbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials. DATA SOURCES: Ten of the most common elective orthopaedic procedures-arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement-were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care. DATA EXTRACTION AND SYNTHESIS: Summary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence. MAIN OUTCOME MEASURES: Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines. RESULTS: Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care. CONCLUSIONS: Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018115917.

Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis.

OBJECTIVES: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. DATA SOURCES: MEDLINE, EMBASE, CENTRAL, and OpenGrey. STUDY SELECTION: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. DATA EXTRACTION: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. DATA SYNTHESIS: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. RESULTS: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. CONCLUSIONS: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Estimation of blood volume and blood loss in primary total hip and knee replacement: An analysis of formulae for perioperative calculations and their ability to predict length of stay and blood transfusion requirements.

INTRODUCTION: Blood loss continues to be a common surgical risk in total hip (THR) and knee replacements (TKR). Accurate prediction of blood loss permits appropriate counselling of risks to patients, target optimisation and forecasting future transfusion requirements. We compared blood volume formulae of Moore and Nadler, and blood loss formulae of Liu, Mercuriali, Bourke, Ward, Gross, Lisander and Meunier, to assess associations between calculated values with length of stay and transfusion requirements and determine which are useful in contemporary practice. METHODS: We retrospectively studied patients undergoing primary THR and TKR. We collected data on patient demographics, surgical interventions, pre- and postoperative haemoglobin and haematocrit values, length of stay and blood transfusion requirements. Spearman correlation tests and least squares multiple linear regression were performed. RESULTS: 149 THRs and 90 TKRs in 239 patients were analysed over four months. There was a very strong correlation between blood volume formulae. There were multiple very strong and strong associations between blood loss formulae. Bourke correlated significantly to length of stay, and Liu, Mercuriali, Lisander and Meunier correlated for incidence of transfusion. CONCLUSION: Accurate estimation of perioperative blood loss is increasingly important as demand for joint replacement surgery increases in an ageing population. If the primary interest is the association of blood loss and length of stay, Bourke's formula should be preferred. If the primary interest is calculating risk of transfusion, the formulae of Liu or Meunier should be preferred. The formulae of Mercuriali and Lisander are becoming redundant in contemporary practice.

Tranexamic acid use to decrease blood loss in primary shoulder and elbow replacement: A systematic review and meta-analysis.

PURPOSE: Tranexamic acid (TXA) is an inexpensive antifibrinolytic agent that significantly reduces peri-operative blood loss and transfusion requirements after total hip and knee replacement. This meta-analysis demonstrates the effects of TXA on blood loss in total shoulder replacement (TSR) and total elbow replacement (TER). METHODS: We systematically searched MEDLINE, EMBASE and CENTRAL from inception to September 03, 2020 for randomised controlled trial (RCTs) and observational studies. Our primary outcome was blood loss. Secondary outcomes included the need for blood transfusion, and post-operative venous thromboembolic (VTE) complications. Mean differences (MD) and relative risks with 95% confidence intervals (CIs) were reported. RESULTS: Four RCTs and five retrospective cohort studies (RCS) met eligibility criteria for TSRs, but none for TERs. RCT data determined that TXA administration significantly decreased estimated total blood loss (MD -358mL), post-operative blood loss (MD -113mL), change in haemoglobin (Hb) (MD -0.71 g/dL) and total Hb loss (MD -35.3g) when compared to placebo. RCS data demonstrated significant association between TXA administration and decreased in post-operative blood loss, change in Hb, change in Hct and length of stay. There was no significant difference in transfusion requirements or VTE complications. CONCLUSION: TXA administration in safe and effective in patients undergoing primary TSR: it significantly decreases blood loss compared with placebo and is associated with shorter length of stay compared with no treatment. No significant increase in VTE complications was found. TXA administration should be routinely considered for patients undergoing TSR. Further research is needed to demonstrate the treatment effect in patients undergoing TER.

Outcomes of Orthopaedic Trauma Services at a UK Major Trauma Centre During a National Lockdown and Pandemic: The Need for Continuing the Provision of Services.

Aim To review the trauma operating workload, theatre time and outcomes at a time of national lockdown at the beginning of the coronavirus disease 2019 (COVID-19) pandemic, comparing it with a year prior. Methods A retrospective case-control study was performed in a single Level 1 Major Trauma Centre (MTC) in the UK. Inclusion criteria were all patients undergoing operative intervention for an emergency or urgent trauma admission within our Trauma and Orthopaedics department. Data collected included anatomical area of injury, cause of injury, operative procedure, type of anaesthesia, total theatre time, complications, and mortality at 30 days. Results A total of 159 operations were performed on 142 patients in April 2019, and 110 operations on 106 patients in April 2020 (time of national lockdown). There was a 30% decrease due to reduced numbers of road traffic accidents and sport-related injuries. The number of hip fractures and those injuring themselves from less than 2m height remained the same. Operative total theatre time increased by a mean of 14 minutes, and complications and mortality were not significantly changed. The incidence of COVID in the patients tested was 8.5%, which matched the population incidence at the time.  Conclusions Orthopaedic trauma services need to be provided during a national lockdown. There was no decrease in the volume of patients sustaining falls, which includes hip fractures. Mean operating time only increases by 14 minutes with the wearing of PPE. This should be part of future planning of any pandemics or national lockdowns.

Flexible nails have a significantly increased risk of complications compared with plating techniques when treating diaphyseal femoral fractures in children aged 5-12: A systematic review.

BACKGROUND: One third of paediatric femoral fractures occur between the ages of 5 and 12. The American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for treating such fractures that occur in children under 5 and over 12 but not for this age cohort. We aimed to synthesise the available evidence comparing flexible nailing versus plating techniques for diaphyseal femoral fractures in children between the ages of 5 and 12. METHODOLOGY: A systematic review of interventional and observational studies was performed using MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, WHO Global Index Medicus and LILACS. The search strategy combined keywords for: children, diaphyseal femoral fractures, plates and nails. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. The primary outcome was overall complication rates. Secondary outcomes assessed rates of individual complications, and operative variables (e.g. operative time, blood loss). RESULTS: Five studies fulfilled the eligibility criteria. No RCTs were identified. The studies included 308 femoral fractures in 306 patients: 174 fractures were treated with flexible nailing and 134 with plating. The post-operative complication rate was 27.0% (n = 47) after flexible nails and 12.7% (n = 17) after plating, relative risk 2.13 (95% CI 1.28, 3.53; p = 0.0035). The relative risk of malunion was 3.59 (95% CI 1.05, 12.25; p = 0.0409) with flexible nails and of prominent metalwork was 5.39 (95% CI 1.25, 23.31; p = 0.0241) with flexible nails. CONCLUSIONS: Data on this topic for this age group is limited despite accounting for one third of paediatric femoral fractures. This review identified a significantly increased relative risk of all complications, and in particular with respect to malunion and prominent metalwork when fractures in this cohort are treated with flexible nails compared to plates. A multi-centre randomised trial to determine if either treatment is superior would be justified.

Challenges and Opportunities of Evidence Use in Practice in Australian Children's Development Programs.

This paper explores the role of evidence and its use in a cluster of Australian community-based child development programs. The paper draws on findings from a 2016-2017 study commissioned by a not-for-profit organization to review their programs' alignment with government evidence-based program expectations. Cunningham and Duffee's (2009) evidence-based practice style typology is utilized to examine how different purposes of use drive styles of and approaches to evidence sourcing, application, and reporting. Perspectives on what constitutes evidence and how such evidence is valued, used, and reported can vary considerably between individual programs, irrespective of enforced standards and expectations. It is argued that a single-dimensional approach to program evidence-based evaluation and reporting is not appropriate and potentially damaging in contexts where community-based programs have different purposes, structures, cultures, and intentions. Given a program's particular evidence-use style, evidence-based criteria, processes, and reporting requirements should be matched accordingly.

Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance.

INTRODUCTION: Severe open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. METHODS: Adult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering pre-hospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. RESULTS: 156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 min and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n = 12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. CONCLUSIONS: There are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.

The "FCR" Approach to the Knee for the Management of Posterior Tibial Plateau Fractures.

Three-column fixation of tibial plateau fractures is now an established philosophy. A direct posterior approach with the patient prone affords enhanced exposure of the posterior column and ease of access for fixation using a buttress plate and posterior-to-anterior screws. A "direct posterior" approach through a reverse L-shaped incision to back of the knee is popular, yet complications associated with raising a fascial flap can occur. We present a simple method of conceptualizing a direct posterior approach through a single longitudinal incision, by likening it to a commonly performed orthopedic approach, the flexor carpi radialis approach to the wrist.

Outcome of total knee arthroplasty in patients with poliomyelitis: A systematic review.

Total knee arthroplasty (TKA) in patients affected by poliomyelitis is technically challenging owing to abnormal anatomical features including articular and metaphyseal angular deformities, external rotation of the tibia, excessive valgus alignment, bone loss, narrowness of the femoral and tibial canals, impaired quadriceps strength, flexion contractures, genu recurvatum and ligamentous laxity. Little information is available regarding the results and complications of TKA in this challenging group of patients.We carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of TKA in patients with poliomyelitis-affected knees. Six studies including 82 knees met the inclusion criteria and were reviewed. The mean patient age was 63 years (45 to 85) and follow-up was 5.5 years (0.5 to 13).All studies reported significant improvement in knee function following TKA. There were six failures requiring revision surgery in 82 cases (7%) occurring at a mean of 6.2 years (0.4 to 12). The reasons for revision surgery were aseptic loosening (17%, n=1), infection (33%, n=2), periprosthetic fracture (17%, n=1) and instability (33%, n=2). Thirty-six knees had a degree of recurvatum pre-operatively (44%), which was in the range of 5° to 30°. Ten of these knees (28%) developed recurrent recurvatum post-operatively.The findings support the use of TKA in patients with poliomyelitis-affected knees. The post-operative functional outcome is similar to other patients; however, the revision rate is higher. Quadriceps muscle power appears to be an important prognostic factor for functional outcome and the use of constrained implant designs is recommended in the presence of less than antigravity quadriceps strength. Cite this article: EFORT Open Rev 2018;3:358-362. DOI: 10.1302/2058-5241.3.170028.