Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months. Objective: Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months? Design, Setting, and Participants: In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021. Interventions: Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group). Main Outcomes and Measures: The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications. Results: Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group. Conclusions and Relevance: Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study. Trial Registration: ANZCTR.org Identifier: ACTRN12616000969460.

A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study.

HYPOTHESIS: Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. METHODS: Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS: There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm ± 1.3 mm) and the TBT (1.9 mm ± 1.1 mm) groups (P = .854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P = .053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N ± 286 N vs. TBT: 1126 N ± 272 N; P = .928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. CONCLUSIONS: Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol.

BACKGROUND: Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The "Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)" study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. METHODS AND DESIGN: Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. DISCUSSION: The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7.

AIMS: Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). METHODS: Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. RESULTS: In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. CONCLUSION: A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769-774.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant-led virtual fracture clinic in an Australian level 1 trauma centre.

BACKGROUND: In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting. METHODS: A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates. RESULTS: A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P = 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P < 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P < 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P < 0.01). No complications or adverse events were reported. CONCLUSION: This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.

Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial.

Importance: The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence. Objective: To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. Design, Setting, and Participants: In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. Intervention: Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR). Main Outcomes and Measures: The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. Results: In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02). Conclusions and Relevance: This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people. Trial Registration: http://anzctr.org.au identifier: ACTRN12616000969460.

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE): a statistical analyses plan.

BACKGROUND: We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan. METHODS/DESIGN: A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p < 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance. DISCUSSION: This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients. TRIAL REGISTRATION: CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number; ACTRN12616000969460 ). This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.

Hip fracture care and national systems: Australia and Asia.

The Asia-Pacific region includes countries with diverse cultural, demographic, and socio-political backgrounds. Countries such as Japan have very high life expectancy and an aged population. China and India, with a combined population over 2.7 billion, will experience a huge wave of ageing population with subsequent osteoporotic injuries. Australia will experience a similar increase in the osteoporotic fracture burden, and is leading the region by establishing a national hip fracture registry with governmental guidelines and outcome monitoring. While it is impossible to compare fragility hip fracture care in every Asia-Pacific country, this review of 4 major nations gives insight into the challenges facing diverse systems. They are united by the pursuit of internationally accepted standards of timely surgery, combined orthogeriatric care, and secondary fracture prevention strategies.

The road to recovery for vulnerable road users hospitalised for orthopaedic injury following an on-road crash.

BACKGROUND: Pedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma. METHODS: A registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale - Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time. RESULTS: 6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian. CONCLUSION: Pedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users.

Using Patient-Reported Outcomes to Predict Revision Arthroplasty Following Femoral Neck Fracture: Enhancing the Value of Clinical Registries through Data Linkage.

The aim of this study was to determine the association between patient-reported outcome measures (PROMs) six months following femoral neck fracture after a low fall and future arthroplasty, and the factors associated with this. Six-month post-fracture PROMs were collected from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for patients aged >55 years who were admitted for a femoral neck fracture after a low fall between March 2007 and June 2015. These cases were linked with those registered by Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) up to October 2016. Multivariable analysis was performed using a Cox proportional hazards model to determine factors associated with future arthroplasty, including six-month PROMs. Of the 7077 hip fracture patients registered by VOTOR during the study period, 2325 met the inclusion criteria. Internal fixation being used for the initial hip fracture surgery, being younger and having no pre-injury disability were all independently associated with future revision or conversion to arthroplasty. Out of all PROMs, reporting pain and discomfort six months post-fracture was associated with a 9.5-fold increase in the risk of future arthroplasty (95% CI: 3.81, 23.67). The value of clinical registries can be enhanced via data linkage, in this case by using PROMs to predict arthroplasty following femoral neck fracture.

The overview of the Australian trauma system.

Trauma management in Australia is predominantly that of blunt mechanism trauma spread across a geographically large and sparsely populated country. A complex network of patient care has evolved to manage major trauma. Over recent decades, focus has been given to improving and co-ordinating transfer of patients into major trauma centers and improved data collection with the corresponding improved patient outcomes. This article provides an overview of the nature and structure of the Australian trauma system and its regulation.

Modified Dorsal Approach in the Management of Lisfranc Injuries.

BACKGROUND: Open reduction and internal fixation of Lisfranc injuries has typically used multiple longitudinal incisions or a single transverse incision to approach the tarso-metatarsal joint (TMTJ). The incidence of wound-related complications is considerable. We describe a novel single-incision approach that utilizes subcutaneous windows to the medial TMTJ. METHODS: A retrospective review identified 150 patients who underwent open reduction and internal fixation for Lisfranc injuries, via the modified dorsal approach, at our center between January 2011 and June 2016. Removal of hardware (ROH) was routinely undertaken in 105 patients at a median of 210 days postoperatively. Medical records were reviewed to record patient demographics, mechanism of injury, and operative details. Outpatient notes were reviewed to identify wound-related complications, including delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma, and impaired sensation. Median age was 37 years (range, 19-78 years). Seventy-three percent of patients (110) were male. Most frequent mechanisms of injury were motor vehicle accident (MVA), 39%; motorbike accident (MBA), 19%; and fall, 18%. Sixteen percent (24) of injuries were open. Five patients required soft tissue reconstruction at the primary operation. Median follow-up was 144 (range, 27-306) weeks. RESULTS: Following the primary procedure, 14% of patients experienced wound-related complications including delayed healing (3%), superficial infection (5%), dehiscence (3%), complex regional pain syndrome (CRPS) (1%), and impaired sensation (1%). MBA injuries were at 15.1 times odds of superficial infection ( P =.01) than were MVA injuries. Following ROH, 13% of patients experienced wound-related complications, including delayed healing (2%), superficial infection (8%), dehiscence (1%), CRPS (2%), and neuroma (1%). Overall, 5 patients returned to surgery for soft tissue reconstruction for wound dehiscence. CONCLUSION: The modified dorsal approach using intervals to the midfoot offers a viable alternative with comparable wound complication rates to existing midfoot approaches. LEVEL OF EVIDENCE: Level IV, case series.

Functional Outcomes Post Lisfranc Injury-Transarticular Screws, Dorsal Bridge Plating or Combination Treatment?

OBJECTIVE: To identify whether transarticular screws, dorsal bridging plates or a combination of the 2 result in the best functional outcome after Lisfranc injury. DESIGN: Case series. SETTING: Level one trauma center. PATIENTS: Fifty patients who underwent surgical fixation of Lisfranc injuries over a 6-year period were retrospectively reviewed. INTERVENTION: One of 3 treatment arms: transarticular screw fixation alone, dorsal bridge plating alone or a combination of dorsal bridge and transarticular screw fixation. MAIN OUTCOME MEASURES: The primary outcome measures were 1 of 2 midfoot scores-the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI) Score. Secondary results included postoperative complications. RESULTS: Quality anatomical reduction is the best predictor of functional outcomes (FFI-P = 0.008, AOFAS-P = 0.02). Functional outcomes with both FFI and AOFAS scores were not significantly associated with any of the fixation groups (FFI-P = 0.495, AOFAS-P = 0.654) on univariate analysis. Injury type by Myerson classification systems or open versus closed status was also not significantly associated with any fixation group. Open exposures were more likely to result in soft-tissue complications, but there was no significant difference in metalware failure or need for removal. CONCLUSION: Functional outcomes after Lisfranc fractures are most dependant on the quality of anatomical reduction and not the choice of fixation implant used. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury.

AIM: The classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility. PATIENTS: We retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores. RESULTS: Injuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p=0.004, AOFAS p=0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p=0.147, AOFAS p=0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p=0.008, AOFAS p=0.02). CONCLUSION: Column involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.

Twelve-month work-related outcomes following hip fracture in patients under 65 years of age.

INTRODUCTION: Recent research has highlighted the need for improved outcome reporting in younger hip fracture patients. For this population, return to work (RTW) is a particularly important measure against which to evaluate treatment outcomes. However, to date, only two small studies have reported RTW outcomes in young hip fracture patients and neither investigated factors predictive of RTW. The aims of this study were to report return to work (RTW) status and predictors of RTW 12 months after hip fracture in patients <65 years. METHODS: Two hundred and ninety-one adults aged <65 years, admitted with hip fractures between July 2009 and June 2013 and registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included in this prospective cohort study. Twelve-month return to work status was collected through structured telephone interviews conducted by trained interviewers. Multivariate logistic regression was used to identify demographic and injury variables that were important predictors of 12-month work status. RESULTS: Sixty-five per-cent of patients had returned to work 12 months after hip fracture (62% of whom had an isolated hip fracture and 38% of whom had additional injuries). Relative to patients aged 16-24 years, odds of RTW was reduced by 78%-89% for each 10-year increase in age (p=0.02). Relative to patients employed as managers/administrators/professionals, odds of RTW were 68% to 95% lower for all other workers (p<0.001). For those reporting a pre-injury disability, odds of RTW were 79% lower compared to those without disability (p=0.004) and 69% lower for patients with multiple injuries compared to isolated hip fracture patients (p=0.002). Finally, patients compensated by a work or transport insurer had a 67% lower odds of RTW relative to patients who were not compensated (p=0.02). CONCLUSIONS: Approximately one third of patients <65years had not returned to work 12 months after hip fracture. Patients who are older, have multiple injuries or pre-existing disabilities or who work in more physical occupations may need more assistance to RTW following hip fracture. The compensation system should be examined to determine why compensated patients may be at risk of poor RTW outcomes.

Plates, Screws, or Combination? Radiologic Outcomes After Lisfranc Fracture Dislocation.

Traditionally, Lisfranc fracture dislocations have been treated with transarticular screw fixation. A more recent development has been the use of dorsal bridging plates. The aim of the present study was to compare the radiologic outcomes for these 2 methods. Currently, no data comparing the outcomes of these 2 treatment options have been reported. A total of 62 patients were treated for Lisfranc fracture dislocations during a 6-year period. The inclusion criteria included ≥6 months of follow-up data available. Each fracture was classified using the Hardcastle classification system. Each fracture was also allocated into 1 of 4 groups: transarticular screw fixation, dorsal plating, a combination of plate and screw fixation, and nonoperative management. The outcome measures included the Kellgren-Lawrence grading of osteoarthritis and the Wilppula classification of anatomic reduction. In terms of results, radiologic osteoarthritis is not associated with the type of injury according to the Hardcastle classification nor with having an open or closed fracture. The Hardcastle classification is not associated with the type of fixation used. Fractures fixed with a combination of plates and screws had a 3.01 (95% confidence interval 1.036 to 8.74) increased risk of having stage 3 or 4 radiologic osteoarthritis compared with being fixed solely with bridging plates (p = .009). Multivariate analysis revealed that this increased risk of osteoarthritis was dependent on the quality of reduction, with good reductions having a 18.2 (95% confidence interval 15.9 to 21.8) times decreased risk of severe osteoarthritis compared with fair or poor reductions, independent of the type of fixation used (p < .0001). No radiologic benefits were found when comparing plate or screw fixation for Lisfranc fracture dislocations (although screw fixation might be associated with a less planus foot and fewer complications). Instead, a good anatomic reduction was the only predictor of the radiologic outcome, and the Hardcastle classification of fractures did not predict the surgery type or radiologic outcome. Finally, treatment with combination plates and screws resulted in worse radiologic outcomes, possibly owing to more complex fracture patterns.

Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome.

INTRODUCTION: Subtrochanteric neck of femur fractures are a challenge to treat due to anatomical and biomechanical factors. Poor reduction, varus deformity, nonunion and return to theatre risks are high. A cerclage wire can augment an intramedullary nail to help fracture reduction and construct stability. Concerns exist regarding the use of cerclage wire on fracture zone vascularity. The aim of this study was to assess the benefits and adverse outcomes associated with the use of cerclage wiring. PATIENTS AND METHODS: A 7-year retrospective review of all subtrochanteric fractures at a Level 1 trauma centre was performed. Pathological fractures, those associated with bisphosphonate use and segmental fractures were excluded. A clinical and radiographic review was performed. Our primary outcome measure was a composite of the major complications of this surgery, defined as either return to theatre for fixation failure, nonunion or implant failure. Fracture displacement, angulation and quality of reduction were measured as secondary outcome measures. Specific complications of the use of cerclage wiring were also reported. RESULTS: One hundred and thirty four cases met the inclusion criteria for primary outcome. Reduction was achieved closed in 51.9% (n=70), open in 33.3% (n=45) and open with cerclage wire in 14.8% (n=20). Overall there were a total of 13 (9.7%) major complications. No cases with cerclage wire had a return to theatre. If cerclage wire was not used the major complication rate was 11.4%. Fracture displacement (11.0mm vs. 7.69mm) and distraction were related to return to theatre (p<0.05). Cerclage wire use improved fracture displacement (3.2mm vs. 8.8mm), angulation and quality of reduction (p<0.05). CONCLUSIONS: Anatomical reduction is the key to success of subtrochanteric fractures. Cerclage wire use results in better fracture reduction. Some subtrochanteric fractures can be successfully treated with indirect reduction alone. If fractures cannot be reduced closed, reduction should be achieved by open methods. If a fracture is opened, a cerclage wire should be used, if the fracture pattern allows.

Too much vacuum-assisted closure.

There has been an explosion in the use of the vacuum-assisted closure device since 1997. Selectively and judiciously used, it is a valuable tool. However, we are concerned by the expanding list of 'indications' for its use. Prolonged applications, frequently several weeks, at the expense of early surgical reconstruction, might compromise the outcome in selected cases. We report four cases that illustrate this problem and stress the importance of timely surgical reconstruction utilizing the range of reconstructive techniques available as well as vacuum-assisted closure dressing.