Current concepts in the management of bisphosphonate associated atypical femoral fractures.

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Tension band suture technique for the fixation of a displaced posterolateral acromion process fracture with subacromial impingement.

An adult old cyclist presented to our hospital and was referred to the orthopaedic department with a left shoulder posterolateral acromion avulsion fracture and subacromial impingement demonstrated on X-ray and CT. This highly unusual fracture pattern was treated by open reduction and internal fixation with cannulated screws and a tension band suture technique. This fracture went onto successful union with full range of motion and good patient-reported outcome measures by the Oxford Shoulder Score at 3 months. Informed consent was taken for the following case report.

The effect of handover location on trauma theatre start time: An estimated cost saving of £131 000 per year.

BACKGROUND: The National Health Service was estimated to be in £2.45 billion deficit in 2015 to 2016. Trauma theatre utilization and efficiency has never been so important as it is estimated to cost £15/minute. METHODS: Structured questionnaires were given to 23 members of staff at our Trust who are actively involved in the organization or delivery of orthopaedic trauma lists at least once per week. This was used to identify key factors that may improve theatre efficiency. Following focus group evaluation, the location of the preoperative theatre meeting was changed, with all staff involved being required to attend this. Our primary outcome measure was mean theatre start time (time of arrival in the anaesthetic room) during the 1 month immediately preceding the change and the month following the change. RESULTS: Theatre start time was improved on average 24 minutes (1 month premeeting and postmeeting change). This equates to a saving of £360 per day, or £131 040 per year. CONCLUSION: Changing the trauma meeting location to a venue adjacent to the trauma theatre can improve theatre start times, theatre efficiency, and therefore result in significant cost savings.

Antiphospholipid syndrome: a series of surgical emergencies and the current evidence for its management.

It is generally accepted that antiphospholipid syndrome remains a major medical problem characterised by hypercoagulability, arterial and venous thrombosis and thrombocytopenia. It is unclear how best to treat these patients should they require emergency surgery. If a lupus anticoagulant is present, hypercoagulability may occur de novo but surgical interventions along with sepsis are two important predisposing factors. We describe three patients with primary antiphospholipid syndrome and discuss the implications for surgery.