Machine learning outperforms clinical experts in classification of hip fractures.

Hip fractures are a major cause of morbidity and mortality in the elderly, and incur high health and social care costs. Given projected population ageing, the number of incident hip fractures is predicted to increase globally. As fracture classification strongly determines the chosen surgical treatment, differences in fracture classification influence patient outcomes and treatment costs. We aimed to create a machine learning method for identifying and classifying hip fractures, and to compare its performance to experienced human observers. We used 3659 hip radiographs, classified by at least two expert clinicians. The machine learning method was able to classify hip fractures with 19% greater accuracy than humans, achieving overall accuracy of 92%.

Syndesmotic fixation in unstable ankle fractures: Does early post-operative weight bearing affect radiographic outcomes?

OBJECTIVE: To analyse whether early post-operative full weight bearing following syndesmotic ankle fixation affected radiographic outcomes suggestive of diastasis. DESIGN: Retrospective comparative cohort study over a two year period. SETTING: Level 1 trauma centre PATIENTS/PARTICIPANTS: 152 consecutive patients sustaining an unstable ankle fracture requiring syndesmotic stabilisation were included. Exclusions were 49 patients who had trimalleolar fixation without syndesmosis screws, one patient who had concomitant ankle and talar fracture. Five patients were lost to follow up and eleven patients were followed up in other centres. A total of 86 patients were analysed INTERVENTION: Protected or full weight bearing. MAIN OUTCOME MEASUREMENT: The primary outcome measure was early diastasis. The secondary outcomes were late diastasis, wound complications and re-operation. Analysis of variance was used for the predictor variable of weight bearing status. We assumed a priori that p values of less than 0.05 were significant. RESULTS: Median age was 36 (IQR 30), with 54 males and 32 females. Median follow up was 12 weeks (IQR 6). There was no significant difference when comparing weight bearing status and change in radiographic measurements intra-operatively compared to 6 and 12 week follow up radiographs (tibiofibular clear space p = 0.799, tibiofibular overlap p = 0.733 and medial clear space p = 0.261). CONCLUSION: After surgical stabilization of an unstable syndesmotic injury, full weight bearing did not lead to syndesmotic diastasis in the early post-operative period. Full weight bearing is recommended following ankle fixation which includes syndesmotic fixation.

Open tibial fractures in major trauma centres: A national prospective cohort study of current practice.

AIMS: To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. MATERIALS AND METHODS: Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. RESULTS: Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. CONCLUSIONS: Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.

The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications.

AIMS: The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications. PATIENTS AND METHODS: We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow-up time was 38 months (interquartile range 24 to 51). RESULTS: Three patients were excluded from the analysis leaving 47 patients with complete follow-up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint. CONCLUSION: The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients. Cite this article: Bone Joint J 2017;99-B.1232-6.

The administration of intermittent parathyroid hormone affects functional recovery from trochanteric fractured neck of femur: a randomised prospective mixed method pilot study.

AIMS: We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks. PATIENTS AND METHODS: We undertook a pilot study comparing the functional recovery after trochanteric hip fracture in patients 60 years or older, admitted with a trochanteric hip fracture, and potentially eligible to be randomised to either standard care or the administration of subcutaneous PTH for six weeks. Our desired outcomes were functional testing and measures to assess the feasibility and acceptability of the study. RESULTS: A total of 724 patients were screened, of whom 143 (20%) were eligible for recruitment. Of these, 123 were approached and 29 (4%) elected to take part. However, seven patients did not complete the study. Compliance with the injections was 11 out of 15 (73%) showing the intervention to be acceptable and feasible in this patient population. TAKE HOME MESSAGE: Only 4% of patients who met the inclusion criteria were both eligible and willing to consent to a study involving injections of PTH, so delivering this study on a large scale would carry challenges in recruitment and retention. Methodological and sample size planning would have to take this into account. PTH administration to patients to enhance fracture healing should still be considered experimental. Cite this article: Bone Joint J 2016;98-B:840-5.

Smoking status and the Disabilities of the Arm Shoulder and Hand score are early predictors of symptomatic nonunion of displaced midshaft fractures of the clavicle.

AIMS: This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery. METHODS: We performed a retrospective study of 88 patients aged between 16 and 60 years that were managed non-operatively. RESULTS: The rate of symptomatic nonunion requiring surgery was 14% (n = 13). Smoking (odds ratio (OR) 40.76, 95% confidence intervals (CI) 1.38 to 120.30) and the six week Disabilities of the Arm Shoulder and Hand (DASH) score (OR 1.11, 95% CI 1.01 to 1.22, for each point increase) were independent predictors of nonunion. A six week DASH score of 35 or more was identified as a threshold value to predict nonunion using receiver operating characteristic curve analysis. Smoking and the threshold value in the DASH and were additive risk factors for nonunion, when neither were present the risk of nonunion was 2%, if one or the other were present the nonunion rate was between 17% to 20%, and if both were present the rate increased to 44%. DISCUSSION: Patients with either of these risk factors, which include approximately half of all patients sustaining displaced midshaft fractures of the clavicle, are at an increased risk of developing a symptomatic non-union. TAKE HOME MESSAGE: Smoking and failure of functional return at six weeks are significant predictors of nonunion of the midshaft of the clavicle. Such patients warrant further investigation as to whether they would benefit from early surgical fixation in order to avoid the morbidity of a nonunion.

The Pattern of Injury and Workload Associated with Managing Patients After Suicide Attempt by Jumping from a Height.

PURPOSE: The aim of this study is to examine the pattern of injuries sustained and the hospital workload generated by patients who deliberately jump from height. METHOD: One regional trauma centre's admissions were scrutinized to find all patients who jumped, or were suspected of jumping from one storey or greater over a four year period. Patients who died prior to admission were excluded. RESULTS: 41 patients were included. Each patient suffered a mean of 3 injuries. The probability of calcaneal fracture was 0.32, of ankle injury 0.2, tibial fracture 0.2, femoral fracture 0.17, pelvic fracture 0.34, spinal injury 0.51, upper limb injury 0.26, head injury 0.2 and trunk injury 0.32. The mean length of inpatient stay was 7.9 days, rising to 17.9 for the 11 patients requiring intensive care. The average number of operations per patient was 1.5. CONCLUSION: Patients who jump from height generate large volumes of operative and inpatient workloads. Our data show that there may be a protective effect of limb trauma against lethal head, chest or pelvic injury. Injury to the upper limb is associated with a 4 times greater risk of head injury. The incidence of pelvic injury in this series is higher than in previous work. There was a high incidence of spinal fracture. Patients generated 64 surgical procedures and consumed a mean of 17.9 inpatient days, including prolonged stay in intensive care.

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society.

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri-operative period. The advice presented is based on previously published advice and clinical studies.

Investigation of occult hip fractures: the use of CT and MRI.

AIM: At present there is no data looking at modern multislice computerised tomography (CT) in the investigation of occult hip fracture. The aim of this study was to retrospectively compare the reports of patients sent for magnetic resonance imaging (MRI) or CT with negative radiographs and a clinical suspicion of a fractured neck of femur. METHODS: All patients presenting to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a three-year period were included. Patients were either investigated with an MRI scan or CT scan. The presence of a fracture, the requirement for surgery, and any further requirement for imaging were recorded. RESULTS: Over three years 92 patients were included of which 61 were referred for a CT and 31 for an MRI. Thirty-four patients were found to have a fracture. Of these, MRI picked up a fracture in 36% and CT in 38% of referrals. DISCUSSION: Up to 10% of proximal femur fractures may be missed on initial radiographs. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative hip radiographs. Our findings show that modern multislice CT may be comparable with MRI for detecting occult fracture.

The Bristol hip view: its role in the diagnosis and surgical planning and occult fracture diagnosis for proximal femoral fractures.

AIM: To evaluate whether a modified radiographic view of the femoral neck improves the diagnosis of occult proximal femoral. MATERIALS AND METHODS: Prospective study of patients presenting with clinically suspected proximal femoral fractures or who underwent traditional plain radiographic views and the Bristol hip view (a 30-degree angled projection). Six blinded independent observers assessed the images for presence of a fracture, anatomical level, and displacement. RESULTS: 166 consecutive patients presenting with the clinical diagnosis of a proximal femoral fracture, of which 61 sustained a fracture. Six of these were deemed occult due to negative plain and had proven fractures on subsequent cross-sectional imaging. The Bristol hip view demonstrated five of these six fractures. It performed better than the traditional lateral hip view to identify the injury. The Bristol hip view predicted correctly the fracture type and displacement in all cases and missed only one of the occult fractures. CONCLUSION: The Bristol hip view is more sensitive and clearer than a lateral projection for patients. It adds useful diagnostic information and performs better than the traditional views in occult fractures. Its use may prevent the need for further cross sectional imaging and subsequent surgical delay.

Survival of ceramic bearings in total hip replacement after high-energy trauma and periprosthetic acetabular fracture.

Surgeons remain concerned that ceramic hip prostheses may fail catastrophically if either the head or the liner is fractured. We report two patients, each with a ceramic-on-ceramic total hip replacement who sustained high-energy trauma sufficient to cause a displaced periprosthetic acetabular fracture in whom the ceramic bearings survived intact. Simultaneous fixation of the acetabular fracture, revision of the cementless acetabular prosthesis and exchange of the ceramic bearings were performed successfully in both patients. Improved methods of manufacture of new types of alumina ceramic with a smaller grain size, and lower porosity, have produced much stronger bearings. Whether patients should be advised to restrict high-impact activities in order to protect these modern ceramic bearings from fracture remains controversial.

The use of LISS femoral locking plates and cabling in the treatment of periprosthetic fractures around stable proximal femoral implants in elderly patients.

A retrospective review was performed of Vancouver type C periprosthetic femoral fractures treated using the Less Invasive Stabilisation System (LISS) femoral locking plate system. Five patients with stable hip prostheses (only one of which was an uncomplicated primary arthroplasty) were treated with the LISS plating system in combination with bone grafting and cables. The average age at the time of fixation was 87 years (range 83-93). All fractures united and all but one of the patients was able to mobilise independently. One case was complicated by superficial wound infection, but there were no other significant complications. One patient is still alive 50 months after surgery; the remaining four died a mean of 27 months postoperatively. Our results indicate that the LISS system is effective in the management of Type C periprosthetic fractures around well-fixed proximal femoral implants in the elderly, even in complex cases.

Determination of pelvic ring stability: a new technique using a composite hemi-pelvis.

Traumatic disruption of the pelvic ring caused by high-energy impact is associated with significant mortality and morbidity. A variety of fixation techniques have been developed for treating these injuries with the main aims of restoring the stability of the pelvic ring and promoting recovery of normal function. The stability of fixation of these techniques is often analysed by cadaveric studies, which can introduce high variability into the results and have small sample numbers. This study presents a new method that uses a composite hemi-pelvis to enable stabilization of the pelvic ring to be accurately determined. The pelvis was loaded cyclically to simulate walking conditions and to assess the stability of the fixation, which was measured using a displacement transducer that monitors the motion of the pelvis in six degrees of freedom. The motions measured showed comparable results with previously published cadaveric studies. This reproducible method of testing with a hemi-pelvis composite model and rig allows valid analysis of pubic symphysis implants, obviating the difficulties of performing a cadaveric study.