Surgical versus non-surgical management of lateral compression type-1 pelvic fracture in adults 60 years and older: the L1FE RCT.

Background: Lateral compression type-1 pelvic fractures are a common fragility fracture in older adults. Patients who do not mobilise due to ongoing pain are at greater risk of immobility-related complications. Standard treatment in the United Kingdom is provision of pain relief and early mobilisation, unlike fragility hip fractures, which are usually treated surgically based on evidence that early surgery is associated with better outcomes. Currently there is no evidence on whether patients with lateral compression type-1 fragility fractures would have a better recovery with surgery than non-surgical management. Objectives: To assess the clinical and cost effectiveness of surgical fixation with internal fixation device compared to non-surgical management of lateral compression type-1 fragility fractures in older adults. Design: Pragmatic, randomised controlled superiority trial, with 12-month internal pilot; target sample size was 600 participants. Participants were randomised between surgical and non-surgical management (1 : 1 allocation ratio). An economic evaluation was planned. Setting: UK Major Trauma Centres. Participants: Patients aged 60 years or older with a lateral compression type-1 pelvic fracture, arising from a low-energy fall and unable to mobilise independently to a distance of 3 m and back due to pelvic pain 72 hours after injury. Interventions: Internal fixation device surgical fixation and non-surgical management. Participants, surgeons and outcome assessors were not blinded to treatment allocation. Main outcome measures: Primary outcome - average patient health-related quality of life, over 6 months, assessed by the EuroQol-5 Dimensions, five-level version utility score. Secondary outcomes (over the 6 months following injury) - self-rated health, physical function, mental health, pain, delirium, displacement of pelvis, mortality, complications and adverse events, and resource use data for the economic evaluation. Results: The trial closed early, at the end of the internal pilot, due to low recruitment. The internal pilot was undertaken in two separate phases because of a pause in recruitment due to the coronavirus disease 2019 pandemic. The planned statistical and health economic analyses were not conducted. Outcome data were summarised descriptively. Eleven sites opened for recruitment for a combined total of 92 months. Three-hundred and sixteen patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reason for ineligibility was that the patient was able to mobilise independently to 3 m and back (n = 161). Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). There were 11 participants, 5 randomised to surgical management with internal fixation device and 6 to non-surgical management. The average age of participants was 83.0 years (interquartile range 76.0, 89.0) and the EuroQol-5 Dimensions, five-level version utility score at 6 months post randomisation (n = 8) was 0.32 (standard deviation 0.37). A limitation of the trial was that study objectives were not addressed due to poor recruitment. Conclusions: It was not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial. Future work: Exploration of equipoise across different healthcare professional groups. Investigate longer-term patient outcomes. Trial registration: This trial is registered as ISRCTN16478561. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information.

When older adults with weak bones fall onto their side, they can fracture the pelvis in a certain way known as a 'lateral compression type-1 fracture'; this summary will use 'pelvic fracture'. Pelvic fractures can heal without surgery; patients are offered pain relief and encouraged to move as much as they can after the injury. Pelvic fractures can be painful, and some people are not able to get up and walk for weeks. These fractures can cause health problems such as chest infections, urinary tract infections, pressure sores and blood clots. To avoid these problems, we are trying to find treatments to help people recover sooner. Pelvic surgeons think patients may benefit from surgery with an internal fixation device (a bar and screws) to stabilise the pelvis; however, there can be risks and complications with any surgery. This study aimed to find out which treatment is better for patients and better value for money for the National Health Service. This required 600 people aged over 60, in hospital with a pelvic fracture and having difficulty walking to take part. Three hundred would receive surgery and 300 would receive non-surgical treatment. Over 6 months, participants would complete questionnaires, a walking assessment and have X-rays to check healing. The trial had a 12-month run-in period to see if enough people would take part. The trial closed early as we were unable to recruit sufficient people into the study. Fewer older patients with pelvic fractures were identified than expected, 51% were able to walk after a few days and therefore were not eligible to be included in the study. Of the patients, 13.6% were eligible and 30.6% of those consented to take part. Restrictions on visitors during the coronavirus disease 2019 pandemic made it difficult to discuss the study with patients' families and fewer patients were admitted to hospital where the study was taking place. The research question could not be answered by this study at the present time.

Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study.

BACKGROUND: Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures. METHODS: We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty. RESULTS: Patients had a median follow up of 12 months (6-98 months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213 min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups. CONCLUSION: We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons. LEVEL OF EVIDENCE: Level III.

Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock.

BACKGROUND: High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS: This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS: Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION: Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.

Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures.

BACKGROUND: Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. METHODS: A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. DISCUSSION: The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.

Acute versus delayed total hip arthroplasty after acetabular fracture fixation: a systematic review and meta-analysis.

BACKGROUND: Post-traumatic osteoarthritis (PTOA) is a disabling complication of open reduction and internal fixation (ORIF) for acetabular fractures. There is a trend towards acute total hip arthroplasty (THA), 'fix-and-replace', in patients considered to have a poor prognosis and likelihood of PTOA. Controversy remains between early fix-and-replace, versus delayed THA as required after initial ORIF. This systematic review included studies comparing functional and clinical outcomes between acute versus delayed THA after displaced acetabular fractures. METHODS: Comprehensive searches following the PRISMA guideline were performed on six databases for articles in English published anytime up to 29 March 2021. Two authors screened articles and discrepancies were resolved by consensus. Patient demographics, fracture classification, functional and clinical outcomes were compiled and analysed. RESULTS: The search yielded 2770 unique studies, of which five retrospective studies were identified with a total of 255 patients. Of them, 138 (54.1%) were treated with acute and 117 (45.9%) treated with delayed THA. Delayed THA group represented a younger cohort compared to the acute group (mean age, 64.3 vs 73.3). The mean follow-up time for the acute and delayed group was 23 and 50 months, respectively. There was no difference in functional outcomes between the two study groups. Complication and mortality rates were comparable. Delayed THA had a higher revision rate compared to the acute group (17.1 vs 4.3%; p = 0.002). CONCLUSION: Fix-and-replace had functional outcomes and complication rates similar to ORIF and delayed THA, but lower revision rates. Although the quality of studies was mixed, sufficient equipoise now exists to justify randomised studies in this area. PROSPERO registration: CRD42021235730.

Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures? - A metanalysis of retrospective cohort studies and systematic review of the current evidence.

INTRODUCTION: Atypical periprosthetic/peri-implant fractures are not recognised in any widely used classification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use. HYPOTHESIS: Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union? MATERIAL AND METHODS: Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports. RESULTS: Metanalysis reported a risk ratio of 14.1, p=0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias. DISCUSSION: Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility. LEVEL OF EVIDENCE: II, Systematic review and metanalysis.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre.

BACKGROUND: Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations, trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom. To promote centralisation of care and optimisation of major trauma outcomes, in 2012 the National Health Service introduced the Trauma Network System. To our knowledge, this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom, since nationwide introduction of the Trauma Network System. AIM: To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre, and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives. METHODS: 227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018. Paediatric patients (< 18 years) and fragility fractures were excluded, leaving 175 patients for inclusion in the study. Statistical analysis was performed using Fisher's exact test for categorical variables. RESULTS: 72% of pelvic and acetabular fractures occurred in male patients at a median age of 45 years. 15% were the result of a suicide attempt. 48% of patients required pelvic or acetabular surgery, with 38% undergoing further surgery for additional orthopaedic injuries. 43% of patients were admitted to intensive care. The median inpatient stay was 13 days, and the 30- day mortality was 5%. Pelvic ring trauma was more commonly associated with abdominal injury (P = 0.01) and spine fractures (P < 0.001) than acetabular fractures. Vertical shear pelvic ring fractures were associated with falls (P = 0.03) while lateral compression fractures were associated with road traffic accidents (P = 0.01). CONCLUSION: High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures (most commonly spine and lower limb), intensive care admission and prolonged inpatient stays. Most pelvic ring injuries secondary to road traffic accidents are lateral compression type, demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.

Theatre efficiency in COVID-19 pandemic conditions: The collaborative experience of four level 1 major trauma centres in the UK.

AIMS: As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London's four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. METHODS: This was a collaborative study across London's MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. RESULTS: In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). CONCLUSION: Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886-892.

Removal of iliosacral screws: the washer problem.

Iliosacral screw removal is an infrequent surgery, and when needed, removal of the washer can be surprisingly difficult. Different forceps, clamps and other non-specific instruments are frequently used to this end, many a time without success, or at the expense of tissue damage, blood loss and radiation exposure. After trying all the tricks in the book, we devised this neat little surgical tactic that ensures easy and reliable retrieval of the washer when removing iliosacral screws percutaneously, with no increased morbidity.

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis.

INTRODUCTION: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients' lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. MATERIALS AND METHODS: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. RESULTS: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo-Anderson classification or varying study characteristics. CONCLUSION: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to 'as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h'.

Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era.

BACKGROUND: Hip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population. AIM: To quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process. METHODS: Two hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors. RESULTS: COVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events. CONCLUSION: The COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.

Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms.

Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures.

AIMS: During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. METHODS: This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. RESULTS: COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. CONCLUSION: Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.

Reflections from London's Level-1 Major Trauma Centres during the COVID crisis.

Emergence of the Covid-19 pandemic resulted in dramatic changes in global healthcare provision. Resources were redirected across all healthcare sectors to support the treatment of viral pneumonia with resultant effects on other essential services. We describe the impact of this on the provision of major trauma care in a major capital city.

TULIP: a randomised controlled trial of surgical versus non-surgical treatment of lateral compression injuries of the pelvis with complete sacral fractures (LC1) in the non-fragility fracture patient-a feasibility study protocol.

INTRODUCTION: Lateral compression type 1 (LC1) pelvic fractures are the most common type of pelvic fracture. The majority of LC1 fractures are considered stable. Fractures where a complete sacral fracture is present increases the degree of potential instability and have the potential to displace over time. Non-operative management of these unstable fractures may involve restricted weight bearing and significant rehabilitation. Frequent monitoring with X-rays is also necessary for displacement of the fracture. Operative stabilisation of these fractures may be appropriate to prevent displacement of the fracture. This may allow patients to mobilise pain-free, quicker. METHODS AND ANALYSIS: The study is a feasibility study to inform the design of a full definitive randomised controlled trial to guide the most appropriate management of these injuries. Participants will be recruited from major trauma centres and randomly allocated to either operative or non-operative management of their injuries. A variety of outcome instruments, measuring health-related quality of life, functional outcome and pain, will be completed at several time points up to 12 months post injury. Qualitative interviews will be undertaken with participants to explore their views of the treatments under investigation and trial processes.Eligibility and recruitment to the study will be analysed to inform the feasibility of a definitive trial. Completion rates of the measurement instruments will be assessed, as well as their sensitivity to change and the presence of floor or ceiling effects in this population, to inform the choice of the primary outcome for a definitive trial. ETHICS AND DISSEMINATION: Ethical approval for the study was given by the South West-Central Bristol NHS Research Ethics Committee on 2nd July 2018 (Ref; 18/SW/0135). The study will be reported in relevant specialist journals and through presentation at specialist conferences. TRIAL REGISTRATION NUMBER: ISRCTN10649958.

Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review.

OBJECTIVES: To undertake a systematic review of the evidence base for the effectiveness of surgical fixation of lateral compression (LC-1) fragility fractures of the pelvis compared with non-surgical approaches. SEARCHES: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and two international trials registers were searched up to January 2017 (MEDLINE to February 2019) for studies of internal or external fixation of fragility fractures of the pelvis. PARTICIPANTS: Patients with lateral compression pelvic fractures, sustained as the result of a low-energy mechanism, defined as a fall from standing height or less. INTERVENTIONS: Surgery using either external or internal fixation devices. Conservative non-surgical treatment was the defined comparator. OUTCOME MEASURES: Outcomes of interest were patient mobility and function, pain, quality of life, fracture union, mortality, hospital length of stay and complications (additional operative procedures, number and type of adverse events and serious adverse events). QUALITY ASSESSMENT AND SYNTHESIS: The Joanna Briggs Institute Checklist for Case Series was used to assess the included studies. Results were presented in a narrative synthesis. RESULTS: Of 3421 records identified, four retrospective case series met the inclusion criteria. Fixation types were not consistent between studies or within studies and most patients had more than one type of pelvic fixation. Where reported, mobility and function improved post-surgery, and a reduction in pain was recorded. Length of hospital stay ranged from 4 days to 54 days for surgical fixation of any type. Reported complications and adverse outcomes included: infections, implant loosening, pneumonia and thrombosis. Use of analgesia was not reported. CONCLUSIONS: There is insufficient evidence to support guidance on the most effective treatment for patients who fail to mobilise after sustaining an LC-1 fragility fracture. TRIAL REGISTRATION NUMBER: CRD42017055872.

Are patient-reported outcome measures in orthopaedics easily read by patients?

BACKGROUND: Patient-reported outcome measures (PROMs) are commonly used by healthcare providers as means of assessing health-related quality of life and function at any given time. The complexity of PROMs can differ and when combined with varying degrees of adult literacy, error can be introduced if patients fail to understand questions. With an average adult literacy level of 11-year-old students in the United Kingdom, it is unclear to what degree PROMs can be read and understood by most patients (readability); to our knowledge, this has not been evaluated. QUESTIONS/PURPOSES: We wished to determine the readability of commonly used PROMs in orthopaedic surgery, as assessed by a validated tool that measures the complexity of the language in these surveys. METHODS: We performed a MEDLINE search to identify the most-commonly reported PROMs in orthopaedic research. One hundred twenty-one PROMs were identified and reviewed by 19 attending orthopaedic surgeons at our institution. Fifty-nine were selected as the most commonly used in our department. Of these, 52 (78%) were disease specific and included: 12 (20%) knee, 10 (17%) shoulder, seven (12%) spine, six (10%) hip, five (8%) foot and ankle, four (7%) elbow, three (5%) pelvis, three (5%) hand and wrist, and two (3%) lower limb. The remaining seven (12%) PROMs were general health questionnaires. The Flesch Reading Ease Score is a validated readability tool measuring average sentence length and syllables per word. It is expressed on a scale from 0 to 100 with higher scores indicating easier reading. We extracted the text from each PROM and inserted it in the same online Flesch Reading Ease Score calculator to generate a score. RESULTS: The mean readability score was 55 (range, 0-93), corresponding to text best understood by 16- to 18-year-old students (11th-12th grades). Twenty-nine PROMs (49%) scored less than 60, classifying them as at least fairly difficult to read. Eight (14%) scored less than 30, best understood by university graduates. Only seven of 59 PROMs analyzed scored greater than 79, corresponding to text that can be understood by the average UK adult. CONCLUSIONS: The majority of PROMs analyzed are written at a level that is incomprehensible to the average UK adult. CLINICAL RELEVANCE: This issue needs to be addressed if we are to continue basing our research conclusions on outcome scores. The information obtained is useful for patients to understand their musculoskeletal health, governmental agencies allocating healthcare resources, provision of management guidelines, and as a link to other data sets, such as hospital episodes statistics. Accurate and reliable data can be obtained only if patients who complete these evaluations are able to read and understand the questions asked.

Pre-operative Waterlow score: Predicts risk of post-operative infection in patients with neck of femur fractures.

INTRODUCTION: Nursing staff prospectively collect Waterlow scores (Ws) on all inpatients across most NHS hospitals, identifying patients at risk of pressure ulcers. This bedside score has not been applied in predicting other negative outcomes in patients with neck of femur (NOF) fractures. OBJECTIVES: To investigate the relationship between increasing Waterlow score and 30-day post-operative infection in patients with NOF fracture. PATIENTS AND METHODS: Pre-operative Ws and 30-day clinical outcome data were collected on 97 consecutive operatively treated NOF fracture patients at our institution (level one trauma centre). RESULTS: 30-day infection rate was 36%, which manifested as hospital acquired pneumonia (66%) and urinary tract infection (34%). For every one point increase in Ws, the odds of having an infection increased by 1.68 times (95% CI 1.37-2.08). The relationship between Ws and 30-day infection was similar when adjusted for potential confounders: patient demographics (age and gender), number of medical comorbidities, ASA grade, and days to surgery. For our data, the Ws predictive of infection was ≥17. This has a sensitivity of 84.9% (95% CI 68.1-94.9%) and a specificity of 84.1% (95% CI 74.7-92.1%). The area under the curve was 0.89 (95% CI 0.82-0.96). CONCLUSION: Our study demonstrates a strong relationship between increasing Ws and post-operative infection risk. This raises the interesting yet controversial question of using Ws to identify patients at high-risk of developing post-operative infections and the potential benefit of an extended period of antibiotic prophylaxis.

'Smart' electronic operation notes in surgery: an innovative way to improve patient care.

AIMS: Operation notes are the only comprehensive account of what took place during surgery. Accurate and detailed documentation of surgical operation notes is crucial, both for post-operative management of patients and for medico-legal clarity. The aims of this study were to compare operation documentation against the Royal College of Surgeons of England guidelines and to compare the before-and-after effect of introducing an electronic operation note system. METHODS: Fifty consecutive operation notes for inpatients that had undergone emergency orthopaedic trauma surgery were audited. An electronic operation note proforma was then introduced and a re-audit carried out after its implementation. RESULTS: The results after implementation of electronic operation notes, demonstrated a marked improvement. All notes contained an operation note (previously 5/6). Seventy five percent included time of surgery and age of patient (vs. 0% previously). A hundred percent included closure details and antibiotic selection at induction (vs. 60% and 69% respectively). Post-operative instructions improved to 100%. All were typed, making for 100% legibility as compared to only 66% of operation notes with legible hand writing in the initial audit. DISCUSSION/CONCLUSION: We used our pilot audit to target specific information that was commonly omitted and we 'enforced' these areas using drop-down selections in electronic operation note. This study has demonstrated that implementation of an electronic operation note system markedly improved the quality of documentation, both in terms of information detail and readability. We would recommend this template system as a standard for operation note documentation.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations.

The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.