Tibiotalocalcaneal nail and primary closure for the management of open ankle fractures in the elderly patient; results from a major trauma centre.

INTRODUCTION: Open ankle fractures in elderly patients are challenging injuries to manage. The aim of this study was to assess the outcome of elderly patients with open ankle fractures treated with a tibiotalocalcaneal nail and primary wound closure. METHODS: We identified all open ankle fractures in patients over 65 referred to our major trauma centre managed with a tibiotalocalcaneal nail and primary wound closure over 10 years. We recorded patient demographics, comorbidities, injury mechanism, length of stay, operation, weightbearing status, re-operations, infections and mortality. RESULTS: We included 34 patients with an average age of 87 (73-99). We found 56 % of patients' mobility status declined post-operatively and 21 % of patients were discharged directly home. Four patients required further unplanned surgery including two deep infections requiring amputation. We had a 6 % three month mortality rate. CONCLUSION: Use of a tibiotalocalcaneal nail with primary wound closure offers a reasonable treatment option for open fractures of the ankle in the elderly patient.

Strain reduction screws for nonunions following fixation around the elbow - A case series and review of the literature.

Background: Nonunions following fracture fixation result in significant patient morbidity and financial burden. Traditional operative management around the elbow consists of removal of metalwork, debridement of the nonunion and re-fixation with compression, often with bone grafting. Recently, some authors in the lower limb literature have described a minimally invasive technique used for select nonunions where simply placing screws across the nonunion facilitates healing by reducing inter-fragmentary strain. To our knowledge, this has not been described around the elbow, where traditional more invasive techniques continue to be employed. Aims: The aim of this study was to describe the application of strain reduction screws for management of select nonunions around the elbow. Methods & Results: We describe 4 cases (two humeral shaft, one distal humerus and one proximal ulna) of established nonunion following previous internal fixation, where minimally invasive placement of strain reduction screws were used. In all cases, no existing metal work was removed, the nonunion site was not opened, and no bone grafting or biologic stimulation was used. Surgery was performed between 9 and 24 months after the original fixation. 2.7 mm or 3.5 standard cortical screws were placed across the nonunion without lagging. Three fractures went on to unite with no further intervention required. One fracture required revision fixation using traditional techniques. Failure of the technique in this case did not adversely affect the subsequent revision procedure and has allowed refinement of the indications. Conclusion: Strain reduction screws are safe, simple and effective technique to treat select nonunions around the elbow. This technique has potential to be a paradigm shift in the management of these highly complex cases and is the first description in the upper limb to our knowledge.

'Modern' distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure: five-year experience from a United Kingdom major trauma centre.

AIMS: Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient's ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function. PATIENTS AND METHODS: All patients treated at our centre with lateral distal femoral locking plates (LDFLP) between 2009 and 2014 were identified. Fracture classification and operative information including weight-bearing status, rates of union, re-operation, failure of implants and mortality rate, were recorded. RESULTS: A total of 127 fractures were identified in 122 patients. The mean age was 72.8 years (16 to 101) and 92 of the patients (75%) were female. A consultant performed the operation in 85 of the cases, (67%) with the remainder performed under direct consultant supervision. In total 107 patients (84%) were allowed to bear full weight immediately. The rate of clinical and radiological union was 81/85 (95%) and only four fractures of 127 (3%) fractures required re-operation for failure of surgery. The 30-day, three- and 12-month mortality rates were 6 (5%), 17 (15%) and 25 (22%), respectively. CONCLUSION: Our study suggests an exponential increase in the incidence of a fracture of the distal femur with age, analogous to the population suffering from a proximal femoral fracture. Allowing immediate unrestricted weight-bearing after LDFLP fixation in these elderly patients was not associated with failure of fixation. There was a high rate of union and low rate of re-operation. Cite this article: Bone Joint J 2017;99-B:951-7.

Auditing orthopaedic audit.

INTRODUCTION: Clinical audit plays an important role in the drive to improve the quality of patient care and thus forms a cornerstone of clinical governance. Assurance that the quality of patient care has improved requires completion of the audit cycle. A considerable sum of money and time has been spent establishing audit activity in the UK. Failure to close the loop undermines the effectiveness of the audit process and wastes resources. PATIENTS AND METHODS: We analysed the effectiveness of audit in trauma and orthopaedics at a local hospital by comparing audit projects completed over a 6-year period to criteria set out in the NHS National Audit and Governance report. RESULTS: Of the 25 audits performed since 1999, half were presented to the relevant parties and only 20% completed the audit cycle. Only two of these were audits against national standards and 28% were not based on any standards at all. Only a third of the audits led by junior doctors resulted in implementation of their action plan compared to 75% implementation for consultant-led and 67% for nurse-led audits. CONCLUSIONS: A remarkably large proportion of audits included in this analysis failed to meet accepted criteria for effective audit. Audits completed by junior doctors were found to be the least likely to complete the cycle. This may relate to the lack of continuity in modern medical training and little incentive to complete the cycle. Supervision by permanent medical staff, principally consultants, and involvement of the audit department may play the biggest role in improving implementation of change.

Focal femoral osteolysis after revision hip replacement with a cannulated, hydroxyapatite-coated long-stemmed femoral component: a new route for particulate wear debris.

We describe a case of symptomatic focal femoral osteolysis around a screw hole distal to the hydroxyapatite-coated portion of a cannulated femoral component in a revision hip replacement. No locking screw had been inserted into this, the most proximal of the three distal holes for locking screws. The presence of polyethylene wear debris in the tissue excised from the lesion suggested that it had passed through the cannulated portion of the stem and out of the proximal unfilled distal locking hole, initiating an osteolytic reaction in an otherwise well-fixed stem. This case highlights an important design characteristic of such cannulated, uncemented femoral components. We recommend that the proximal aperture of these cannulated stems be occluded at implantation.

From presentation to publication: the natural history of orthopaedic abstracts in the United Kingdom.

BACKGROUND: Up to 63% of the chapters in major orthopaedic textbooks use the results from abstracts that have been presented at international orthopaedic meetings. METHODS: Orthopaedic abstracts were reviewed that were presented at the 1997 and 1998 meetings of the British Orthopaedic Association and other specialist orthopaedic meetings. The number of abstracts that had gone on to a full text publication was assessed and changes in study design or outcome were determined. RESULTS: Of the 415 abstracts 137 (33.0%) went on to full text publication. Abstracts presented at the British Orthopaedic Association were significantly more likely to go on to full text publication than abstracts from the other meetings studied. The mean time to publication was 15.6 months. Sample sizes in unpublished studies were smaller (mean 129.8 subjects compared with a mean of 191.4 subjects for published studies). Of full text papers, 19.0% differed regarding study design from the abstract presented at the initial meeting and 10.9% had published different results. Randomised controlled trials had the highest rate of later full text publication (53.6%) followed by observational studies (32.8%), basic science studies (31.4%), and case reports (6.7%). CONCLUSIONS: In comparison with a study from North America, similar numbers of abstracts presented at meetings finally became published as full text articles, the abstracts had fewer authors, more often included randomised controlled trials and follow up data, and had fewer changes to the results. It is questionable whether the inclusion of such results from abstracts presented at international meetings by major orthopaedic textbooks should be undertaken before full text publication.

Balancing priorities in the management of hip fractures: guidelines versus resources.

BACKGROUND: About 60,000 patients are treated for hip fractures each year in the UK and the incidence is increasing. The majority of these patients are elderly and sick, and delay to operation may be fatal. The National Confidential Enquiry into Peri-Operative Deaths (NCEPOD) guidelines aim to improve quality of care for such patients. However, we present an audit highlighting the importance of balancing the implementation of such guidelines with available local resources to ensure that established priorities in the care of these patients remain paramount. METHODS: The 2001 NCEPOD report recommends that pre-operative transthoracic echocardiography be performed in patients who have evidence of aortic stenosis in order to identify those requiring invasive monitoring and high dependency unit care postoperatively. RESULTS: We have assessed the impact of the implementation of these guidelines on surgery for fractured neck of femur at our hospital, auditing both delay to surgery and the effect of the investigation on subsequent management. In the period studied prior to the introduction of the NCEPOD guidelines, no patients underwent pre-operative echocardiography. Subsequent to their introduction, 10% of patients underwent the investigation, which in the current study did not alter management but did delay surgery by 4-8 days in all cases. CONCLUSIONS: For such guidelines to be implemented, adequate resources should first be provided. In the absence of these resources, clinicians must balance the need for adequate pre-operative assessment with the need for urgent surgery.