Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures.

The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.

High rate of radiolucent lines following the cemented original design of the ATTUNE total knee arthroplasty.

Aims: Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. Methods: A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken. Results: Of 263 studies, 12 were included with a total of 3,861 TKAs. Meta-analysis of ten studies showed high rates of overall tibial or femoral RLLs for the cemented original design of the ATTUNE TKA. The overall rate was 21.4% (95% confidence interval (CI) 12.7% to 33.7%) for all types of design but was higher for certain subgroups: 27.4% (95% CI 13.4% to 47.9%) for the cruciate-retaining type, and 29.9% (95% CI 15.6% to 49.6%) for the fixed-bearing type. Meta-analysis of five studies comparing the ATTUNE TKA with other implants showed a significantly higher risk of overall tibial or femoral RLLs (odds ratio (OR) 2.841 (95% CI 1.219 to 6.623); p = 0.016) for the ATTUNE. The rates of loosening or revision for loosening were lower, at 1.2% and 0.9% respectively, but the rates varied from 0% to 16.3%. The registry data did not report specifically on the original ATTUNE TKA or on revision due to loosening, but 'all-cause' five-year revision rates for the cemented ATTUNE varied from 2.6% to 5.9%. Conclusion: The original cemented ATTUNE TKA has high rates of RLLs, but their clinical significance is uncertain given the overall low associated rates of loosening and revision. However, in view of the high rates of RLLs and the variation in the rates of loosening and revision between studies and registries, close surveillance of patients who have undergone TKA with the original ATTUNE system is recommended.

Peer review practices in academic medicine: how the example of orthopaedic surgery may help shift the paradigm?

PURPOSE: To establish the current peer-reviewed practices in the discipline of orthopaedic surgery and correlate these to the journal's impact factor. Unfortunately, this is not receiving much attention and a critical literature gap in various disciplines; thus, determining the current practices in the discipline of orthopaedic surgery could provide valid insight that may be potentially applicable to other academic medicine disciplines as well. METHODS: Orthopaedic surgery journals belonging to the Journal Citation Reports were queried, and the following was extracted: impact factor (IF) and blinding practices: single (SBPR), double (DBPR), triple (TBPR), quadruple (QBPR), and open (OPR) blinding review process and possibility of author-suggested reviewer (ASR) and non-preferred reviewer (NPR) options. RESULTS: Of the 82 journals, four were excluded as they allowed submission by invitation only. In the remaining, blinding was as follows: SBPR nine (11.5%), DBPR 52 (66.7%), TBPR two (2.6%), QBPR zero (0%), and OPR three (3.8%), and in 12 (15.4%), this was unclear. ASR and NPR options were offered by 34 (43.6%) and 27 (34.6%) journals respectively, whereas ASR was mandatory in eight (10.2%). No correlation between IF and any other parameter was found. CONCLUSION: The rules of the "game" are unclear/not disclosed in a significant number of cases, and the SBPR system, along with the ASR (mandatory sometimes) and NPR, is still extensively used with questionable integrity and fairness. Several recommendations are provided to mitigate potentially compromising practices, along with future directions to address the scarcity of research in this critical aspect of science.

Patient perspective on the use of carbon fibre plates for extremity fracture fixation.

INTRODUCTION: Carbon fibre-reinforced polyetheretherketone (CFR-PEEK) plates represent an exciting development within trauma and orthopaedic surgery, offering advantages including radiolucency, material properties similar to bone, and lack of localised tissue reaction. As more call for trials examining their use, there is no data available as to the acceptability of these implants to patients. This study aimed to therefore examine the acceptability of CFR-PEEK plates to patients undergoing fracture surgery. METHODS: This was a prospective cross-sectional survey of patients undergoing surgery for a fracture of the ankle, distal femur, distal radius, or proximal humerus. Once a decision had been made to pursue operative fixation with a plate, patients were provided with descriptions of both CFR-PEEK and stainless steel and titanium metal implants alongside the current clinical evidence. All patients undertook a questionnaire examining their views as to the advantages and disadvantages of CFR-PEEK plates, and whether they would be happy to participate in a trial comparing both. RESULTS: Ninety-nine patients were happy to participate (64 females, mean age 50). Eighty-seven patients reported that they would want a CFR-PEEK implant for their fracture, and 76 reported that they would be willing to participate in an RCT comparing their use. Commonly reported advantages included radiolucency, low weight and biocompatibility. Disadvantages reported included cost and concerns regarding durability. CONCLUSIONS: This study demonstrates that CFR-PEEK implants would be acceptable to patients undergoing fracture surgery, with high numbers of patients stating that they would be willing to participate in a randomised study examining their use.

Has anything changed in Evidence-Based Medicine?

The Evidence-Based Medicine (EBM) movement, undoubtably one of the most successful movements in medicine, questions dogma and "clinical authority" and combines the "best available evidence" with clinical expertise and patient values in order to provide the best care for the individual patient. Although since its inception in the 1990s its strong theoretical foundations remain unaltered, a lot has changed in its practical implementation due to the electronic explosion of information and the unprecedented COVID-19 crisis. The purpose of this article is to succinctly provide the reader with an update on the major changes in EBM, including the important most recent ones that were "fast-tracked" due to the COVID-19 challenge.

Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique.

PURPOSE: The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis-Ilizarov method (ILF), or with Masquelet technique (MIF). METHODS: Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF). RESULTS: The average defect length was 5.6 cm (2.6-9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459-£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9. CONCLUSIONS: The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

Opportunities arising from the COVID-19: an international orthopaedic surgeons' perspective.

PURPOSE: The unprecedented COVID-19 experience has posed severe challenges to the health care system and several of these are documented in orthopaedic surgery; however, although the pandemic has also brought positive changes, these have not been precisely documented. The purpose of this survey is to identify positive perceptions by orthopaedic surgeons at an international level. METHODS: A cross-sectional, web-based survey inviting 120 orthopaedic surgeons was conducted in April 2020 querying about the positive lessons COVID-19 would teach us. From all responses, thematic codes were obtained and an exploratory thematic analysis was carried out to determine the prevalent themes. RESULTS: A total of 100 responses (83% response rate) from a total of seven countries were received. The variety of responses received were grouped into 13 different thematic codes. The thematic analysis generated two major themes: "Virtual reorganization" and "Wellness and sustainability". Fifty-four per cent of the participants reported positive changes in service reorganization and virtual consultation, whereas 30% replied with an increased feeling of well-being which overlapped with environmental benefits, including reduced paperwork, reduced travelling and increased quality time for family and reflection. CONCLUSIONS: Despite the negative aspects of the pandemic, responders reported several positive changes particularly relating to service reorganization and personal well-being. This study prompts further larger scale research to unravel further detail in those positive aspects and strongly enhance our future orthopaedic practice.

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures.

BACKGROUND: The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the 'gold standard' of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal. OBJECTIVES: The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post-operatively. METHODS: Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8-year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow-up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra-operative transfusion or transfusion during the first 48 h post-operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post-operatively. RESULTS: Incidence of blood transfusion was 6.0% pre-operatively, compared to 62.7% post-operatively. A total of 230 patients (52.3%) required either intra-operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post-operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30-day (p = 0.033) and one-year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post-operative hours was a pre-operative Hb <100 g/L (OR 6.64); a nail/canal ratio <70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre-operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30-day mortality (OR 12.07). CONCLUSION: Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48-h post-operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and mortality risk. LEVEL OF EVIDENCE: III.

Induced membrane technique for acute bone loss and nonunion management of the tibia.

Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects. Design: Retrospective study of prospectively collected data (Level IV). Setting: Level I trauma center in the UK. Patients/Participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss.Intervention: Two-stage Masquelet Procedure for the tibia. Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union. Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4-8 cm) and an 88.2% union rate at a mean of 8 months (range 5-18 months). Mean range of motion was 95 degrees of knee flexion (range 80°-130°). All patients but 2 returned to their previous occupation. Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.

Surgical Treatment of Marginal Impaction Injuries of The Acetabulum Associated with Posterior Wall Fractures.

Posterior-wall acetabular fractures have been reported to be associated with marginal impaction characteristics in approximately 16% to 38% of cases1-3. Early recognition of this special entity of joint impaction is essential for effective preoperative planning, intraoperative execution, and favorable outcomes. The 2-level reconstruction technique is safe and effective in experienced hands. Description: The procedure is performed with the patient under general anesthesia, placed under traction in either the prone or lateral position with use of a radiolucent flat-top fracture table and fluoroscopic guidance. The Kocher-Langenbeck approach is utilized. The big posterior wall fracture is identified and reflected in order to visualize the joint surface. Subsequently, traction is applied to facilitate visualization of the marginal impaction area(s). With use of an osteotome, the impacted fragments are disimpacted and elevated. The femoral head is utilized as a template for accurate reduction of the impacted fragments to the acetabular joint surface. The resultant subchondral void is assessed and may be grafted with use of a variety of bone graft materials. The 2-level reconstruction technique may also be considered when the surgeon desires to optimize stability of the impacted fragments and maintain anatomical reduction. The big posterior wall fragment is reduced and fixed with use of the standard posterior-wall reconstruction technique. Finally, irrigation and wound closure in layers is performed. Alternatives: Treatment alternatives include either delayed or acute primary total hip arthroplasty in elderly patients >70 years old. Rationale: Preoperative identification of the marginal impaction is critical because articular incongruency leads to the development of early posttraumatic osteoarthritis. Achieving joint congruency is especially important in the young population in order to avoid an otherwise unnecessary early total hip arthroplasty. Expected Outcomes: Expected radiographic outcomes are excellent or good in 82% of cases, as measured with use of the Matta radiographic score1-3. Expected function outcomes are good to excellent in 67.5% of patients, as measured with use of the Modified Merle d'Aubigné system1-3. Total hip arthroplasty has been reported as a secondary procedure within 2 years postoperatively in 7.6% of patients1-3. Important Tips: Joint irrigation is crucial in order to clarify the details of the fragmentation and facilitate removal of debris. Impacted articular cartilage fragments are often rotated and face away from the femoral head. Utilize osteotomes to elevate the impacted area, taking care to mobilize adequate subchondral bone and the accompanying cartilage in case the 2-level reconstruction technique is needed and can be successfully applied. Utilize the femoral head as a template after traction is released to facilitate anatomical reduction. A 1.6-mm Kirschner wire should be available in case it is needed to temporarily stabilize the impacted fragments. Avoid overstuffing the void with bone graft because this may subsequently hinder successful reduction of the posterior wall fragment. Acronyms and Abbreviations: CT = computed tomographyAP = anteroposteriorK wire = Kirschner wirePDS = polydioxanone sutureAVN = avascular necrosis.

Management and Outcomes of Bilateral Acetabular Fractures: A Critical Review of the Literature.

Background: Bilateral acetabular fractures constitute a rare entity, and their optimal management is unknown. Materials and Methods: A systematic literature search was conducted in PubMed, Embase and Cochrane Library between 1995 and 2020. Inclusion criteria were studies presenting cases of bilateral acetabular fractures and reporting outcomes. Extracted data included patient demographics, injury mechanism, fracture classification, associated injuries, management and outcomes. Results: Thirty-seven studies (47 cases; 35 males vs 12 females) were included. Mean age was 46 years old (range 13-84) and mean follow-up was 19.8 months (range 1.5-56). High-energy injuries (49%) and seizures (45%) were the most common injury mechanisms. Fracture type distribution differed according to injury mechanism. Treatment was surgical in 70% of cases (75% open reduction and internal fixation vs 25% acute total hip arthroplasty). Outcomes were excellent/good in 58% of patients. Complications included heterotopic ossification (11%), nerve injury (11%), degenerative arthritis (6%), DVT (6%), and infection (3%). Conclusions: Bilateral acetabular fractures most commonly occur either after trauma or seizures and are commonly managed operatively. They are not devoid of complications, however, more than half (58%) achieve complete functional recovery.

Ectopic bone formation causing chronic pubis symphysis pain: successful management with resection and pubic fusion.

Chronic musculoskeletal anterior pelvic pain may originate from a variety of different sources making the diagnosis difficult. Ectopic bone formation on the pubic symphysis is extremely rare and may cause significant disability. Reported herein is the case of a very active patient with symphysis pubis ectopic bone formation causing disability for more than 10 years. Resection of the ectopic bone combined with pubis symphysis fusion led to a successful outcome allowing the patient to return to his previous recreational activities.

A technical note: How to extract broken Reamer-Irrigator-Aspirator (RIA) metal intramedullary debris.

The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick as a bailout in this difficult situation.

Fifth metatarsal fractures: an update on management, complications, and outcomes.

Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term 'Jones' fracture has been used inconsistently in the literature. In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes. Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient's needs and the 'personality' of the fracture. If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the 'gold standard' of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems. Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain. Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.

Peer-reviewing in Surgical Journals: Revolutionize or Perish?

The gold standard of safe-guarding the quality of published science is peer review. However, this long-standing system has not evolved in today's digital world, where there has been an explosion in the number of publications and surgical journals. A journal's quality depends not only on the quality of papers submitted but is reflected upon the quality of its peer review process. Over the past decade journals are experiencing a rapidly escalating "peer review crisis" with editors struggling in recruiting reliable reviewers who will provide their skilled work for free with ever-diminishing incentives within today's restricted time-constraints. The problem is complex and difficult to solve, but more urgent than ever. Time is valuable and academicians, researchers and clinicians are overburdened and already extremely busy publishing their own research along with their ever growing clinical and administrative duties. Fewer and fewer individuals volunteer to provide their skilled work for free which is expected. The current incentives to review do not have a big impact on one's career and therefore are not realistic effective countermeasures. As the limits of the system are constantly stretched, there will inevitably come a "point of no return" and Surgical Journals will be the ones to first take the hit as there is an overwhelming evidence of burnout in the surgical specialties and the Surgical community is almost 50% smaller than its Medical counterpart. This review identifies the potential causes of the peer-review crisis, outlines the incentives and drawbacks of being a reviewer, summarizes the currently established common practices of rewarding reviewers and the existing and potential solutions to the problem. The magnitude of the problem and unsustainability that will make it perish are discussed along with its current flaws. Finally, recommendations are made to address many of the weaknesses of the system with the hope to revive it.

Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today.

PURPOSE: To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications. METHODS: A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out. RESULTS: Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups. CONCLUSION: CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating.

Case report: Forearm infected non-united fracture managed with the Masquelet technique in a 71-year-old female patient.

Infected non-union status post forearm fracture fixation is a challenge to treat and may be associated with unpredictable outcomes. The management of such a case involving a 71-year-old female suffering from Parkinson's disease is reported herein. The patient referred to our unit for a second opinion while she was under consideration for amputation at her local hospital. Utilising the two stage Masquelet technique successful limb salvage and excellent function were achieved.

Case report: Restoration of an open 12 cm femoral defect treated with the Masquelet technique in a 20-year-old polytrauma.

Infected post-traumatic femoral defects are challenging to treat, and limited options exist. The case of a 20-year-old polytrauma male who sustained a segmental femur fracture involving the femoral neck, distal femur and an intermediate diaphyseal bone defect of 12 cm is presented. The patient declined a long-term frame in his femur. The 2-stage Masquelet procedure resulted in successful outcome with limb preservation.