Early results of fixed-bearing unicompartmental knee replacement designed for the lateral compartment.

BACKGROUND: Isolated lateral compartment knee arthritis is less prevalent than medial. While the reported results of medial unicompartmental knee replacement (UKR) have been good and comparable to total knee replacement, the results of lateral UKR have been mixed. We present the short-term results and survivorship of a fixed-bearing UKR designed specifically for the lateral compartment. METHODS: We report the result of 130 primary fixed-bearing lateral Oxford (FLO) UKRs (123 patients) performed between 2015 and 2019 with a minimum follow-up of 1 year. The indications for lateral UKR were: isolated lateral osteoarthritis (n = 122), post-trauma (n = 5) and osteonecrosis (n = 3). The mean age was 69.1 (± 11.6), mean BMI 28.4 (± 4.9), 66.9% female, 60% right-sided, and mean follow-up 3 (range 1-4.8 years, standard deviation ± 1) years. The primary outcome measure was the Oxford knee score (OKS). Survival analysis was performed with "revision for any reason", "reoperation", and "implant failure" as the endpoints. RESULTS: Six patients died from unrelated reasons. None of the implants failed. One required the addition of a medial UKR for medial arthritis. There were no other reoperations. At 4 years, the survival for implant failure was 100% and for both revision and all reoperations was 99.5% (95% CI 96.7-99.9%). At the last review, at a mean of 3 years, the mean Oxford knee score was 41. CONCLUSION: The good survivorship and outcome scores suggest that UKR designed for the lateral compartment is an excellent alternative to total knee replacement in selected patients with isolated lateral tibiofemoral arthritis at short-term follow-up.

Bleeding Risk Associated With Hemodynamically Stable Low-Energy Pelvic Fracture.

INTRODUCTION: Life-threatening hemorrhage associated with low-energy pelvic fracture has been described in single cases in the literature. However, there is limited evidence available on the bleeding risk associated with hemodynamically stable osteoporotic pelvic fractures. The objective of this study was to estimate the bleeding risk associated with low-energy osteoporotic pelvic fractures in the elderly population. MATERIALS AND METHODS: A retrospective review of patients aged > 65 years old with pelvic fractures admitted between 2015 and 2018 was performed. Eighty-two patients were identified: 12 males and 70 females with a median age of 86 years. The median Charlson comorbidity index was 6 (interquartile range = 5-7). Eighty-one fractures were classified as lateral compression I or Tile A2, and 1 fracture was classified as lateral compression II or Tile B2. Forty patients were on concurrent anticoagulation treatment. In 4 patients on warfarin, this treatment was reversed on admission. RESULTS: The mean hemoglobin (Hb) level on arrival was 12.36 g/dL (±1.67 g/dL). There were significant drops in Hb levels on day 1 (Hb = 11.22 ± 1.86 g/dL, P < .001) and day 4 (Hb = 10.97 ± 1.6 g/dL, P < .001). Nine percent of patients required a blood transfusion. The mean baseline Hb level pre-transfusion was 8.33 g/dL (±1.15). Preexisting anticoagulation treatment did not predispose patients to greater decreases in Hb levels on day 1 (mean difference = 0.16 g/dL, P = .62) or day 4 (mean difference = 0.29 g/dL, P = .48) post-admission. DISCUSSION: An observed mean decrease in Hb level of up to 1.4 g/dL can occur in hemodynamically stable elderly patients with osteoporotic pelvic fractures, reflecting an approximate loss of 1.4 units of packed red blood cells. CONCLUSION: This degree of decrease in Hb may be clinically significant in geriatric patients with chronic anemia and a history of cardiovascular disease.

Oblique proximal locking screw in tibial fracture intramedullary nailing: a clinical imaging study of proximity to common peroneal nerve.

Intramedullary nailing (IMN) is the treatment of choice in the surgical management of most tibia shaft fractures. The aim of the study was to evaluate the proximity of the common peroneal nerve (CPN) to the oblique proximal locking screw inserted from the anteromedial to the posterolateral direction. We identified all the patients who underwent the IMN of the tibia between 2008 and 2018. Patients who underwent post-operative computed tomography for any reason were identified. Patients were included if the CPN was visible on the axial slices, the proximal oblique locking screw was used, or the line of the drilling could be reconstructed. Twenty-nine patients met the inclusion criteria. The median length of the intramedullary nail was 345 mm. The median nail diameter was 10 mm. The median number of proximal interlocking screws was 2. All scans were reviewed by the musculoskeletal radiologist for verifying the visibility and marking of the CPN. The mean screw trajectory angle to the CPN was 9° (± 9°). Most of the drilling trajectories passed posterior to the CPN (79%). The depth of the intramedullary nail was on average - 8 mm (± 10 mm). A negative correlation was observed between the depth of the nail and the distance from the CPN (P < 0.001). During the insertion of the oblique proximal locking screw from the anteromedial to the posterolateral direction, the CPN is potentially at risk if the drill is allowed to plunge or an incorrectly long screw is used. Sinking the nail provides a better margin of safety.

Chromic phosphate-32 colloid radiosynovectomy for the treatment of haemophilic synovitis: A long-term follow-up study.

AIM: We previously reported the outcome of chromic phosphate-32(32 P) colloid synoviorthesis in 53 haemophilic patients with an average follow-up of 31 months. The purpose of the present study was the long-term follow-up of the same cohort on both clinical and radiographic features. MATERIALS: Nine patients failed to attend the recall appointment. The mean follow-up for the remaining 44 patients (52 procedures) was 15 years (range, 14.6-15.5). The mean age at the time of reassessment was 31 years (range, 18-43). RESULTS: The haemarthrosis frequency was not statistically significant at the latest follow-up years compared with 31 months (0.8 vs 0.4 per week, P = .3). There was no significant change in the clinical severity of haemophilic arthropathy (P = .5). Most of the treated joints still are in stage III of Fernandez-Palazzi and Caviglia classification. There was a trend towards the radiologic deterioration of arthritis with nearly 50% of patients at Arnold-Hilgartner Stage V. 13% of patients underwent a total knee arthroplasty (TKA). The age at which the initial radiosynovectomy was performed was significantly higher in patients who had a TKA than those who had not (22 vs 15 years, P < .002). CONCLUSION: The bleeding control effect of 32P on the target joint remains over time; however, it did not appear to halt the progression of radiographic changes in haemophiliacs. It could delay the need for TKA if it performs at the right time.

Identification of the lateral femoral safe zone for drilling during LISS plate fixation of distal femur fractures.

BACKGROUND: The incidence of arterial injury associated with femoral fractures is approximately 1%. Lateral sub-muscular plate fixation is gaining popularity for the management of distal femoral fractures. The objective of this study was to assess the iatrogenic risk to the superficial femoral artery (SFA) during Less Invasive Stabilisation System (LISS) plate fixation of distal femoral fractures by analysing the range of distances and angles between LISS plate screws and the drilling line to the SFA. MATERIALS AND METHODS: We identified all patients who underwent LISS plate fixation of distal femoral fractures between 2008 and 2018 in our level-1 trauma centre. Patients who underwent postoperative computed tomography for any reason were eligible for inclusion in the study. Twenty-five patients met the inclusion criteria. The sample comprised 10 male and 15 female patients with a mean age of 55 years. The most common fracture type was a supracondylar femur fracture (56%), followed by an intercondylar fracture (36%). A 13-hole LISS plate was the most common plate length used (44%). A consultant radiologist reviewed all scans to verify the visibility and marking of the SFA. RESULTS: The median distance between the screw tip and the SFA was 21 mm (range, 8-65 mm). There was a negative correlation between the LISS plate hole number and the trajectory of drilling (Pearson coefficient: -0.87, p < 0.001). Using a linear regression model, the SFA was more likely to be in the line of drilling when the 6th to 10th holes in the LISS plate were used. CONCLUSION: Extra care is needed when drilling into the LISS plate holes from the lateral to the medial direction in order to reduce the risk of iatrogenic injury to the SFA, especially in the high-risk plate zone where the artery can be close to the drilling line.

Hook Plate Fixation for Acute Unstable Distal Clavicle Fracture: A Systematic Review and Meta-analysis.

OBJECTIVES: To compare the outcome of hook plate fixation with other techniques in surgical fixation of acute unstable distal clavicle fractures. DATA SOURCES: In July 2018, a systematic search of electronic databases (PubMed, Medline, Embase, and Cochrane databases for systematic reviews) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles were limited to English language. STUDY SELECTION: Studies were included if they compared the results of hook plate fixation of acute unstable distal clavicle fracture in adults with other surgical techniques. DATA EXTRACTION: Data on the study setting, functional outcome, union, and complication rates were extracted. A quality assessment was performed using the Newcastle-Ottawa Scale. DATA SYNTHESIS: Eleven studies were found that met the inclusion criteria. Six hundred thirty-four patients were pooled using a random effects model. There were 397 male and 237 female patients. Primary outcome measure was functional result, and the secondary outcome measures were union and complication rates. There was no significant difference between the functional outcome and union rate between hook plate fixation, coracoclavicular (CC) stabilization, and locking plate fixation. Hook plate fixation resulted in a higher Constant-Murley score compared with tension band wiring (TBW) [odds ratio (OR), 3.52; 95% confidence interval (CI), 0.79-6.26]. It was also associated with a higher complication rate compared with CC stabilization (OR, 3.68; 95% CI, 1.19-11.33) and the locking plate (OR, 5.19; 95% CI, 1.58-17.06). Compared with TBW, hook plate fixation was associated with a lower complication rate (OR, 0.28; 95% CI, 0.10-0.77). CONCLUSIONS: Hook plate fixation achieves a similar functional outcome and union rate compared with CC stabilization and locking plate fixation. However, it has a superior functional result compared with TBW. The complication rate is higher compared with CC stabilization and locking plate fixation and is lower compared with TBW. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute medial clavicle fracture in adults: a systematic review of demographics, clinical features and treatment outcomes in 220 patients.

BACKGROUND: Medial third clavicle fractures are rare injuries, with limited information available on their characteristics or treatment results. MATERIALS AND METHODS: We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management and treatment outcome. Electronic searches of the MEDLINE, EMBASE and Cochrane databases were performed. RESULTS: Seventeen studies were included, consisting of 7 case series and 10 case reports. Two hundred twenty fractures were identified. Seventy-eight percent of fractures occurred in men with mean age of 48 years (16-94 years). Road traffic accident was the most common mechanism of injury (64%). Associated injuries occurred in 81% of patients, with thoracic trauma being the most common (47%). The most common fracture type was extra-articular, with no or minimal displacement (60%). In 9% of patients the fracture was segmental. One hundred ninety-one patients received nonoperative treatment. Twenty-nine patients were treated operatively. The overall nonunion rate was 5% (7/137). The nonunion rate following nonoperative management was 4.6% (5/108). The functional result following nonoperative treatment indicated overall "good" functional outcome. There was no report of catastrophic intraoperative complication amongst patients undergoing surgical fixation. CONCLUSION: Medial third clavicle fractures represent a distinct subgroup of clavicle fractures. Nonoperative treatment of these fracture seems to result in high union rate and overall favourable functional outcome. Further high-quality research in this area is warranted to investigate the outcomes and indication for nonoperative versus operative management of these fractures. LEVEL OF EVIDENCE: IV.

Total knee arthroplasty after patellectomy: A meta-analysis of case-control studies.

BACKGROUND: Post-patellectomy patients represent a specific subset of patients who can develop painful and disabling knee osteoarthritis that requires Total Knee Arthroplasty (TKA). The aim of this study was to conduct a meta-analysis comparing the outcome of TKA in patients with previous patellectomy to those with an intact patella. METHODS: A systematic search of electronic databases (PubMed, Medline, Embase, and Cochrane Library) was performed. Data on study setting, type of implant, outcome and associated complications were extracted. Quality assessment was performed using the Newcastle-Ottawa Scale. Random effects meta-analyses were used to combine the results of included studies. RESULTS: Seven case-control studies were found that met the search criteria. Compared to patients with an intact patella, patients with a previous patellectomy were less likely to have an 'excellent' or 'good' outcome (OR: 0.3, 95% CI: 0.14 to 0.65). The weighted mean post-operative knee flexion arc was 6.58° less in patients with a previous patellectomy (95% CI: -12.79, -0.37). The risk of complication occurring in a patella-deficient knee was higher, with a pooled OR of 1.97 (95% CI=1.10 to 3.51). CONCLUSIONS: The current evidence that compares the outcome of knee arthroplasty in patients with a previous patellectomy to patients with an intact patella is mostly based on TKAs performed in the 1980s and 1990s. Total knee replacement in patients with an intact patella results in superior outcomes compared to those with a previous patellectomy. In patients with a previous patellectomy, the arc of flexion is slightly less and the complication rate is significantly higher.

Reliability of radiographic measurements for acute distal radius fractures.

BACKGROUND: The management of distal radial fractures is guided by the interpretation of radiographic findings. The aim of this investigation was to determine the intra- and inter-observer reliability of eight traditionally reported anatomic radiographic parameters in adults with an acute distal radius fracture. METHODS: Five observers participated. All were routinely involved in making treatment decisions based on distal radius fracture radiographs. Observers performed independent repeated measurements on 30 radiographs for eight anatomical parameters: dorsal shift (mm), intra-articular gap (mm), intra-articular step (mm), palmar tilt (degrees), radial angle (degrees), radial height (mm), radial shift (mm), ulnar variance (mm). Intraclass correlation coefficients (ICCs) and the magnitude of retest errors were calculated. RESULTS: Measurement reliability was summarised as high (ICC > 0.80), moderate (0.60-0.80) or low (<0.60). Intra-observer reliability was high for dorsal shift and palmar tilt; moderate for radial angle, radial height, ulnar variance and radial shift; and low for intra-articular gap and step. Inter-observer reliability was high for palmar tilt; moderate for dorsal shift, ulnar variance, radial angle and radial height; and low for radial shift, intra-articular gap and step. Error magnitude (95 % confidence interval) was within 1-2 mm for intra-articular gap and step, 2-4 mm for ulnar variance, 4-6 mm for radial shift, dorsal shift and radial height, and 6-8° for radial angle and palmar tilt. CONCLUSIONS: Based on previous reports of critical values for palmar tilt, ulnar variance and radial angle, error margins appear small enough for measurements to be useful in guiding treatment decisions. Our findings indicate that clinicians cannot reliably measure values ≤1 mm for intra-articular gap and step when interpreting radiographic parameters using the standardised methods investigated in this study. As a guide for treatment selection, palmar tilt, ulnar variance and radial angle measurements may be useful, but intra-articular gap and step appear unreliable.

Complications associated with operative fixation of acute midshaft clavicle fractures.

INTRODUCTION: The aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated in a level I trauma centre. PATIENTS AND METHODS: We identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients) and included 107 men (78%) and 31 women (22%); the median age of 35 years (interquartile range (IQR) 24-45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n=83) had an injury severity score of ≥15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1-6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 men and 25 women in the plate fixation group with median age of 35 years (IQR 25-45) There were 22 men and six women in the intramedullary fixation group with median age of 31 years (IQR 24-42 years). Statistical analysis was performed using independent sample t test, Mann Whitney test, and Chi square test. Significant P-value was <0.05. RESULTS: The overall incidence of complication was 14.5% (n=20). The overall nonunion rate was 6%. Postoperative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (nine of 28 cases; P=0.003). Thirty-five percent of complications were related to inadequate surgical technique and were potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n=31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P=0.03). CONCLUSIONS: Intramedullary fixation of midshaft clavicle fracture is associated with a higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.

Distal radial fractures in children: risk factors for redisplacement following closed reduction.

BACKGROUND: Distal radial fractures represent one of the most common fractures in children with the majority treated by closed reduction and cast application. Redisplacement after manipulation can occur resulting in potential poor outcome. We performed a prospective study of children undergoing closed reduction of distal radial fracture and evaluated a range of possible risk factors contributing to loss of reduction. METHODS: The prospective study included 135 displaced distal radial fractures. There were 48 girls (36%) and 87 boys (64%), with a mean age of 9.9 years (range, 3 to 17 y). The risk factors for redisplacement, which were evaluated, were age, sex, location of the fracture, preoperative fracture displacement, presence of ulna fracture, grade of surgeon, quality of reduction, quality of plaster, and residual postreduction displacement. RESULTS: Redisplacement occurred in 39 of 135 cases (28.8%). Initial complete displacement was the most important risk factor for loss of reduction (odds ratio, 6.94; P=0.001). Completely displaced fractures were 7 times more likely to redisplace than fractures with some bony contact or no translation. Achievement of anatomic reduction decreases the risk of redisplacement (odds ratio, 0.29; P=0.046). Ten of the 39 fractures that lost position needed a second procedure (7.4%). CONCLUSIONS: Completely displaced distal radial fractures that cannot be anatomically reduced have a high risk of redisplacement after closed reduction. Only a small number of fractures that lose reduction will require a second intervention. LEVEL OF EVIDENCE: Level II.

Management of acute displaced midshaft clavicular fractures using Herbert cannulated screw: Technique and results in 114 patients.

PURPOSE: A new and simple operative technique has been developed to provide internal fixation for midshaft clavicle fractures. This involves the use of a large fragment Herbert Screw that is entirely embedded within the bone. Screw fixation is combined with bone grafting from intramedullary reamings of the fracture fragments. The purpose of this report is to assess the outcomes following treatment of midshaft clavicular fracture using this method. MATERIALS AND METHODS: One hundred and fourteen patients with acute displaced midshaft fracture were identified between 2002 and 2007. All patients were followed until fracture union. Patients' medical records were reviewed. Disability of the Arm, Shoulder, and Hand questionnaire (DASH), and American Shoulder and Elbow Surgeons Elbow form (ASES) were posted to all patients. Outcome measures included union rate, time to union, implant removal rate, DASH, and ASES scores. RESULTS: Patients' median age was 29.5 years (interquartile range, 19-44 years). The most common injury mechanism was sports injury (28%). The median time from injury to surgery was 5 days (interquartile range, 2-9 days). Union occurred in an average of 8.8 weeks. Non-union occurred in three cases (2.6%). The re-operation rate for symptomatic hardware prominence screw was 1.7%. The median DASH score was 0.83 and the median ASES was 100 (n = 35). CONCLUSIONS: Intramedullary fixation using cannulated Herbert screw can be used as an effective approach for operative management of midshaft clavicular fractures. Using this method, an appropriate outcome could be achieved and a second intervention for implant removal could be avoided in great majority of cases. LEVEL OF EVIDENCE: Level III.

Elbow fracture-dislocation combined with Galeazzi fracture in adult: A case report and literature review.

INTRODUCTION: Galeazzi fracture associated with ipsilateral posterior elbow dislocation and radial head fracture is a rare pattern of injury. Few reports exist that describes this injury pattern and its treatment. We describe a case report of simultaneous occurrence of Galeazzi fracture and ipsilateral dislocation of elbow. PRESENTATION OF CASE: A 58 year-old female presented with Galeazzi fracture and posterior elbow dislocation associated with radial head fracture of left upper extremity. This was managed with closed reduction of the elbow, open reduction and internal fixation of the radial shaft fracture and K-wire stabilisation of the unstable distal radioulnar joint. Prophylactic fasciotomy was performed. At 10 months follow-up, the outcome was favourable with the American shoulder and elbow surgeon score of 92 and the disabilities of the arm, shoulder and hand score of 18. DISCUSSION: The presumed mechanism of the injury was a forceful axial loading of a hyperpronated forearm and extended elbow. Our literature review shows that this pattern of injury occurs as a result of high energy trauma in young individuals, and successful outcome can be achieved by addressing each component of this complex injury individually. CONCLUSION: Simultaneous occurrence of elbow dislocation and Galeazzi fracture seems to be the result of extreme axial force and unique position of upper extremity at the time of impact. Individualised approach to each component of this injury can result in favourable outcome.

Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature.

BACKGROUND: Flexor tendon rupture is a rare but major complication associated with volar plate fixation of distal radius fractures. MATERIALS AND METHODS: We performed a systematic review to evaluate the demographics, clinical profile, treatment and outcome of flexor tendon rupture following volar plate fixation of distal radius fracture. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases for systematic reviews and conference proceedings were performed. Studies were included if they reported flexor tendon rupture (partial or complete) as a complication of distal radius fracture plating (all levels of evidence). RESULT: Our search yielded 21 studies. There were 12 case reports and 9 clinical studies. A total of 47 cases were reported. There were 11 males and 23 females (n = 16 studies). The mean age was 61 years old (range 30-85). The median interval between the surgery and flexor tendon rupture was 9 months (interquartile range, 6-26 months). Twenty-nine plates were locking and 15 were nonlocking (n = 20 studies). FPL was the most commonly ruptured tendon (n = 27 cases, 57 %), with FDP to index finger being the second most common (n = 7 cases, 15 %). Palmaris longus tendon graft and primary end-to-end repair were the most common surgical methods used in cases of FPL tendon rupture. CONCLUSION: Flexor tendon rupture is a recognised complication of volar plating of distal radius fracture. Positioning of the plate proximal to the "watershed" line and early removal of the plate in cases with plate prominence or warning symptoms can reduce the risk of this complication.

Single versus multiple doses of antibiotic prophylaxis in limb fracture surgery.

BACKGROUND: There is no consensus with regard to optimum prophylactic antibiotic regimen in orthopaedic fracture surgery. OBJECTIVE: A systematic review and meta-analysis were performed to determine if multiple-dose perioperative antibiotic prophylaxis is more effective than a single preoperative dose in the prevention of surgical wound infection in patients undergoing operative treatment of low-energy closed fractures. DATA RESOURCES: Medline, Medline in Process and other non-indexed citations, Embase, Cochrane database of systematic reviews and conference proceedings were searched. REVIEW METHODS: Studies were included if they were randomized or quasi-randomized trials comparing the results of a single antibiotic prophylaxis versus multiple doses of the same antibiotic in patients undergoing surgical fixation of closed fractures. RESULTS: Four studies were found to meet the searching criteria. The mean score for quality assessment of these studies was 16 (8-24 points). Only two out of four studies had detailed analysable data and therefore were included in the final analysis. 921 patients were pooled using a random-effects model. Compared to multiple-dose prophylaxis, administration of a single preoperative dose demonstrated no significant difference regarding the overall surgical site infection rate (risk ratio (RR) = 0.3, 95% confidence interval (CI): 0.07-1.25). Multiple-dose antibiotic prophylaxis is marginally more effective than single dose in reducing the incidence of deep surgical wound infection (risk ratio: 0.13, 95% CI: 0.02 to 0.99). CONCLUSION: There is lack of definite evidence that multiple-dose antibiotic prophylaxis is superior to single preoperative dose in low-energy closed fracture surgery.

Delayed surgical treatment of displaced midshaft clavicle fracture using Herbert cannulated screw with intramedullary bone graft.

There is an increasing trend towards operative treatment for displaced midshaft clavicle fractures. This retrospective study was performed to assess the outcome of delayed fixation of displaced midshaft clavicle fractures and test the null hypothesis that there is no difference in results between early and delayed surgical treatment for displaced midshaft clavicle fractures. Using the hospital database, two groups of patients who were surgically treated using Herbert cannulated screw for displaced midshaft clavicle fractures were identified. There were 114 cases in acute (median time to operation of 5 days) and 21 cases in delayed groups (median time to operation 10.5 weeks). Thirty-five cases were available for follow-up in the acute and 16 cases in the delayed series. The primary outcome was assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons score (ASES) and Constant-Murley score. Union occurred in 14 cases in the delayed group. The median DASH, mean ASES and Constant-Murley scores were 4.1, 97 and 88.7, respectively. Compared with the delayed group, the early group had a higher union rate (P = 0.033), trend towards lower DASH score (P = 0.051), and higher ASES score (P = 0.047). The delayed group had significantly more problems with prominent, symptomatic screws that required removal (P = 0.002). There were no significant differences in union time and complication rate. Delayed fixation of displaced midshaft fractures using the Herbert cannulated bone screw and bone graft is effective and provides a good functional outcome that only slightly reduced from that recorded for early fixation.

Management guideline in haemodynamically unstable patients with pelvic fractures: Outcomes and challenges.

Clinical practice guidelines for haemodynamically unstable patients with pelvic fractures were initiated in February 2005 at our level 1 trauma centre. The purpose of the present study was to evaluate guideline adherence and outcome of guideline performance. In a retrospective clinical study all patients admitted with a pelvic fracture from August 2003 to March 2007 were identified from a prospective trauma registry database. Medical records of all patients were reviewed. Patients with pelvic fractures associated with haemodynamic instability were included. Patients were divided into two groups: preguideline and postguideline. The two groups were compared. Main outcome measurements were 24 h fluid requirement, total blood transfusion, length of stay in ICU and hospital, and mortality rate. Of the 210 patients with pelvic fractures, 32 patients met the inclusion criteria. Preguideline group consisted of 13 and postguideline group 19 patients. Non-invasive pelvic stabilization was applied significantly more postguideline (92.3% vs 33.3%, P= 0.004). Focused abdominal sonography for trauma and pelvic angiography/embolization have been used significantly more in the postguideline group (5 vs 14, P= 0.046 and 0 vs 6, P= 0.025, respectively). There was no significant difference in 24 h fluid requirement, total blood transfusion, length of stay in ICU and hospital, and mortality rate between the two groups. The introduction of guidelines has influenced the approach to haemodynamically unstable patients with pelvic fractures. Multiple factors can potentially influence the strict adherence to the guideline. Care provided can still be improved by addressing the challenges in guideline performance.

Periosteal osteoblastoma: report of a case with a rare histopathologic presentation and review of the literature.

Osteoblastoma is an uncommon benign bone tumor most commonly located in the vertebral column or metaphysis of a long bone. Periosteal location is rare. We report a periosteal-based osteoblastoma, arising from the proximal tibia, in a 20-year-old woman who presented with knee swelling and pain of 2-year duration. Imaging studies showed a metaphyseal surface-based lesion with patchy radiodensities. The cortico-medullary junction was intact. The lesion was totally excised. Histopathologic evaluation disclosed immature bone and osteoid deposition in a vascularized stroma, associated with numerous osteoblasts and osteoclasts rimming the bony trabeculae. Plate-like arrangements of cartilage in the margin of the neoplastic tissue were also identified. At 16 months postoperatively, the patient was well without recurrence. Although extremely unusual, the presence of cartilage does not necessarily exclude the diagnosis of osteoblastoma.

Functional outcome following treatment of transolecranon fracture-dislocation of the elbow.

Elbow fracture-dislocations are considered as difficult injuries to treat. Anterior olecranon fracture-dislocation consist an uncommon pattern which is likely to be under-diagnosed. Eight patients identified as anterior fracture-dislocation of the elbow were retrospectively reviewed. There were seven men and one woman with an average age of 35 years (range, 22-58 years). Proximal ulna fracture was comminuted in seven and simple oblique in one patient. Associated fractures were of coronoid in four and radial head in two. Reconstruction plate was used in seven patients and tension band wiring in just one. Nevertheless, tension wiring failed and was successfully revised to plate fixation combined with bone graft. Patients were followed for an average of 37.4 months (range, 10-50 months). The end results were two excellent, five good and one fair, based on Broberg and Morrey scale. An average score of 89 points was obtained using American Shoulder and Elbow Surgeons elbow scoring system. Treatment of anterior olecranon fracture dislocation is mostly satisfactory if contour and dimension of greater sigmoid notch is accurately restored.