The Posttaumatic Adjustment Scale (PAS) is an effective measure in predicting psychological distress in patients following major trauma.

AIMS: To determine whether a psychological screening tool - the Posttraumatic Adjustment Scale (PAS), predicts later psychological distress for admissions to a Major Trauma Centre (MTC) and to identify whether there was an unmet need in relation to the psychological support offered. METHODS: Patient demographics and details of their injuries were retrieved from the Trauma Audit & Research Network (TARN) database. All patients admitted to Leeds General Infirmary MTC were approached for inclusion in the study over a three-month period. The PAS was administered to all participants at baseline. Following discharge, patients were sent two validated psychological measures via post, the Impact of Events Scale - Revised (IES-R) and the Clinical Outcomes in Routine Evaluation System (CORE-10). Relationships between continuous variables were examined using a Spearman's rank test (SR). The diagnostic accuracy of the different psychological screening systems was examined and compared using Receiver Operator Characteristic (ROC) analysis. RESULTS: Eighty-two patients completed the PAS, 26 of whom had been referred to clinical psychology and 56 who were not. Fifty-seven of these patients (70%) returned follow-up IES-R and CORE-10 data, 20 who had been referred to psychology and 37 who had not. The PAS-P score recorded shortly after admission correlated strongly with the CORE-10 (SR rs 0.54, p<0.0001) and IES-R (SR rs 0.63, p<0.0001) scores recorded at early follow up. A PAS-P of more than 10 predicted the development of PTSD symptoms (IES-R 33 or more) or moderate global psychological distress (CORE-10 15 or more) with 72% sensitivity and 71% specificity. To identify patients who went on to develop psychological symptoms according to either measure (IES-R 33 or more or CORE-10 15 or more), the PAS-P was more sensitive than clinician referral (71% vs 52%, p<0.05) with similar specificity (72% vs 75%, p=0.78). CONCLUSIONS: In an unselected group of trauma inpatients treated in a MTC, the PAS is an effective means of identifying those who are likely to go on to suffer PTSD symptoms or psychological distress. It may useful to use the PAS as a measure to formalise psychology referrals.

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.

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.

Wrist fusion using an induced membrane technique for forearm salvage in a patient with an infected open injury with segmental bone loss: A case report.

This case report describes the management of a 27-year-old male who, after a quadbike accident, presented with an open, infected, segmental both bone forearm injury with significant bone and soft tissue loss including the radio-carpal joint. Limb salvage was accomplished in the form of a single bone forearm fusion utilising Masquelet's two-stage induced membrane technique to reconstruct the segmental bone defect. The patient proceeded to uneventful bony union by 6 months and returned to driving and riding a quadbike. Despite significant deep infection, successful salvage was achieved using the induced membrane technique. Critical to success was aggressive, repeated debridement alongside restoration of vascular supply and reconstruction of soft tissue defects. We highlight the multidisciplinary approach to management including relevant specialists with a particular interest in limb reconstruction.

Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction.

AIM AND OBJECTIVE: This study was designed to test and compare the mechanical performance of the biplanar ArthroSave KneeReviver and a circular frame construct with the intended use of providing a mechanically favourable environment for cartilage regeneration across a knee joint. MATERIALS AND METHODS: Three similar constructs of the two devices were applied to biomechanical testing sawbones, with the knee distracted by 8 mm. The constructs were vertically loaded to 800 N in an Instron testing machine at 20 mm/minute. Tests were conducted in neutral hip flexion and at 12° of hip flexion and extension, to mimic leg position in gait. Displacement measurements were taken from the Instron machine, and three-dimensional joint motion was recorded using an Optotrak Certus motion capture system. RESULTS: Overall axial rigidity was similar between the two devices (circular frame, 81.6 N/mm ± 5.9; and KneeReviver, 79.5 N/mm ± 25.1 with hip neutral) and similar in different hip positions. At the point of joint contact, the overall rigidity of the circular frame increased significantly more than the KneeReviver (491 N/mm ± 27 and 93 N/mm ± 32, respectively, p <0.001). There was more variability between models in the KneeReviver. There was more off-axis motion in the KneeReviver, mainly due to increasing knee flexion on loading. This was exacerbated with the hip in flexion and extension but remained small, with the maximal off-axis displacement being 7 mm/3°. CONCLUSION: The circular frame provides a similar mechanical environment to the novel KneeReviver device, for which most clinical data are available. These findings suggest that both devices appear a viable option for knee joint distraction (KJD). Further clinical data will help inform mode of application. CLINICAL SIGNIFICANCE: KJD is a relatively novel technique for use in osteoarthritis (OA), and it remains unclear which distraction devices provide appropriate mechanics. Our testing gives evidence to support either option for further use. HOW TO CITE THIS ARTICLE: Chowdhury JMY, Lineham B, Pallett M, et al. Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction. Strategies Trauma Limb Reconstr 2021;16(2):71-77.

Simultaneous induced membrane technique to reconstruct an obliterated floating knee.

The induced membrane technique, first described by Masquelet, is a powerful surgical approach that can be used to address segmental bone loss of various aetiologies. Despite ongoing debate regarding optimal delivery, the indications and limits of its application have been tested in increasingly complex situations, highlighting its considerable potential. We present a case of a devastating open lower limb injury with simultaneous femoral and ipsilateral tibial bone loss including articular injury on both sides of the joint. The Masquelet technique was used to successfully address both segments of bone loss within the same limb.

Ilizarov Method for Acute Paediatric Tibial Fractures.

AIM AND BACKGROUND: A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit's practice in adult patients. The indications, underlying principles and rationale for the method are also discussed. TECHNIQUE: The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing. CONCLUSION AND CLINICAL SIGNIFICANCE: Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve. HOW TO CITE THIS ARTICLE: Messner J, Prior CP, Pincher B et al. Ilizarov Method for Acute Paediatric Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):46-52.

Managing soft tissues in severe lower limb trauma in an ageing population.

PURPOSE: With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. METHOD: Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. RESULTS: Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67-95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4-85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). CONCLUSION: Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.

What Are the Biomechanical Properties of the Taylor Spatial Frame™?

BACKGROUND: The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to quantify the biomechanical effect of substituting the tried-and-tested Ilizarov construct for the TSF hexapod system. QUESTIONS/PURPOSES: This study was designed to investigate the mechanical properties of the TSF system under physiologic loads, with and without the addition of a simulated bone model, with comparison to the standard Ilizarov frame. METHODS: The mechanical behaviors of three identical four-ring TSF and Ilizarov constructs were tested under levels of axial compression, bending, and rotational torque to simulate loading during normal gait. An acrylic-pipe fracture model subsequently was mounted, using fine wires and 5 mm half pins, and the testing was repeated. Load-deformation curves, and so rigidity, for each construct were calculated, with statistical comparisons performed using paired t-tests. RESULTS: Under axial loading, the TSF was found to be less rigid than the Ilizarov frame (645 ± 57 N/mm versus 1269 ± 256 N/mm; mean difference, 623 N/mm; 95% CI, 438.3-808.5 N/mm; p < 0.001), but more rigid under bending and torsional loads (bending: 42 ± 9 Nm/degree versus 78 ± 13 Nm/degree; mean difference, 37 Nm/degree; 95% CI, 25.0-47.9 Nm/degree; p < 0.001; torsion: 16 ± 2 Nm/degree versus 5 ± 0.35 Nm/degree; mean difference, 11 Nm/degree; 95% CI, 9.5-12.2 Nm/degree; p < 0.001). On mounting the bone models, these relationships broadly remained in the half-pin and fine-wire groups, however the half-pin constructs were universally more rigid than those using fine wires. This effect resulted in the TSF, using half pins, showing no difference in axial rigidity to the fine-wire Ilizarov (107 ± 3 N/mm versus 107 ± 4 N/mm; mean difference, 0.05 N/mm; 95% CI, -6.99 to 7.1 N/mm; p > 0.999), while retaining greater bending and torsional rigidity. Throughout testing, a small amount of laxity was observed in the TSF construct on either side of neutral loading, amounting to 0.72 mm (±0.37 mm) for a change in loading between -10 N and 10 N axial load, and which persisted with the addition of the synthetic fracture model. CONCLUSIONS: This study broadly shows the TSF construct to generate lower axial rigidity, but greater bending and torsional rigidity, when compared with the Ilizarov frame, under physiologic loads. The anecdotally described laxity in the TSF hexapod strut system was shown in vitro, but only at low levels of loading around neutral. It also was shown that the increased stiffness generated by use of half pins produced a TSF construct replicating the axial rigidity of a fine-wire Ilizarov frame, for which much evidence of good clinical and radiologic outcomes exist, while providing greater rigidity and so improved resistance to potentially detrimental bending and rotational shear loads. CLINICAL RELEVANCE: If replicated in the clinical setting, these findings suggest that when using the TSF, care should be taken to minimize the observed laxity around neutral with appropriate preloading of the construct, but that its use may produce constructs better able to resist bending and torsional loading, although with lower axial rigidity. Use of half pins in a TSF construct however may replicate the axial mechanical behavior of an Ilizarov construct, which is thought to be conducive to bone healing.

Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes.

This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18-80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean length of the bone defect area was 4.2 cm (range 2-12 cm). All patients were managed with the two stage technique receiving composited grafting (Autologous bone graft (Iliac crest/RIA), graft expander as required, osteoprogenitor cells, growth factor) during the second stage. There was one failure (humeral infected non-union) in a previous background of bone radiation that necessitated reconstruction with a free fibula vascularized graft. One patient had a fall and sustained implant failure (humeral defect) 3 months after reconstruction and following re-plating progressed to union 4 months later. Two patients required re-grafting due to failure of healing in one of the defect sides. One patient presented with a discharging sinus 2 years after successful healing of a tibial defect that was treated successfully with soft tissue and bone debridement without necessitating further interventions. One patient despite union (distal 1/3 tibia) underwent a below knee amputation due to a dysfunctional ankle/foot (previous foot compartment syndrome-regional pain syndrome). Of those patients, with lower limb injuries, 4 patients had leg length discrepancies of 1 cm, 1.5 cm, 2 cm (two patients) respectively. The mean time to radiological union was 5.4 months (range 2-12 months). The average time of healing of 1 cm bone defect was 1.24 months. Patients with upper limb reconstruction recovered earlier than those with lower limb injuries. At the latest follow up all patients were able to mobilize full weight bearing without residual pain. The induced membrane technique appears to be an alternative good option for the management of large bone defects secondary to acute bone loss or infected non-unions. The incidence of re-interventions was low in this challenging cohort of patients. The technique should be considered in the surgeon's armamentarium as it is effective and is associated with a low rate of complications.

What Are the Biomechanical Effects of Half-pin and Fine-wire Configurations on Fracture Site Movement in Circular Frames?

BACKGROUND: Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical conditions for fracture healing, allowing axial micromotion while limiting interfragmentary shear. Use of half-pins increases fixation options and may improve patient comfort by reducing muscle irritation, but they are thought to induce interfragmentary shear, converting beam-to-cantilever loading. Little evidence exists regarding the magnitude and type of strain in such constructs during weightbearing. QUESTIONS/PURPOSES: This biomechanical study was designed to investigate the levels of interfragmentary strain occurring during physiologic loading of an Ilizarov frame and the effect on this of substituting half-pins for fine-wires. METHODS: The "control" construct was comprised of a four-ring all fine-wire construct with plain wires at 90°-crossing angles in an entirely unstable acrylic pipe synthetic fracture model. Various configurations, substituting half-pins for wires, were tested under levels of axial compression, cantilever bending, and rotational torque simulating loading during gait. In total three frames were tested for each of five constructs, from all fine-wire to all half-pin. RESULTS: Substitution of half-pins for wires was associated with increased overall construct rigidity and reduced planar interfragmentary motion, most markedly between all-wire and all-pin frames (axial: 5.9 mm ± 0.7 vs 4.2 mm ± 0.1, mean difference, 1.7 mm, 95% CI, 0.8-2.6 mm, p < 0.001; torsional: 1.4% ± 0.1 vs 1.1% ± 0.0 rotational shear, mean difference, 0.3%, 95% CI, 0.1%-0.5%, p = 0.011; bending: 7.5° ± 0.1 vs 3.4° ± 0.1, mean difference, -4.1°, 95% CI, -4.4° to -3.8°, p < 0.001). Although greater transverse shear strain was observed during axial loading (0.4% ± 0.2 vs 1.9% ± 0.1, mean difference, 1.4%, 95% CI, 1.0%-1.9%, p < 0.001), this increase is unlikely to be of clinical relevance given the current body of evidence showing bone healing under shear strains of up to 25%. The greatest transverse shear was observed under bending loads in all fine-wire frames, approaching 30% (29% ± 1.9). This was reduced to 8% (±0.2) by incorporation of sagittal plane half-pins and 7% (±0.2) in all half-pin frames (mean difference, -13.2% and -14.0%, 95% CI, -16.6% to 9.7% and -17.5% to -10.6%, both p < 0.001). CONCLUSIONS: Appropriate use of half-pins may reduce levels of shear strain on physiologic loading of circular frames without otherwise altering the fracture site mechanical environment at levels likely to be clinically important. Given the limitations of a biomechanical study using a symmetric and uniform synthetic bone model, further clinical studies are needed to confirm these conclusions in vivo. CLINICAL RELEVANCE: The findings of this study add to the overall understanding of the mechanics of circular frame fixation and, if replicated in the clinical setting, may be applied to the preoperative planning of frame treatment, particularly in unstable fractures or bone transport where control of shear strain is a priority.

Novel anticoagulants: new evidence for emerging drugs and their potential application in major lower limb surgery.

For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated heparins or vitamin K antagonists, have been used as anticoagulants for prevention of venous thromboembolism following major lower limb surgery. However, these regiments have limitations that rendered the quest for new anticoagulants mandatory. Recently, research has been focused on the development of orally active small molecules that directly target thrombin or activated factor X (FXa). These regiments exhibit a number of characteristics that an "ideal" anticoagulant should possess. Currently, two agents, dabigatran etexilate and rivaroxaban, which inhibit thrombin and FXa, respectively have been approved in the European Union and Canada for venous thromboprophylaxis in patients undergoing elective hip- or knee-replacement surgery. Other agents are at an early or late stage of clinical evaluation. In this study, we summarize the current evidence for these new developed or under development drugs regarding their applications in the filed of lower limb orthopaedic surgery.

The timing of drug administration for thromboprophylaxis following orthopaedic surgery: evidence and controversies related to treatment initiation and duration.

Patients undergoing major orthopaedic surgery of the lower extremities or spine are at increased risk of venous thromboembolism (VTE). Although consensus exists as to the need for routine thromboprophylaxis in high risk patients, some aspects of this approach, such as the timing of the first dose and overall duration of the anticoagulation regimen, are subject to debate. Reviewing the available literature, there appears to be little evidence to support initiation of thromboprophylaxis more than 12 hours before surgery. Perioperative thromboprophylaxis (2 hours pre to 6 hours post -op) has been associated with an increased risk of bleeding complications whilst initiating prophylaxis more than 12 hours after surgery appears to increase the incidence of subsequent thromboembolic complications. Overall evidence would appear to support initiation of thromboprophylaxis 6 to 9 hours postoperatively, though further confirmatory studies investigating this variable in isolation would be useful to guide clinical decision making. Although evidence exists supporting extended duration thromboprophylaxis after major orthopaedic procedures, further evidence is required, using clinically important end points, prior to adoption of such an approach in all patients. Stratification of prophylaxis duration, based on risk factors for thromboembolic or bleeding complications, would seem a more rational approach than strict adherence to guidelines.

Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation).

AIMS AND OBJECTIVES: To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury. METHODS: One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover. RESULTS: Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p<0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response. CONCLUSIONS: These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible.

The risk of local infective complications after damage control procedures for femoral shaft fracture.

OBJECTIVES: To determine infection rates after damage control orthopaedics (DCO) and primary intramedullary nailing (1' IMN) in multiply injured patients with femoral shaft fracture. DESIGN: Retrospective case analysis. SETTING: Level I trauma center. PATIENTS: All patients with New Injury Severity Score (NISS) >20 and femoral shaft fracture (AO 32-) treated in our unit between 1996 and 2002. INTERVENTION: Damage control orthopaedics, defined as primary external fixation of the femoral shaft fracture and subsequent conversion to an intramedullary nail, or primary IMN. MAIN OUTCOME MEASUREMENTS: Rates of infection classified as contamination (positive swabs with no clinical change), superficial, deep (requiring surgery), and removal of hardware (those requiring removal of femoral instrumentation or amputation). RESULTS: A total of 173 patients with 192 fractures were included; 111 fractures were treated by DCO and 81 by primary IMN. Mean follow-up was 19.1 months [median, 16.7, range, 1 (patient died)-67 months]. DCO patients had a significantly higher NISS and more grade III open fractures (P<0.001). IMN procedures took a median of 150 minutes compared with 85 minutes for DCO (P<0.0001). Although wound contamination (including contaminated pin sites) was more common in the DCO group (P<0.05), the risk of infectious complications was equivalent (P=0.86). Contamination was significantly more likely when conversion to IMN occurred after more than 14 days (P<0.05); however, this did not lead to more clinically relevant infections. Logistic regression analysis showed that although a DCO approach was not associated with infection, delay before conversion in the DCO group might be [P=0.002 for contamination and removal of hardware, P=0.065 for serious infection (deep or worse), not significant for other infection outcomes]. Grade III open injury also was significantly associated with serious infection in all patients (P<0.05). CONCLUSIONS: Infection rates after DCO for femoral fractures are comparable to those after primary IMN. We see no contraindication to the implementation of a damage control approach for severely injured patients with femoral shaft fracture where appropriate. Pin-site contamination was more common where the fixator was in place for more than 2 weeks. For patients treated by using a DCO approach, conversion to definitive fixation should be performed in a timely fashion.

Which AIS based scoring system is the best predictor of outcome in orthopaedic blunt trauma patients?

BACKGROUND: Abbreviated Injury Scale (AIS)-based systems-the Injury Severity Score (ISS), New Injury Severity Score (NISS), and AISmax-are used to assess trauma patients. The merits of each in predicting outcome are controversial. METHODS: A large prospective database was used to assess their predictive capacity using receiver operator characteristic curves. RESULTS: In all, 10,062 adult, blunt-trauma patients met the inclusion criteria. All systems were significant outcome predictors for sepsis, multiple organ failure (MOF), length of hospital stay, length of intensive care unit (ICU) admission and mortality (p < 0.0001). NISS was a significantly better predictor than the ISS for mortality (p < 0.0001). NISS was equivalent to the AISmax for mortality prediction and superior in patients with orthopaedic injuries. NISS was significantly better for sepsis, MOF, ICU stay, and total hospital stay (p < 0.0001). CONCLUSIONS: NISS is superior or equivalent to the ISS and AISmax for prediction of all investigated outcomes in a population of blunt trauma patients. As NISS is easier to calculate, its use is recommended to stratify patients for clinical and research purposes.

Application of bone morphogenetic proteins in orthopaedic practice: their efficacy and side effects.

Bone morphogenetic proteins (BMPs) have been extensively studied since the discovery of agents within bone that could induce bone formation at ectopic sites by Urist in the 1960s. Extensive preclinical research has been carried out showing the efficacy of these products in promoting bone healing. Clinical trials are encouraging, with meta-analysis of results revealing better rates of healing than treatment with autologous bone grafting (risk ratio [RR]: 0.845; 95% confidence interval [CI]: 0.772 - 0.924; p < 0.001 for clinical outcome and RR: 0.884; 95% CI: 0.825 - 0.948; p < 0.001 for radiological outcome). Preclinical and clinical safety assessments have revealed little evidence of toxic effects and there have been few reports of adverse events related to their use. A small rate of immunological reaction following administration, resulting in antibody formation, has been observed in some patients, without clinical consequence, although the long-term implications of this are unknown. Ongoing research is revealing that BMPs act on an extremely wide range of body tissues in a variety of manners and this is far from fully understood. It should be noted, however, that given the role of BMP as a differentiation factor, the production of undifferentiated neoplastic tissue seems unlikely. It has also been shown in an animal model that artificially administered BMP can cross the placenta and subsequently be detected in the growing embryo. As this area has been little investigated, use in pregnancy is currently contraindicated. Until the long-term safety profile is more fully documented it would seem sensible to continue to carefully control use and monitor patients closely. However, the current evidence is very promising.