The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles.

PURPOSE: This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes. METHODS: PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised. RESULTS: Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes. CONCLUSION: The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.

The effect of weight compared to BMI on patient reported outcomes at long term follow up of primary total hip arthroplasty.

Introduction: Obesity has been linked to the development of osteoarthritis meaning that a large portion of arthroplasty patients are overweight or obese. Whilst the short-term complications associated with obesity are well described there is a paucity of evidence on the effect of weight compared to BMI for long term functional outcomes of total hip replacements (THR). The aim of this study was to investigate the influence of BMI and weight on long-term patient reported outcome measures following primary THR. Methods: 846 patients who underwent primary THR at the Royal Adelaide Hospital between 2000 and 2009 had a pre-operative height and weight recorded. Patient reported outcome measures (PROMs) were completed at 1, 5 and greater than 10 years follow-up. Categorical comparison of PROMs was performed for patients in weight categories of 0-65 kg, 65-80 kg, 80-95 kg, 95-110 kg and >110 kg; and BMI categories as per the WHO Classifications. Results: There was no difference in absolute or change in PROMs for any weight category. BMI did not have an effect on the change in (HHS), however there was a statistically significant decrease in absolute (HHS) values at 1 and 5 years with increasing obesity. 65 patients underwent revision within the first ten years. Conclusion: The results from this study confirm for the first time that there was no impact of weight or BMI on the change in long-term PROMs of THR. There remains a need for larger registry studies to investigate the effect of weight and BMI on long-term patient outcomes and revision rate.

Retention of kinematic patterns during a 6-minute walk test in people with knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) is a chronic condition affecting the entire joint and surrounding tissue, resulting in pain, stiffness and impaired movement. Recent studies have suggested the use of physical performance tests, such as the six-minute walk test (6MWT) to assess joint function for those with knee OA. This study assessed lower limb sagittal plane joint angles during a 6MWT for people with mild-moderate knee OA. METHODS: Thirty-one participants (18 male, 13 female; 62.9 ± 8.4 years) with knee OA were recruited. Gait data were collected in a single session during which participants completed a 6MWT around a 20 m course. Sagittal plane joint angles for the hip, knee and ankle were calculated during the first and last minute of the 6MWT. Statistical parametric mapping (SPM) was used to investigate changes in kinematic traces over the gait cycle. RESULTS: Mean joint angles for the hip and knee showed no significant differences between the first and last minute of the 6MWT. Ankle joint kinematic traces indicated there to be a decrease in plantarflexion approaching toe-off in the last minute of the test - a 1.5° reduction from the first minute. No significant differences were calculated for walking speed or joint range of motion. DISCUSSION: The lack of significant change in joint kinematic parameters and walking speed suggests the relative fatigue and pain burden to the participant over the duration of the 6-minute period is insufficient to elicit any mechanical changes to walking gait.

Gait biomechanics after proximal femoral nailing of intertrochanteric fractures.

Proximal femur fractures in the elderly are associated with significant loss of independence, mobility, and quality of life. This prospective study aimed to: (1) investigate gait biomechanics in intertrochanteric fracture (ITF) patients (A1 and A2 AO/OTA) managed via femoral nailing at 6 weeks and 6 months postoperative and how these compared with similarly aged elderly controls; and (2) investigate whether femoral offset shortening (FOS) and lateral lag screw protrusion (LSP) were associated with changes in gait biomechanics at postoperative time points. Hip radiographs and gait data were collected for 34 patients at 6 weeks and 6 months postoperatively. Gait data were also collected from similarly aged controls. FOS and LSP were measured from radiographs. Joint angles, external moments, and powers were calculated for the hip, knee, and ankle and compared between time points in ITF patients and healthy controls using statistical parametric mapping. The relationship between radiographic measures with gait speed, step length, peak hip abduction, and maximum hip abduction moment was assessed using a Pearson correlation. External hip adduction moments and hip power generation improved in the first 6 months postoperative, but differed significantly from healthy controls during single limb stance. LSP showed a moderate correlation with maximum hip abduction moment at 6 weeks postoperative (r = -0.469, p = 0.048). These results provide new detail on functional outcomes after ITF and potential mechanisms that functional deficiencies may stem from. Lag screw prominence may be an important factor in maintaining functional independence and minimizing the risk of secondary falls after ITF in the elderly.

Outcomes analysis of anterior and lateral approach for open repair of hip abductor tendons.

BACKGROUND: Gluteal tendons tears are increasingly being recognised as a cause of recalcitrant trochanteric pain, but there is a paucity of robust studies analysing the type of tears, results and predictors of outcome. METHODS: Patients with gluteal tendon tears resistant to conservative treatment who underwent isolated open repair (IR) or total hip arthroplasty and concomitant repair (THA+repair) with a minimum 1-year follow-up were retrospectively assessed separately. Type of tear, surgical approach, and fixation methods were registered. Complications and postoperative outcomes were analysed: visual analogue scale (VAS) of pain, VAS satisfaction, and activity level. Univariate regressions and multivariable models were developed. RESULTS: 90 cases were included: 62 cases underwent IR and 28 cases THA+repair, with an average follow-up of 3.9 years and 2.6 years, respectively. 13 complications were found (n = 5 IR, n = 8 THA+repair), including 9 re-operations (n = 4 IR, n = 5 THA+repair). Mean VAS pain score was 3.02 (SD 2.74) for the IR and 2.32 (SD 2.43) for THA+repair group. Mean VAS satisfaction was 7.09 (SD 3.07) and 7.68 (SD 2.71) for the IR and THA+repair group, respectively. In the IR group 61.4% returned to all pre-injury activities, whereas in the THA+repair group 79% did. Full-thickness tears had higher VAS pain scores (p = 0.0175), and there was trend (p > 0.05) towards higher complications, re-tears and lower VAS satisfaction in this type of tears in both groups. No statistically significant differences were found in outcomes when comparing THA+repair through direct anterior (DAA) with lateral approach (LA). CONCLUSIONS: Isolated gluteal tendon repair or THA+repairs seem to be safe procedures with high levels of satisfaction at short- to mid-term follow-up. The presence of a full-thickness tear is a predictor of inferior outcomes.

The Accuracy of Percutaneous Sacro-Iliac Screw Fixation for Pelvic Ring Injuries using the Lateral view as the Corner Stone for Screw Placement: A Prospective Cohort Study.

This paper has been temporarily removed by the publisher, Wolters-Kluwer, as it may have been published in error. We regret any confusion this may have caused.

Visualising knee loading patterns during kneeling and the development of a laboratory-based adaptation of the Aberdeen Weight-Bearing Test (Knee).

BACKGROUND: Information regarding the loading of key anatomical structures of the knee during kneeling would enhance existing functional tests, yet current visualisation methods are limited and require further development. AIMS: (1) Develop a knee loading visualisation technique to investigate loading patterns of the knee during kneeling; and (2) determine the utility of the technique in combination with vertical ground reaction forces and centre of pressure data in the lab-based Aberdeen Weight-Bearing Test (Knee) by assessing their reliability. METHODS: Fourteen healthy participants conducted kneeling tasks with and without knee pads across two testing sessions. Eight force-sensitive resistors were affixed to the right knee throughout different kneeling tasks: upright kneeling, and reaching forward, back, left, and right. A photo of the force-sensitive resistor configuration was used to generate participant-specific heat maps of knee loading. Two in-ground force platforms were used to measure vertical ground reaction forces and centre of pressure. RESULTS: The inferior patella tendon showed the highest proportion of activation during both bare and knee pad kneeling for all kneeling tasks. Knee pads reduced the repeatability of knee loading patterns. Force-sensitive resistor activation and vertical ground reaction force components of the lab-based Aberdeen Weight-Bearing Test (Knee) were shown to be reliable, whereas the centre of pressure data was unreliable. CONCLUSION: We have developed a lab-based technique for visualising knee loading using force-sensitive resistors. The combination of force-sensitive resistor activation and vertical ground reaction force data provides valuable insights into both the magnitude and locations of applied loads throughout kneeling.

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis.

Purpose: The purpose of this study was to investigate differences in aseptic reoperation rates between single or dual lag screw femoral nails,in the treatment of intertrochanteric fractures (ITF) in elderly patients. Methods: Electronic databases were searched for RCTs and prospective cohort studies treating elderly ITF patients with a single or dual screw femoral nails. Data for aseptic reoperation rates between single screw, dual separated screw and dual integrated screw devices were pooled using a random-effects meta-analysis with 95% CIs. Pooled proportions were compared using a N-1 chi-squared test. Complications contributing to aseptic reoperation rates were extracted, and the contribution of cut-out and periprosthetic fracture as a proportion of reoperations was analysed using a negative binomial regression model. Results: Forty-two (n = 42) studies were evaluated, including 2795 patients treated with a single screw device, 1309 patients treated with a dual separated screw device and 303 patients treated with a dual integrated screw device. There was no significant difference in aseptic reoperation rates between single and dual lag screw femoral nails of both separated and integrated lag screw designs. Moreover, complications of cut-out and periprosthetic fracture as a proportion of reoperations did not differ significantly between devices. Conclusion: The current evidence showed that aseptic reoperation rates were not significantly different between single and dual screw nails of a separated lag screw design. For dual integrated screw devices, due to insufficient evidence available, further high quality RCTs are required to allow for decisive comparisons with these newer devices.

Investigating and defining outcomes of suprapatellar versus infrapatellar intramedullary nailing of tibial shaft fractures: a protocol for a pilot randomised controlled trial.

BACKGROUND: Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures. METHODS: This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery. DISCUSSION: This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing. TRIAL REGISTRATION: This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909 .

Is unrestricted weight bearing immediately after fixation of rotationally unstable pelvic fractures safe?

INTRODUCTION: Rotationally unstable pelvic fractures treated with surgical fixation have traditionally been treated with restricted weight bearing on the affected side for 6-8 weeks post operatively. We have been developing pelvic fixation standards to allow for unrestricted weight bearing immediately post operatively in type B rotationally unstable pelvic fractures. AIMS: To assess for safety and efficacy of allowing unrestrictive weight bearing in this cohort of patients, we have clinically and radiologically monitored outcomes up to two years post operatively. METHODS: Through retrospective review, two cohorts of patients with Tile Type B pelvic fractures were identified that were treated at the Royal Adelaide Hospital, South Australia. Patient demographics, injury classification, surgical fixation and weight bearing status post operatively was recorded. One cohort of patients was allowed to fully weight bear post operatively, whilst the other was treated with 6 weeks of restricted post op weight bearing. At clinical follow up, post-operative x-rays were assessed for loss of reduction, screw or plate breakage and reoperation. RESULTS: Between January 2018 and January 2021, 53 patients with rotationally unstable pelvic fractures that underwent surgical fixation were included in this study. One group of patents were allowed to immediately weight bear as tolerated (WBAT) post operatively (n = 28) and the other with restricted weightbearing (RWB) (n = 25). There was 1 re operation for failure of fixation in each group. Metalwork breakage was more common in the WBAT group than in the RWB group and this was seen only in APC fractures. This increase in metalwork failure was not associated with loss of reduction. CONCLUSIONS: With surgical fixation, Tile type B rotationally unstable pelvic fractures can be allowed immediate weight bearing post operatively. We found this to be safe and effective, employing surgical strategies to address both anterior and posterior injuries to allow immediate unrestricted weight bearing. Broken metalwork was more commonly seen in the WBAT group but this was not associated with loss of reduction or reoperation.

An instrumented walker in three-dimensional gait analysis: Improving musculoskeletal estimates in the lower limb mobility impaired.

BACKGROUND: In three-dimensional (3D) gait analysis of individuals requiring a walking frame (walker), acquisition of artefact-free motion and force data is challenging. Without inclusion of handle-reaction forces alongside ground reaction forces, external forces used in musculoskeletal modelling are incomplete. This may increase dynamic inconsistencies between the model and measured motions and forces, thus, uncertainties in estimates of musculoskeletal load. RESEARCH QUESTION: To develop an instrumented walker and evaluate the effects of including handle-reaction forces on residual forces during musculoskeletal modelling. METHODS: An instrumented walker measuring handle-reaction forces synchronously with motion capture and ground reaction force data was developed. 3D gait analysis was conducted in ten elderly participants recovering from a proximal femur fracture and requiring a walker for ambulation. Joint kinetics and residual forces were calculated between two external load conditions: (1) external loads applied using only force platforms; or (2) external loads applied using force platforms and walker handle-reaction forces. RESULTS: Including handle-reaction forces reduced residual forces and improved estimates of musculoskeletal loads of the torso (P = <0.001). SIGNIFICANCE: A wide instrumented walker measuring handle-reaction forces allows for the gait analysis of individuals requiring a walker and improves reliability of musculoskeletal dynamics.

Operative management of fragility fractures of the pelvis - a systematic review.

BACKGROUND: The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention. METHODS: A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients. RESULTS: The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed. There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients. CONCLUSIONS: Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications. PROSPERO Systematic Review ID: CRD42020171237.

Current concepts: managing acetabular fractures in the elderly population.

The aim of this review is to summarise the current concepts in the management of acetabular fractures in the elderly population. A literature review of the evidence regarding the management of elderly acetabular fractures was performed utilising PubMed and Ovid. The predominant causes and fracture patterns of acetabular fractures are changing as populations age. Consequently, the operative management has had to change also. Judet and LeTournel did not offer operative treatment to any patients older than sixty. However, in the present time, according to the German Pelvic Registry, over half the patients aged sixty or over, sustaining acetabular fractures underwent operative fixation. We find that the increasing age of the population raises particular challenges for the operating surgeon. Postoperative rehabilitation should be focused on early mobilisation. More research needs to be focussed on standardised treatment protocols and long-term outcomes for this cohort of patients.

The burden of cycling-related trauma to the orthopaedic and trauma department of a level 1 trauma hospital in Adelaide, South Australia.

BACKGROUND: With the fourth largest metropolitan population density, motor vehicle drivers in Adelaide, South Australia, record the most number of motor vehicle insurance claims in Australia. Previous studies have shown a rise in cycling-related emergency department presentations from 2005 to 2010. There is no specific data available specifically related to South Australia. Our institution is the largest level 1 trauma centre in South Australia and Northern Territory and has a local geographic pool of the central metropolitan region of Adelaide. The aims of this study were to establish the demographics of cycling-related presentations to our institution that involved the admission of a patient under the Orthopaedic and Trauma service. Secondary aims were to investigate whether there were any common variables among these presentations that could be modified to prevent or reduce the morbidity of cycling-related trauma. METHODS: A prospective study was performed at our institution from 1 March 2018 until 31 December 2019 of all inpatient admissions under the Orthopaedics and Trauma department, where the patient was injured as a cyclist. We collated patient-reported information about the accident and their cycling habits. RESULTS: One hundred and ten patients were included in the study. One hundred and thirty-one injuries were recorded, requiring 89 surgical procedures. Eighty were upper limb injuries (61%), 49 were lower limb (37%), and 2 injuries occurred in either the spine or ribs. The most common reason for the accident was excessive cyclist speed. CONCLUSIONS: The majority of cyclists admitted to our unit with orthopaedic injuries were male patients who assessed themselves as experienced riders, and yet still were involved in accidents that resulted predominantly from episodes of poor judgement. Speed is a common and avoidable factor involved in the presentation of orthopaedic-related trauma to the public system. Involvement of other vehicles was relatively uncommon, as was poor weather; upper limb injuries predominate in this group.

The Anatomic Relevance of the Iliopectineal Fascia for Acetabular Surgery.

OBJECTIVE: To describe in detail the variability of the attachments of the iliopectineal fascia (IPF) and its relation to the external iliac vessels to inform surgical approaches and help prevent injury to the adjacent vascular structures. METHODS: A cadaveric study was performed on 16 specimens. The IPF was identified from the lateral and medial perspectives of the II and anterior intrapelvic approaches, respectively, and its anatomic characteristics were described. RESULTS: The IPF originates in the fascia of the psoas muscle, it has variable attachments in the pelvic brim, and it inserts in the medial surface of the iliac bone where it is continuous with the obturator internus fascia. Two variants were found in relation to the external iliac vessels. In one variant found in 4 cadavers, the IPF formed a sail-like structure that surrounds the external iliac vessels. In the other variant observed in 4 cadavers, the IPF overlaid the iliac fossa, under the external iliac vessels which laid free in the iliac fossa. CONCLUSIONS: The anatomic variants of the attachment of the IPF to the pelvic brim and its variants in relation to the external iliac vessels must be accounted for when performing acetabular surgery to prevent vascular injury and attain adequate exposure.

Perception of quality of intraoperative fluoroscopy and the influence on postoperative management: an international survey.

PURPOSE: Intraoperative precise visualization of fractures and assessment of the quality of reduction is essential in orthopedic trauma surgery. Fluoroscopic skills will lead to an increased detection rate of minimal abnormalities needing revision intraoperatively. The definition of fluoroscopic skills and the interpretation of acceptable "minimal abnormalities" remains somehow unclear. The purpose of this study was to analyze the subjective quality assessment of intraoperative radiographs (IR) and whether they are influenced by cultural and demographic factors. Furthermore, we aimed to answer the question whether the indication for revision surgery is international comparable or rather influenceable by cultural aspects. METHODS: Intraoperative radiographs of 30 patients operated for an ankle or radius fracture were selected for an international survey. In total, 22 patients were randomly selected from an already existing database and eligible for inclusion if reduction was accomplished during initial operation without planed revision. Eight patients of this group had undergone an unplanned revision surgery (26.6%). Fifteen orthopedic trauma surgeons from three different countries answered this survey. All raters were senior consultants. RESULTS: The quality of reduction was rated as good in both the AP (7.95 of 10) and lateral (7.84 of 10) views. The inter-observer reliability was substantially weaker in Country B (kappa of 0.23) compared to Countries A (p value < 0.05) and C (range 0.33-0.43). In only 33% of the cases the raters requested a postoperative radiograph. This was significantly fewer (p value < 0.001) in Country A. The frequency of postoperative requested CT's was comparable between the countries. CONCLUSION: This study showed acceptable IR assessment in terms of quality rating. Furthermore, it revealed substantial differences in the postoperative decision-making process in different countries, especially regarding the necessity for postoperative radiographs. This suggests that definition for indication of revision surgery is culturally influenced.

Radiostereometric Analysis Allows Assessment of the Stability and Inducible Displacement of Pelvic Ring Disruptions during Healing: A Case Series.

There is currently no accurate data on fracture displacement during the rehabilitation of pelvic ring injuries. This study investigated the use of radiostereometric analysis (RSA) in assessing the stability of C1 pelvic ring injuries stabilised with a posterior plate and an anterior external fixator. Six patients, instructed to weight-bear as tolerated after surgery, were reviewed at 2, 4, 6, 12, 26, 52 and 104 weeks. The external fixators were removed at 6 weeks. Outcomes, including the Iowa Pelvic Score (IPS), and complications were recorded. Fracture stability was assessed using measurements on plain radiographs and RSA. All patients progressed to full weight-bearing without support within 6 weeks. At 104 weeks, the IPS was excellent in four patients, good in one patient and fair in one patient. Plain radiographs showed that all fractures were well reduced, and no loss of reduction occurred over time. By contrast, RSA measurements identified displacement in all cases. The maximum three-dimensional (3D) displacement at any time point in each patient ranged from 2 to 10 mm. Two patients with the largest displacement over time had the lowest IPS. RSA also demonstrated displacements above the currently defined normal threshold through the 'un-injured' sacroiliac joint in the same two patients, suggesting a subtle C2 injury, missed at initial assessment. This study demonstrates the limitations of plain radiographs in assessing pelvic fracture stability and displacement during healing, and the potential of RSA to monitor more accurately the effects of stabilisation and weight-bearing on fracture stability.

Proximal Femoral Nail Unlocked versus Locked (ProFNUL): a protocol for a multicentre, parallel-armed randomised controlled trial for the effect of femoral nail mode of lag screw locking and screw configuration in the treatment of intertrochanteric femur fractures.

INTRODUCTION: Intertrochanteric fractures are common fragility injuries in the elderly. Surgical fixation using intramedullary devices are one of the widely used management options. To date, evidence demonstrating the effects of lag screw configuration and the mode of lag screw locking in these devices is lacking. The purpose of this study is to investigate whether the lag screw configuration (single vs integrated dual interlocking screw) and the mode of lag screw locking (static vs dynamic) of a femoral nail device result in differences in clinical and functional outcomes. METHODS AND ANALYSIS: A multicentre, pragmatic, single-blinded randomised controlled trial (RCT) with a three-arm parallel group design is proposed. Nine-hundred patients with intertrochanteric fractures (A1 and A2 AO/OTA) will be randomised to fracture treatment using a Gamma3 nail (Stryker; proximally dynamic) or a Trigen Intertan nail (Smith & Nephew) in a dynamic or static lag screw configuration. The primary outcome measure consists of radiological evidence of construct failure within 6 months following surgery, with failure being defined as breakage of the femoral nail or distal locking screw, a change in tip-apex distance of more than 10 mm or lag screw cut-out through the femoral head. Secondary outcomes include surgical data (operation time, fluoroscopy time), complications (surgical site infection, reoperation, patient death), return to mobility and home circumstances, functional independence, function and pain. Patients who are able to walk independently with or without a mobility aid and are able to answer simple questions and follow instructions will be asked to participate in three dimensional gait analysis at 6 weeks and 6 months to assess hip biomechanics from this cohort. Additional secondary measures of gait speed, hip range of motion, joint contact and muscle forces and gross activity monitoring patterns will be obtained in this subgroup. ETHICS AND DISSEMINATION: The Central Adelaide Local Health Network Human Research Ethics Committee has approved the protocol for this RCT (HREC/17/RAH/433). The results will be disseminated via peer-reviewed publications and presentations at relevant conferences. TRIAL REGISTRATION NUMBER: ACTRN12618001431213.

Risk factors for femoral stem breakage: an analysis of the AOANJRR results.

INTRODUCTION: Breakage of the femoral stem component of a total hip replacement is now uncommon but continues to be seen with certain stem designs and in certain patient groups. Data previously published on this topic has been limited, either gathered from a single surgeon or centre, or included only a single stem design. METHODS: We reviewed the data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), identified and analysed 143 stem breakages over a period of 16 years, covering 44 different stem designs. RESULTS: Our data confirms previously published findings that risk factors for stem breakage include patient age at implantation of under 70, male gender, as well as the use of exchangeable necks. We found no association with initial diagnosis, or type of acetabular component implanted. We did however also find, excluding exchangeable neck designs, that after 4.5 years a cemented stem had a significantly higher risk of breakage then a cementless stem. DISCUSSION: To our knowledge this is the 1st paper to suggest cemented fixation as a specific risk factor for stem breakage. The analysis of rare complications such as stem breakage is only possible through large data collection systems such as the AOANJRR. Whilst there have been recent advances in materials and manufacturing techniques, we recommend that surgeons are aware of all the specific risks when considering implant choices for individual patients.