Acetabular Fractures in older patients Intervention Trial (AceFIT): a feasibility triple-arm randomized controlled study.

Aims: To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods: Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients' willingness to participate, clinicians' capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results: Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion: This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation.

The floating hip injury: a descriptive study and case-control analysis.

PURPOSE: A "floating hip" (FH) injury is a rare injury describing the simultaneous ipsilateral fracture of the femur and pelvis or acetabulum (P/A). We describe our experience with patients presenting with FH injuries and compare them to controls with similar P/A fractures but without femoral involvement. METHODS: Medical records and radiographs of FH patients and controls presenting to our tertiary centre between 2015 and 2020 were reviewed. Follow-up data from outpatient clinical records were also extracted. The control group were extensively matched by age, sex, body mass index, fracture classification and energy of injury. RESULTS: From 1392 recorded P/A fractures, 42 FH cases were identified (average age 39 years, 78.6% males). The most common femoral fracture was the midshaft (35.7%), followed by the neck of femur (26.2%). 90.5% of FH injuries were due to high-energy mechanisms. 64.3% of P/A fractures, and 100% of femoral fractures were managed surgically. Compared to controls, FH cases were more likely to have additional orthopaedic injuries (73.8% vs. 40.5%, p = 0.002), more total theatre admissions (mean 2.5 vs. 1.19, p < 0.001), longer hospital stays (28.3 vs. 14.9 days, p = 0.02), and a higher rates of post-op complications (53.8% vs. 20%, p = 0.025). CONCLUSIONS: We report differences in the presentation, management, and outcomes of FH injuries versus controls, even after extensive matching for confounders. These differences may inform future treatment strategies for the FH injury.

The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity.

INTRODUCTION: Paediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans. METHODS: The trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries. RESULTS: 65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3-22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2-20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037). CONCLUSION: PPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Fix and replace: Simultaneous fracture fixation and hip replacement for acetabular fractures in older patients.

INTRODUCTION: Displaced acetabular fractures in the elderly present significant treatment challenges. The 'fix and replace' concept involves open reduction and internal fixation of the acetabulum, providing bony stability to accept the press-fit of an acetabular cup, with a cemented femoral stem. This allows early mobilisation and the advantages this confers. This study of 57 patients treated with fix and replace describes our technique, outcomes, and survival analysis. METHODS: A retrospective review of 57 'fix and replace' procedures in patients aged over 60 was performed. Data was collected on mechanism, fracture type, demographics, time to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs were reviewed for fracture healing, implant loosening, cup migration, and heterotopic ossification. RESULTS: 57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3. The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns were anterior column posterior hemitransverse (67%), associated both columns (9%), posterior column (9%), posterior column and posterior wall (9%), and transverse (2%). The mean time to surgery was 8.4 days (0-14). 26 out of 57 (46%) received a blood transfusion. Mean length of stay was 17.6 days (7-86). The mean follow-up was 35.5 months. 4 dislocations were treated with closed reduction, whilst 1 required excision arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention (DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated requiring revision. The median pre-injury OHS was 44 (26-48) compared to 37.3 (28-48) at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died. Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival was 90% at 1 year. CONCLUSION: While fix and replace is conceptually attractive, this medically complex patient group requires considerable support peri­ and post-operatively. Further studies are required to provide clinicians with more information to decide on how best to provide a holistic management strategy for such injuries in this frail patient cohort.

Cycling-related trauma admissions to the major trauma centre in the cycling capital of the United Kingdom.

PURPOSE: This study aims to characterise cycling related injuries presenting to a major trauma centre located within a region with the highest rates of cycling in the UK. METHODS: A retrospective analysis of cycling related trauma admissions occurring between January 2012 and June 2020 was performed. Our institution's electronic patient record system was used to collect relevant data for analysis including age, gender, mechanism of injury, Glasgow coma scale (GCS) on arrival, incident date and time, injured body regions, 30-day mortality, helmet use and intubation rate. Comparison was made between groups of patients based on mechanism of injury. RESULTS: A total of 605 cycling related trauma cases were identified, with 52 being excluded due to incomplete data. The most common mechanism was 'fall from cycle' (53.5%). The 'cyclist v vehicle' group was associated with a significantly higher Injury Severity score (ISS), lower GCS and higher intubation rate. Helmet wearers were significantly older than non-wearers and helmet use was associated with a significantly reduced risk of head injury, lower ISS and intubation rate and a higher GCS. DISCUSSION: With a likely increase in future cycling uptake, it is crucial that effective interventions are implemented to improve the safety of cyclists. The findings of this study may be used to guide any such intervention. A multi-faceted strategy involving driver and cyclist education, effective road infrastructure changes and helmet promotion campaigns specifically targeting the younger generation could be employed.

The Harrington plus reconstruction for pelvic and acetabular metastases.

BACKGROUND: Surgical management of periacetabular bone metastases is challenging. The Harrington Plus reconstruction is a modification of the original Harrington rod technique. An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss. METHODS: A retrospective review of the 13 patients who have undergone the Harrington Plus procedure to date was performed. Mobility status, EQ5D and Oxford Hip scores were assessed. RESULTS: There was a significant improvement in mobility status, EQ5D and Oxford Hip Scores at 6 months postoperatively (p < 0.05). Two patients returned to theatre for debridement of infection. There were no postoperative dislocations, cup medialisation or cases of loosening of the prosthesis. No patient required revision arthroplasty surgery. CONCLUSION: The Harrington Plus procedure produces a reliable construct that allows patients with extensive periacetabular metastatic defects to fully weight-bear. Careful patient selection and multidisciplinary management is essential.

Factors associated with mortality in older patients sustaining pelvic or acetabular fractures.

INTRODUCTION: This study aimed to investigate potential factors, including delay to surgical stabilisation, affecting mortality in older patients sustaining pelvic or acetabular (PA) fractures. MATERIALS AND METHODS: A retrospective review of the Trauma Audit and Research Network (TARN) database was performed to identify older patients (aged 65 and over) sustaining PA fractures treated surgically in a UK Major Trauma Centre (MTC) between 2015 and 2019. Chi-squared and Fisher tests were used to compare 1-year mortality rates following operative intervention between patients treated within 72 h and after 72 h. Kaplan-Meier curves were used to visualise survival probability; significant predictors of survival were found using Cox proportional hazard models. RESULTS: Of 564 older patients with PA fractures, 70 met the inclusion criteria. The mean age was 76.1 years. The overall 1-year mortality rate was 20%. When patients were grouped by time to surgery (fracture fixation within or greater than 72 h), there was no statistically significant difference in 1-year mortality. Patients whose surgery was delayed more than 72 h were more likely to have longer hospital stays (p = 0.002) or to have suffered from polytrauma (p = 0.025). Age, Charlson Co-morbidities Index (CCI) and pre-op mobility status were associated with statistically significant differences in overall mortality. The same factors were associated with a significantly increased hazard of death in the multivariate Cox proportional hazards model. Patient gender, mechanism of injury, Injury Severity Score (ISS) > 15 and head injury were not significant predictors of mortality. CONCLUSION: Surgical intervention within 72 h of injury did not result in decreased mortality in older patients with PA fractures. The 1-year mortality rate between older PA fractures and hip fractures was comparable. Consideration should be given to a combined multidisciplinary approach between orthogeriatric and expert PA surgeons for these patients.

Cycling-related orthopaedic fractures admitted to the Major Trauma Centre in the cycling capital of the UK.

INTRODUCTION: The popularity of cycling in the United Kingdom is increasing, with a further rise likely due to recent government cycling promotion schemes. This study aims to characterise fractures sustained due to cycling-related collisions in patients presenting to a Major Trauma Centre, in the region with the highest cycling rates in the United Kingdom. METHODS: A retrospective analysis of cycling injuries presenting to our centre between January 2012 and December 2020 was performed using a prospectively collected electronic database. Comparison of fracture characteristics was made according to patient age and mechanism of injury (collision with a motorised vehicle versus collision with a non-motorised object.). RESULTS: Of the 737 patients who suffered a cycling-related injury, 292 (39.6%) suffered at least 1 fracture to the appendicular skeleton. Overall, fractures were most commonly seen in those over 50 years of age. Upper limb fractures were more common than lower limb fractures. Fractures sustained during motorised injuries were more likely to require surgical intervention than those sustained during non-motorised collisions. CONCLUSION: This study provides valuable information regarding the nature, epidemiology and treatment of fractures sustained following cycling-related accidents, adding to the paucity of similar literature in the field. Given the likely increase in future cycling uptake, our results are important to clinicians treating patients with cycling-related injuries and policymakers designing safety interventions.

Trauma epidemiology after easing of lockdown restrictions: experience from a level-one major trauma centre in England.

PURPOSE: The COVID-19 pandemic transformed the delivery of trauma care. We examined the effect of lockdown easing on trauma presentation and management from one Major Trauma Centre (MTC). METHODS: Data was retrospectively analysed from Trauma Audit and Research Network (TARN) on patients presenting to our MTC with trauma. The first 47 days of lockdown (23rd March-9th May 2020, period 1) were compared with the next 47 (10th May-26th June 2020, period 2) and last (27th June-13th August 2020, period 3). Data collected included demographics, mechanism and severity of injury, management and length of stay. RESULTS: 1249 patients were included; 62.2% were male with a mean age of 57.73. Footfall declined in April 2020 compared with 2019 (56 vs. 143) but rebounded by May (123 vs. 120 patients). Road traffic collisions increased over periods one-three (18.8% vs. 23% vs. 30.1%, p = 0.038); deliberate self-harm (DSH) increased in period two compared with one and three (6.3% vs. 3.4% vs. 1.4%, p = 0.03), respectively. When compared with 2019, the 2020 patient age was lower, with less trauma relating to alcohol (7.3% vs. 13.2%, p = 0.009), but more from DSH (3.6% vs. 2.1%, p = 0.10). In 2020 less patients were assessed by a consultant and trauma team, with a shorter stay in hospital and critical care. CONCLUSION: This is the first study to document trauma trends through a lockdown and thereafter. After lockdown easing, trauma footfall rapidly rebounded to 2019 levels. This should be acknowledged in resource allocation decisions if future lockdowns are necessitated.

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma.

INTRODUCTION: Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. MATERIALS AND METHODS: All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. RESULTS: The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. CONCLUSION: Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

Dynamic hip screw fixation of subtrochanteric femoral fractures.

INTRODUCTION: A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct. MATERIALS AND METHODS: We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014-May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality. RESULTS: During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm2 compared to 288.86 mGy cm2 in the IMN group. CONCLUSION: Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.

Acetabular avascular necrosis following high-dose steroid treatment and chemotherapy for leukemia : Computer tomography analysis of treatment with impaction bone grafting.

Avascular necrosis (AVN) of the bone is thought to be a serious complication of treatment for acute lymphoblastic leukemia (ALL). The acetabulum is an unusual area to be affected by AVN, and there are currently no reports of successful joint salvage procedures found in the literature. We present a case of a 20-year-old man with ALL who was diagnosed with debilitating AVN of both acetabula 2 years following initial diagnosis of ALL and treatment with a multi-agent chemotherapy regimen including high-dose corticosteroids. After unsuccessful treatment with bisphosphonate therapy, the acetabular AVN underwent bilateral curettage and impaction bone grafting to prevent collapse of subchondral fractures with the hope of salvaging both hip joints. Computer tomography (CT) of the AVN affected areas, pre- and post-bone impaction grafting, demonstrated healing of the subchondral fractures and a doubling of bone density that was maintained at 2 years after surgery. The patient resumed full weight-bearing at 3 months after first surgery, continues to ambulate unrestricted, and remains pain free 3 years post-surgery.

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.

Knee Fix or Replace Trial (KFORT): a randomized controlled feasibility study.

AIMS: The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients. PATIENTS AND METHODS: Seven centres recruited patients into the study. Patients were eligible if they were greater than 65 years of age with a distal femoral fracture, and if the surgeon felt that they were suitable for either form of treatment. Outcome measures included the patients' willingness to participate, clinicians' willingness to recruit, rates of loss to follow-up, the ability to capture data, estimates of standard deviation to inform the sample size calculation, and the main determinants of cost. The primary clinical outcome measure was the EuroQol five-dimensional index (EQ-5D) at six months following injury. RESULTS: Of 36 patients who met the inclusion criteria, five declined to participate and eight were not recruited, leaving 23 patients to be randomized. One patient withdrew before surgery. Of the remaining patients, five (23%) withdrew during the follow-up period and six (26%) died. A 100% response rate was achieved for the EQ-5D at each follow-up point, excluding one missing datapoint at baseline. In the DFR group, the mean cost of the implant outweighed the mean cost of many other items, including theatre time, length of stay, and readmissions. For a powered RCT, a total sample size of 1400 would be required with 234 centres recruiting over three years. At six months, the EQ-5D utility index was lower in the DFR group. CONCLUSION: This study found that running a full-scale trial in this country would not be feasible. However, it may be feasible to undertake an international multicentre trial, and our findings provide some guidance about the power of such a study, the numbers required, and some challenges that should be anticipated and addressed. Cite this article: Bone Joint J 2019;101-B:1408-1415.

Structured-mentorship Program for Periacetabular Osteotomy Resulted in Few Complications for a Low-volume Pelvic Surgeon.

BACKGROUND: The Bernese periacetabular osteotomy (PAO) is a complex surgical procedure with a substantial learning curve. Although larger hospital and surgeon procedure volumes have recently been associated with a lower risk of complications, in geographically isolated regions, some complex operations such as PAO will inevitably be performed in low volume. A continuous structured program of distant mentoring may offer benefits when low numbers of PAOs are undertaken, but this has not been tested. We sought to examine a structured, distant-mentorship program of a low-volume surgeon in a geographically remote setting. QUESTIONS/PURPOSES: The purposes of this study were (1) to identify the clinical results of PAO performed in a remote-mentorship program, as determined by patient-reported outcome measures and complications of the surgery; (2) to determine radiographic results, specifically postoperative angular corrections, hip congruity, and progression of osteoarthritis; and (3) to determine worst-case analysis of PAO survivorship, defined as nonconversion to THA, in a regionally isolated cohort of patients with a high rate of followup. METHODS: Between August 1992 and August 2016, 85 PAOs were undertaken in 72 patients under a structured, distant-mentorship program. The patients were followed for a median of 5 years (range, 2-25 years). There were 18 males (21 hips) and 54 females (64 hips). The median age of the patients at the time of surgery was 26 years (range, 14-45 years). One patient was lost to followup (two PAOs) and one patient died as a result of an unrelated event. Patient-reported outcome measures and complications were collected through completion of patient and doctor questionnaires and clinical examination. Radiographic assessment of angular correction, joint congruity, and osteoarthritis was undertaken using standard radiology software. PAO survivorship was defined as nonconversion to THA and is presented using worst-case analysis. The loss-to-followup quotient-number of patients lost to followup divided by the number of a patients converted to THA-was calculated to determine quality of followup and reliability of survivorship data. RESULTS: The median preoperative Harris hip scores of 58 (range, 20-96) improved postoperatively to 78 (range, 33-100), 86 (range, 44-100), 87 (range, 55-97), and 80 (range, 41-97) at 1, 5, 10, and 14 years, respectively. Sink Grade III complications at 12 months included four relating to the PAO and one relating to the concomitant femoral procedure. The median lateral center-edge angle correction achieved was 22° (range, 3°-50°) and the median correction of acetabular index was 19° (range, 3°-37°). Osteoarthritis progressed from a preoperative mean Tönnis grade of 0.6 (median, 1; range, 0-2) to a postoperative mean of 0.9 (median, 1; range, 0-3). Six hips underwent conversion to THA: five for progression of osteoarthritis and one for impingement. At 12-year followup, survivorship of PAO was 94% (95% confidence interval [CI], 85%-98%) and survivorship with worst-case analysis was 90% (95% CI, 79%-96%). The loss-to-followup quotient for this study was low, calculated to be 0.3. CONCLUSIONS: When PAO is performed using a structured process of mentoring under the guidance of an expert, one low-volume surgeon in a geographically isolated region achieved good patient-reported outcomes, a low incidence of complications at 12 months, satisfactory radiographic outcomes, and high survivorship. A structured distant-mentorship program may be a suitable method for initially learning and continuing to perform low-volume complex surgery in a geographically isolated region. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Spinopelvic Dissociation: A Retrospective Case Study and Review of Treatment Controversies.

INTRODUCTION: Spinopelvic dissociation is a rare injury resulting in discontinuity between the spine and pelvis. We review the English- language literature and discuss critical treatment controversies. We present a series of spinopelvic dissociation cases from a level I trauma center. METHODS: In this retrospective review of 18 consecutive cases treated surgically over a period of 4 years, we collected patient, injury, and surgical demographics and clinical and radiographic outcome measures. RESULTS: Twelve patients had associated injuries, five were intubated on arrival, and six had neurologic deficits at presentation. No patient had spinal decompression, and all patients underwent closed reduction and percutaneous fixation. There were no cases of iatrogenic nerve injury, despite the use of partially threaded sacroiliac screws and closed reduction techniques. Five patients showed progressive neurologic improvement postoperatively. After reduction, eight patients (44%) had radiographic loss of the sacrococcygeal angle at the latest follow-up, but correction of fracture translation was preserved in all. DISCUSSION: Spinopelvic dissociation represents a heterogeneous group of injuries often in the context of polytraumatized patients with other injuries. Our closed reduction and fixation technique resulted in satisfactory outcomes. We present a treatment algorithm for these rare injuries.

Trochanteric Femoral Fracture Around a Birmingham Hip Resurfacing Prosthesis: A Case Report and Review of the Literature.

CASE: A traumatic nondisplaced periprosthetic trochanteric fracture around a well-fixed and functioning Birmingham Hip Resurfacing prosthesis was managed with a reconstruction intramedullary nail. The surgical procedure provided excellent pain relief, and the patient was able to mobilize with crutches the day after surgery. Follow-up at 1 year confirmed excellent clinical and radiographic results. CONCLUSION: In a patient with a previously well-functioning hip resurfacing prosthesis, internal fixation rather than revision hip arthroplasty can offer good clinical and radiographic outcomes. The use of a reconstruction intramedullary nail may be a good option for fixing a periprosthetic trochanteric fracture around a Birmingham Hip Resurfacing implant.

Bilateral Proximal Tibial Sleeve Fractures in a Child: A Case Report.

INTRODUCTION: A sleeve fracture classically describes an avulsion of cartilage or periosteum with or without osseous fragments and usually occurs at the inferior margin of the patella. Tibial tubercle sleeve fractures in the skeletally immature are extremely rare. CASE PRESENTATION: In this report the authors describe a 12-year-old boy with no systemic disease and no steroid use who sustained bilateral proximal tibial sleeve fractures whilst playing football. Both ruptures were associated with rupture of the medial patellofemoral ligament and tear of the medial retinaculum. Treatment was performed with primary end-to-end repair, reinforcement with bone anchors and cerclage wires with an excellent outcome. CONCLUSIONS: We feel this rare, currently unclassified variant of a tibial tubercle avulsion fracture should be recognised and consideration taken to adding it to existing classification systems.

Polyaxial versus uniaxial volar locking plate for distal radial fractures.

PURPOSE: To compare the penetration of the distal screws in relation to the thickness of the distal metaphysis in the polyaxial versus uniaxial volar locking plates. METHODS: Records of 78 patients aged 16 to 79 years who underwent open reduction and internal fixation for distal radial fractures (n=81) were reviewed. All fracture subtypes were included. 20 men and 22 women aged 18 to 79 (mean, 50) years were treated with the uniaxial locking plate, whereas 15 men and 21 women aged 16 to 79 (mean, 51) years were treated with the polyaxial locking plate. The choice of plate was determined by the operating surgeon based on familiarity and perceived advantages of the 2 plates. Penetration of the distal locking screws in relation to the volar-dorsal thickness of the distal radial metaphysis was measured, and the percentage of subchondral bone unsupported by the screws calculated. RESULTS: The mean percentage of unsupported subchondral bone was significantly lower in the polyaxial than uniaxial volar locking plate group (12% vs. 23%, p<0.001). No patient had screw over-penetration. CONCLUSION: The polyaxial volar locking plate system enabled deeper insertion of distal screws into the subchondral bone, and thus providing better buttress for the fracture fragments.

Prevalence of developmental dysplasia of the hip in children with clubfoot.

PURPOSE: The relationship between congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH) remains uncertain. The role of routine hip screening in children with CTEV is debated. A recent study has found a high incidence of DDH in patients with CTEV. The aim of our study was to determine the true prevalence of radiographic hip dysplasia and identify the need for routine hip screening in patients treated for CTEV. METHODS: From a single centre database of 165 children consisting of 260 CTEV, a prospective radiological prevalence study of 101 children was performed over a period of 3 months. A single anterior-posterior pelvic radiograph was performed at a minimum age of 5 months. The DDH was determined by a single senior investigator based on the age-adjusted acetabular index (AI) as described by Tonnis. RESULTS: There were no dislocations or subluxations. According to the age-adjusted AI, 16 children had 'light' dysplasia and one child had 'severe' dysplasia. The child with severe dysplasia was known to have DDH and had already undergone treatment. The 16 children with light dysplasia did not require any form of treatment. CONCLUSION: Out of one hundred and one children with CTEV, only one had DDH requiring treatment. This is consistent with the majority of the literature supporting the premise that there is no true association between CTEV and DDH. We, therefore, feel that routine hip screening for children with CTEV is not supported by current evidence and cannot be recommended.