Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial.

Importance: Fractures of the hip have devastating effects on function and quality of life. Intramedullary nails (IMN) are the dominant implant choice for the treatment of trochanteric fractures of the hip. Higher costs of IMNs and inconclusive benefit in comparison with sliding hip screws (SHSs) convey the need for definitive evidence. Objective: To compare 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS. Design, Setting, and Participants: This randomized clinical trial was conducted at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopaedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patient recruitment occurred between January 2012 and January 2016, and patients were followed up for 52 weeks (primary end point). Follow-up was completed in January 2017. The analysis was performed in July 2018 and confirmed in January 2022. Interventions: Surgical fixation with a Gamma3 IMN or an SHS. Main Outcomes and Measures: The primary outcome was health-related quality of life (HRQOL), measured by the EuroQol-5 Dimension (EQ5D) at 1-year postsurgery. Secondary outcomes included revision surgical procedure, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score). Results: In this randomized clinical trial, 850 patients were randomized (mean [range] age, 78.5 [18-102] years; 549 [64.6% female) with trochanteric fractures to undergo fixation with either the IMN (n = 423) or an SHS (n = 427). A total of 621 patients completed follow-up at 1 year postsurgery (304 treated with the IMN [71.9%], 317 treated with an SHS [74.2%]). There were no significant differences between groups in EQ5D scores (mean difference, 0.02 points; 95% CI, -0.03 to 0.07 points; P = .42). Furthermore, after adjusting for relevant covariables, there were no between-group differences in EQ5D scores (regression coefficient, 0.00; 95% CI, -0.04 to 0.05; P = .81). There were no between-group differences for any secondary outcomes. There were also no significant interactions for fracture stability (ß [SE] , 0.01 [0.05]; P = .82) or previous fracture (ß [SE], 0.01 [0.10]; P = .88) and treatment group. Conclusions and Relevance: This randomized clinical trial found that IMNs for the treatment of trochanteric fractures had similar 1-year outcomes compared with SHSs. These results suggest that the SHS is an acceptable lower-cost alternative for trochanteric fractures of the hip. Trial Registration: ClinicalTrials.gov Identifier: NCT01380444.

Overview of fracture liaison services in the UK and Europe: standards, model of care, funding, and challenges.

Fragility fractures represent a growing global problem, including in the United Kingdom and European countries. Reports demonstrate the benefits of national guidance and organized fragility fracture programs through fracture liaison services to deliver care to patients who sustain these injuries. The challenge of assembling multidisciplinary teams, providing routine screening of appropriate patients, and monitoring therapies where there is a known compliance problem, remains an obstacle to the success of fragility fracture treatment programs to all. Efforts should continue to introduce and maintain fracture liaison services through coordinated national approaches and advanced systems.

Long-term patient reported sexual and urological dysfunction in males after operatively treated pelvic ring injuries Do generic outcome measures identify genitourinary health problems?

BACKGROUND: A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22). METHODS: Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome. RESULTS: Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores. CONCLUSION: In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

Open acetabular fracture: Case report and literature review.

Acetabular fractures are a rare injury, with a reported annual incidence of 3 patients per 100,000 per year. Open fractures of the acetabulum are extremely rare, with only explosive penetrating trauma (blast or gunshot injury) being previously reported. An open acetabular fracture as a result of blunt trauma is presented, in which the only indication was a wound in the buttock, in which early definitive surgical management of the injury provided a good clinical outcome.

Long-Term Patient-Reported Functional Outcome of Polytraumatized Patients With Operatively Treated Pelvic Fractures.

OBJECTIVES: To report the long-term functional outcome of a cohort of patients with operatively treated unstable pelvic fractures using validated patient-reported outcome measures. DESIGN: Long-term observational study using prospective and retrospective data. SETTING: Tertiary referral pelvic trauma center, Bristol, United Kingdom. PATIENTS: Seventy-four polytraumatized patients with operatively treated unstable pelvic ring injuries (50 OTA/AO type B and 24 OTA/AO type C, mean Injury Severity Score 17) treated between 1994 and 2005. INTERVENTION: Sixty-four (86%) patients were treated with internal fixation. The remaining 10 patients (14%) were treated with either combined percutaneous posterior fixation and anterior external fixation or external fixation in isolation. MAIN OUTCOME: Patient-reported functional outcome. MEASUREMENTS: Short Form-36, with UK norm-based comparator scores and EQ-5D-3L. RESULTS: Patients were between 11 and 22 years after injury (mean 15 years). We found no significant association between fracture classification and outcome score, but compared with age- and sex-matched scores for a UK population, differences were statistically significant in 3 of the 8 domains of health: physical function (P = 0.04), bodily pain (P = 0.001), and vitality (P = 0.001). The level of disability remained constant for these patients compared with their patient-reported outcome measure scores reported 8 years previously. CONCLUSION: Patients who sustain an unstable pelvic fracture continue to have significant functional limitations compared with an uninjured population. These changes were not found to be related to age, injury pattern, genitourinary injury, or neurological injury. Functional outcome scores did not change over the 2 long-term time points. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does Routine Postoperative Computerized Tomography After Acetabular Fracture Fixation Affect Management?

INTRODUCTION AND AIMS: The use of routine postoperative computerized tomography (CT) scan after acetabular fracture reconstruction remains controversial. CT scan may provide more accurate detail regarding metalwork position, retained intra-articular fragments, and quality of reduction but does expose the patient to additional radiation dosage and incurs increased cost. The aim of this study was to evaluate a protocol of routine postoperative CT scan for all acetabular fractures after surgical fixation and assess the effect this has on patient management. PATIENTS AND METHODS: The perioperative fluoroscopic images and postoperative plain radiographs of 122 patients who underwent surgical stabilization of a displaced acetabular fracture were reviewed and categorized into 3 groups: (1) safe, when there was no suspicion of metalwork malposition or intra-articular fragments; (2) inconclusive, when it was not possible to exclude malposition; or (3) definite malposition or intra-articular penetration of implants. The findings were compared with postoperative CT scans. The quality of reduction of the acetabular fracture was graded on plain radiographs using the Matta criteria and compared with the CT scan using a standardized technique. RESULTS: Fractures that were categorized as safe on plain radiographs were confirmed to have no metalwork malposition on CT scan in 94% of the cases, with the other 6% having insignificant findings that did not require revision surgery. When plain radiographs were inconclusive (n = 17), 4 patients had metalwork malposition documented on CT scan and 2 of these required revision surgery. There was an increased risk of implant malposition with use of spring plates for posterior wall stabilization. There was significant variation between the quality of reduction when assessed with plain radiographs as compared with CT scans (P < 0.001). In 42% of the patients who were thought to have anatomic reduction on plain radiographic assessment, the reduction was either imperfect or poor based on CT assessment. CONCLUSIONS: CT scans were more accurate than plain radiographs in detecting metalwork malposition and in assessing quality of reduction of the acetabular fracture. The use of postoperative CT scans may be restricted to a group of fractures that have inconclusive or definite malpositioning of implants on perioperative or postoperative radiographs, especially with use of spring pates or to those patients in whom quality of reduction needs more accurate assessment for quality assurance or prognostic reasons. LEVEL OF EVIDENCE: Level IV; Diagnostic -Investigating a diagnostic test.

Routine Postoperative Computed Tomography Scans After Pelvic Fracture Fixation: A Necessity or a Luxury?

INTRODUCTION: There is no consensus regarding the postoperative radiology imaging protocol after pelvic fracture surgery. Some institutes routinely scan all patients after their surgery, others do not. The aim of this study was to assess the value of routine use of computed tomography (CT) scans after pelvic fracture surgery and to determine the sensitivity of conventional plain radiographs and intraoperative fluoroscopy in detecting metalwork malposition. PATIENTS AND METHODS: The radiographs and clinical notes of patients undergoing pelvic fracture surgery in the period between January 2010 and December 2015 were reviewed. Patients were categorized into 2 main groups: group A-patients whose fixation entailed the use of a sacroiliac (SI) screws and group B-patients whose fixation did not require an SI screw. Furthermore, the patients were classified according to the position of metalwork in their postoperative plain radiographs and perioperative fluoroscopy into 3 groups: (1) Safe: When there was no suspicion of metalwork malposition. (2) Suspicious: When there was some suspicion of malposition but radiographs were inconclusive. (3) Definite: When plain imaging showed a definite malposition. RESULTS: One hundred ninety-eight patients were included in this study (161 in group A and 37 in group B). In group A, 148 (92%) were classified as safe, 10 were suspicious (6%), and 3 (2%) showed definite malposition. Of the fractures that were believed to be safe on plain radiographs, 78% were confirmed to be safe on CT scans, whereas 22% showed malpositioned metalwork, and 7 patients (4%) required a revision surgery. Plain radiographs showed a sensitivity of 27% in detecting metalwork malposition and a specificity of 99%. Increasing the number of screws significantly increased the risk of malposition and reoperation (P = 0.006 and 0.002 respectively). The plain images of group B were all classified as safe. The CT scans detected 2 cases with long metalwork protruding into the soft tissues, none of which required a revision surgery. CONCLUSION: Perioperative fluoroscopy and plain postoperative radiographs have a low sensitivity in detecting the metalwork malposition after pelvic fracture surgery. We recommend the use of routine postoperative CT scans in patients whose fixation entails the use of SI screws. In this series, routine scanning of patients who did not have SI screws added no significant clinical value. LEVEL OF EVIDENCE: Level IV Diagnostic. See Instructions for Authors for a complete description of levels of evidence.

Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial.

Importance: Ankle fractures cause substantial morbidity in older persons. Surgical fixation is the contemporary intervention but is associated with infection and other healing complications. Objective: To determine whether initial fracture treatment with close contact casting, a molded below-knee cast with minimal padding, offers outcome equivalent to that with immediate surgery, with fewer complications and less health resource use. Design, Setting, and Participants: This was a pragmatic, equivalence, randomized clinical trial with blinded outcome assessors. A pilot study commenced in May 2004, followed by multicenter recruitment from July 2010 to November 2013; follow-up was completed May 2014. Recruitment was from 24 UK major trauma centers and general hospitals. Participants were 620 adults older than 60 years with acute, overtly unstable ankle fracture. Exclusions were serious limb or concomitant disease or substantial cognitive impairment. Interventions: Participants were randomly assigned to surgery (n = 309) or casting (n = 311). Casts were applied in the operating room under general or spinal anesthesia by a trained surgeon. Main Outcomes and Measures: The primary 6-month, per-protocol outcome was the Olerud-Molander Ankle Score at 6 months (OMAS; range, 0-100; higher scores indicate better outcomes and fewer symptoms), equivalence prespecified as ±6 points. Secondary outcomes were quality of life, pain, ankle motion, mobility, complications, health resource use, and patient satisfaction. Results: Among 620 adults (mean age, 71 years; 460 [74%] women) who were randomized, 593 (96%) completed the study. Nearly all participants (579/620; 93%) received allocated treatment; 52 of 275 (19%) who initially received casting later converted to surgery, which was allowable in the casting treatment pathway to manage early loss of fracture reduction. At 6 months, casting resulted in ankle function equivalent to that with surgery (OMAS score, 66.0 [95% CI, 63.6-68.5] for surgery vs 64.5 [95% CI, 61.8-67.2] for casting; mean difference, -0.6 [95% CI, -3.9 to 2.6]; P for equivalence = .001). Infection and wound breakdown were more common with surgery (29/298 [10%] vs 4/275 [1%]; odds ratio [OR], 7.3 [95% CI, 2.6-20.2]), as were additional operating room procedures (18/298 [6%] for surgery and 3/275 [1%] for casting; OR, 5.8 [95% CI, 1.8-18.7]). Radiologic malunion was more common in the casting group (38/249 [15%] vs 8/274 [3%] for surgery; OR, 6.0 [95% CI, 2.8-12.9]). Casting required less operating room time compared with surgery (mean difference [minutes/participant], -54 [95% CI, -58 to -50]). There were no significant differences in other secondary outcomes: quality of life, pain, ankle motion, mobility, and patient satisfaction. Conclusions and Relevance: Among older adults with unstable ankle fracture, the use of close contact casting compared with surgery resulted in similar functional outcomes at 6 months. Close contact casting may be an appropriate treatment for such patients. Trial Registration: isrctn.com Identifier: ISRCTN04180738.

High rates of sexual and urinary dysfunction after surgically treated displaced pelvic ring injuries.

BACKGROUND: Pelvic ring injuries may be associated with genitourinary injury (GUI) and result in urinary or sexual dysfunction. QUESTIONS/PURPOSES: We determined (1) incidence of new sexual and urinary dysfunction after surgically treated pelvic ring injuries, (2) association of sexual or urinary dysfunction to fracture type and GUI, and (3) incidence and association between new sexual and urinary dysfunction in male and female patients without GUI. METHODS: We retrospectively studied 151 patients by postal questionnaire after pelvic reconstruction. Presence, type, and severity of new sexual dysfunction and urinary dysfunction were related to GUI and type of pelvic fracture using the Young and Burgess classification. Minimum followup was 1 year (median, 5 years; range, 1-12 years). RESULTS: New sexual dysfunction occurred in 61 of 143 (43%) and urinary dysfunction in 61 of 150 (41%) responding patients. Neither new sexual nor urinary dysfunction was associated with sex or GUI. In patients with no GUI, new sexual dysfunction was associated with chronologic age (odds ratio [OR], 1.04/year; 95% CI, 1.01-1.07) and pelvic fracture type. Lateral compression injury was less likely to result in new sexual or urinary dysfunction compared with AP type (sexual OR, 1.73; 95% CI, 0.67-4.47; urinary OR, 2.97; 95% CI, 1.15-7.66) and vertical shear type (sexual OR, 2.60; 95% CI, 1.02-6.64; urinary OR, 4.6; 95% CI, 1.81-11.73). CONCLUSIONS: Our data suggest new sexual and urinary dysfunction occur at relatively high rates after pelvic fracture in patients with or without GUI. We recommend early assessment and referral for specialist treatment. LEVEL OF EVIDENCE: Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial.

BACKGROUND: Controversy exists with regard to whether to treat AO/OTA 31-A2 fractures of the proximal part of the femur with an intramedullary device or an extramedullary device. A prospective, randomized, controlled trial was performed to compare the outcome of treatment of these unstable fractures of the proximal part of the femur with either a sliding hip screw or a long gamma nail. METHODS: Two hundred and ten patients presenting with an AO/OTA 31-A2 fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a long gamma nail or a sliding hip screw. The primary outcome measure was reoperation within the first postoperative year. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and quality of life as measured with the EuroQol 5D outcome score. RESULTS: There was no significant difference between the reoperation rates for the two groups. In total, five patients (three from the long-gamma-nail group and two from the sliding-hip-screw group) underwent revision surgery because of cut-out. Tip-apex distance was found to correlate with the implant cut-out rate. There was no significant difference between the two groups in terms of the EuroQol 5D outcome scores, the mortality rates after correction for the mini-mental score, or any of the secondary outcome measures. CONCLUSIONS: When compared with the long gamma nail, the sliding hip screw should remain the gold standard for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur because it is associated with similar outcomes with less expense.

The influence of outside temperature and season on the incidence of hip fractures in patients over the age of 65.

BACKGROUND: It is often assumed that hip fractures occur more commonly in winter, but the evidence is conflicting. It is important to clarify this issue to aid planning of health resources and understanding of the aetiology of these fractures in the elderly. AIM: To determine whether the incidence of fractures altered with the daily temperature, seasons or months of the year. METHOD: Over a five-year period we studied 818 patients, over the age of 65, who presented to one district general hospital with a fracture of the proximal femur. RESULTS: No significant difference was found in the incidence of fractures with different temperatures, changes of temperature, season or month of the year. Also, there was no significant difference in the characteristics of patients (age, sex, pre-injury mobility, residence, functional and mental scores) presenting in different seasons or temperature ranges. Patients presenting in winter months had a significantly longer inpatient stay, which may have been due to the strain on the social services over this time. CONCLUSION: Other factors must be analysed when considering the aetiology of hip fractures in the elderly. There may be no extra demand on surgical facilities or other acute resources to treat hip fractures during the winter months in southern England.