P.V. Giannoudis

Operative treatment of displaced fractures of the acetabulum: A META-ANALYSIS

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.

Radial nerve palsy associated with fractures of the shaft of the humerus A SYSTEMATIC REVIEW

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.

Current concepts of the inflammatory response after major trauma: an update

Abstract During the past century explosive developments have taken place in the field of molecular medicine and genetics, vastly expanding our understanding of the normal physiological response to injury. We have been able to characterise specific molecular and cell biological processes and apply some of this knowledge to the treatment of multiply injured patients. Despite the significant steps we have made, there still remains much work to be done in this area. This review article highlights the current concepts of post-traumatic immunological changes and their impact in the management of trauma patients.

A review of the management of open fractures of the tibia and femur

The annual incidence of open fractures of long bones has been estimated to be 11.5 per 100 000 persons[1][1] with 40% occurring in the lower limb, commonly at the tibial diaphysis.[2][2] Open fractures in the leg tend to be more severe compared with those in the arm because of the degree of soft-

Principles of fixation of osteoporotic fractures

Despite advances in the prevention and treatment of osteoporotic fractures, their prevalence continues to increase. Their operative treatment remains a challenge for the surgeon, often with unpredictable outcomes. This review highlights the current aspects of management of these fractures and focuses on advances in implant design and surgical technique.

Incidence and aetiology of anterior knee pain after intramedullary nailing of the femur and tibia

Intramedullary nailing is considered to be the optimum treatment for fractures of the long bones of the lower limbs and various studies have been published describing the functional outcome of both reamed and unreamed nailing.[1][1]–[15][2] Several complications have been described including

The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage

We studied the outcome and functional status of 33 patients with 34 severe open tibial fractures (Gustilo grade IIIb and IIIc). The treatment regime consisted of radical debridement, immediate bony stabilisation and early soft-tissue cover using a muscle flap (free or rotational). The review included standardised assessments of health-related quality of life (SF-36 and Euroqol) and measurement of the following parameters: gait, the use of walking aids, limb-length discrepancy, knee and ankle joint function, muscle wasting and the cosmetic appearance of the limb. Personal comments and overall patient satisfaction were also recorded. The mean follow-up was 46 months (15 to 80). There were 30 Gustilo grade IIIb fractures and and four grade IIIc fractures. Of the 33 patients, 29 had primary internal fixation and four, external fixation; 11 (34%) later required further surgery to achieve union and two needed bone transport procedures to reconstruct large segmental defects. The mean time to union was 41 weeks (12 to 104). Two patients (6.1%) developed deep infection; both resolved with treatment. The mean SF-36 physical and mental scores were 49 and 62 respectively. The mean state of health score for the Euroqol was 68. Patients with isolated tibial fractures had a better outcome than those with other associated injuries on both scoring systems. Knee stiffness was noted in seven patients (21%) and ankle stiffness in 19 (56%); 12 patients (41%) returned to work. Our results compare favourably with previous outcome measurements published for both limb salvage and amputation. All patients were pleased to have retained their limbs.

Percutaneous fixation of the pelvic ring: AN UPDATE

With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.

Distal femoral fractures: long-term outcome following stabilisation with the LISS.

We studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system (LISS). Four patients were excluded from the final follow-up (three deaths and one case of quadriplegia). The mean age of the remaining 25 patients (9 males and 16 females) was 60.9 years and the mean follow-up 18 months (range 12-24 months). Eleven patients were tertiary referrals from other hospitals (seven cases were referred due to failure of primary fixation). Overall, there were 12 cases of high-energy trauma (7 open fractures). According to the AO classification, there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the modified Hospital for Special Surgery (HSS) and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months (range 2-5 months). All of the acute cases united without the need for bone grafting. There were three out of seven cases of non-union in the salvage group still undergoing treatment. The overall result in the acute cases was good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilising acute distal femoral fractures. However, when the LISS is used as a revision tool the results seem to be less satisfactory. The system appears to be user-friendly and no technical difficulties were encountered.

Serum CRP and IL-6 levels after trauma: Not predictive of septic complications in 31 patients

We studied 31 blunt trauma victims, Injury Severity Score (ISS) mean 14 (9-57), for the pattern of release of C-reactive protein (CRP) and cytokine interleukin-6 (IL-6). Blood samples were taken on admission (within 6 hours of injury), as well as at 24 hours, and 3, 5 and 7 days. Serum CRP and IL-6 were measured by ELISA. Subsequent surgical events and sepsis were noted. Serum IL-6 levels on admission were considerably higher (median 135 pg mL-1) than our laboratory reference range (< 5 pg mL-1), slowly returning towards reference values during the study. Serum CRP levels were similar to laboratory normal values on admission (median 8.5 mg L-1 vs 7.5 mg L-1), reaching peak values (median 110 mg L-1) after 3 days. There was a correlation between IL-6 release and ISS but not between CRP and ISS. Patients undergoing surgery showed further increases in IL-6 and CRP levels postoperatively. Of 24 surgical patients, 9 developed postoperative sepsis. In blunt trauma patients, early assessment of the markers CRP or IL-6 were not useful for the diagnosis of sepsis. Levels of CRP following accidental or surgical trauma should be assessed with caution.