The management of segmental tibial shaft fractures: A systematic review.

INTRODUCTION: Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures. METHOD: A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data. RESULTS: Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'. DISCUSSION: The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available. CONCLUSION: IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem

A bibliometric analysis assessing temporal changes in publication and authorship characteristics in The Knee from 1996 to 2016.

BACKGROUND: Evidence-based practice is a foundation to clinical excellence. However there remains little evidence on the characteristics of authors who contribute to the evidence-base and whether these have changed over time. The purpose of this study was to explore these characteristics by undertaking a bibliometric analysis to explore publication and authorship characteristics in a leading sub-speciality orthopaedic journal (The Knee) over a 20-year period. METHODS: All articles published in The Knee in 1996, 2006 and 2016 were identified. For each article, data collected included: highest academic award; profession; gender; continent of first and last author; total number of authors; the level of evidence; and funding source. We analysed temporal changes in these variables using appropriate statistical models. RESULTS: A total of 413 papers were analysed. Between 1996 to 2016 there has been a significant increase in the overall number of authors, the number of paper submitted from Asia, the proportion of Level 1 or 2 tiered evidence, the proportion of people with Bachelor or Master-level degrees as their highest level of educational award and the proportion of non-medically qualified authors (P<0.001). From 2006 to 2016 there was a significant increase in the proportion of articles whose first author was female (P=0.03), but no significant change in the number of females as last author (P=0.43). CONCLUSION: The findings indicate that there have been changes in publication and authorship characteristics in this sub-speciality orthopaedic journal during the past 20years. This provides encouraging indication of greater diversification and internationalisation of orthopaedic research

The effect of quadriceps anatomical factors on patellar stability: A systematic review.

PURPOSE: The aim of this systematic review was to analyse the effect of quadriceps anatomical factors on patellar stability. METHODS: The protocol for this review was registered on PROSPERO with registration number CRD42022334265. A systematic PRISMA compliant database search was conducted. Electronic databases (MEDLINE, Global Health, MIDIRS, Embase, PsycARTICLES and APA PsycInfo), currently registered studies, conference proceedings and the reference lists of included studies were searched. A narrative synthesis provided a summary of current evidence pertaining to the effect of quadriceps anatomical factors on patellar stability. RESULTS: A total of 9168 records were screened in the initial search. Of these, 20 articles satisfied the inclusion criteria, assessing 754 knees of 689 patients, and 69 cadaveric knees. Vastus medialis obliquus strength (VMO) affected patellar stability up to 15° of knee flexion, whereas medial retinaculum integrity did so up to 30° of knee flexion. Studies disagreed as to whether this applied to the rest of knee flexion. There is conflicting evidence regarding the effect of VMO elevation, cross-sectional area and angulation on patellar stability. The lateral retinaculum contributed to patellar stability throughout the entirety of knee flexion. Quadriceps angle altered patellar orientation during knee flexion, but not extension. CONCLUSION: Whilst vastus medialis obliquus strength was found to be a determinant of patellar stability, there is conflicting evidence regarding the effect of VMO morphological parameters on patellar stability. The lateral retinaculum provided stability throughout the entirety of knee flexion, and the medial retinaculum did so up to 30° of flexion

Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes.

This study systematically reviews the evidence-base for the use of expandable nails in the treatment of acute diaphyseal fractures of the lower limb. Both electronic and hand searches were undertaken of the published and grey literature to 1 December 2011. A total of 154 citations were identified, of which 15 were deemed suitable and assessed with the Critical Appraisals Skills Programme tool. A total of 625 nailing procedures were performed in 620 patients: 279 femoral and 346 tibial nails. The expandable nail was found to be significantly quicker to insert than interlocked nails (p < 0.05), and the total incidence of non-union or other complication was 13 and 14 % for expandable femoral and tibial nails, respectively. Notable complications with the expandable nail included fracture propagation on nail inflation in 2.5 % and post-operative shortening in 3.3 %. Device failure secondary to problems with the expansion mechanism was seen in 2.9 %. The rate of non-union and infection following expandable nailing was 3.1 and 1.4 %, respectively. Despite promising initial results, there remains a paucity of good quality studies to support the use of expandable nails over interlocked nails for the treatment of acute diaphyseal fractures of the lower limb

Psychometric properties of the Norwich Patellar Instability Score in people with recurrent patellar dislocation.

BACKGROUND: Patellar dislocations account for two percent of all knee injuries with a 17% chance of re-dislocation. There are few validated scores specific to instability. One of these is the Norwich Patellar Instability Score. There has been limited assessment of the validity, floor-ceiling effect and responsiveness of the Norwich Patellar Instability (NPI) Score from an independent centre. The purpose of this paper is to address this limitation. METHODS: Data from 90 patients referred to a tertiary referral patellofemoral clinic were analysed. All routinely completed data including NPI Score, Kujala Patellofemoral Disorder Score, and demographic outcomes during appointments, up to 36 months following initial clinical assessment was analysed. Convergent validity was assessed by correlating outcomes of the Kujala Patellofemoral Disorder Score to the NPI Score. Effect size (ES) was determined between baseline to 12-month and 12 to 36-month assessments to determine responsiveness. Floor-ceiling effect was evaluated at baseline, 12-month and 12 to 36-month follow-up. RESULTS: NPI Score demonstrated good convergent validity to the Kujala Patellofemoral Disorder Score (p < .001; 95% confidence interval (CI): -0.71 to -0.52). NPI Score demonstrated good responsiveness to change both between baseline to 12 months (ES: 0.43; 95% CI: 0.42 to 0.10) and 12 to 36 months (ES: 0.67; 95% CI: 0.60 to 0.15). Whilst the NPI Score did not demonstrate a ceiling effect, there was moderate risk of a floor-effect where 13% of the cohort reported the lowest levels of NPI scores. CONCLUSIONS: The NPI Score is a valid and responsive outcome for people with recurrent patellar dislocation

An evaluation of outpatient service provision in the National Health Service in Great Britain: A freedom of information request.

RATIONALE: The National Health Service (NHS) Long Term Plan was published in January 2019. One of its objectives was restructuring outpatient services, as part of an Outpatient Transformation initiative. Monitoring of trusts' adherence to the objectives of the Long Term Plan is therefore required to benchmark progress against national objectives. AIMS AND OBJECTIVES: We aimed to explore whether outpatient transformation initiatives and phlebotomy services that are managed by outpatients are appropriately staffed and to evaluate trusts' adherence to the objectives outlined in the Long Term Plan. METHOD: A freedom of information (FOI) request was sent in January 2023 to 153 trusts across Great Britain (time span: 1 January 2022-31 December 2022). Parameters requested included number of outpatients seen/discharged, phlebotomy episodes, number of sites/wards covered by phlebotomy, target/actual did not attend (DNA) rates, time since inception of the outpatient transformation project (OTP), advice and refer (A&R) and patient-initiated follow-up (PIFU), phlebotomy and outpatient managerial establishment and use of electronic notes and patient portals. RESULTS: A total of 117 trusts (76.5%) provided responses to the FOI request. The mean number of new outpatients seen face-to-face was 185,810. Of 73 trusts reporting both actual and target DNA rates, 62 (84.9%) did not meet their DNA targets. The actual DNA rate was significantly greater than the target DNA rate across trusts (p < 0.001, mean: 8.8% vs. 6.5%, respectively). A total of 58 different electronic systems and 29 patient portals were utilised across trusts. Thirty-six trusts (30.3%) did not have an outpatient transformation project manager and 16 trusts (13.7%) did not initiate an OTP. With phlebotomy provision, the mean number of outpatient phlebotomy episodes was lower than inpatient episodes (83,383 vs. 91,020, respectively). CONCLUSION: There are deficiencies in current outpatient establishments that may hinder the achievement of objectives set in the NHS Long Term Plan. Changes at all levels of healthcare are required, with increased reliance on technologies and investment in support for transformation management

How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study.

BACKGROUND: Tibial fractures have an incidence of 15% of all adult fractures. They have been shown to have the highest incidence of non-union in long bone fractures and the highest incidence of vascular injury. Evidence from the literature suggests that a good vascular supply is important to ensure bone union. The aim of our study was to prospectively assess the incidence of vascular injuries in open tibial fractures and determine whether they were associated with an increased risk of non-union. METHODS: We performed a prospective study to investigate the incidence of arterial injuries with computed tomography angiography (CTA) in patients with Gustilo-Anderson grade I-III open tibial fractures between 2013 and 2015. CTA was performed with the trauma series at acute admission and reported by two independent musculoskeletal radiologists. Patients were followed up with clinical and radiographic assessment for 1 year. RESULTS: We recruited 77 patients into the study, and 56 patients (47 males, 9 females) were available for the final analysis, between 16 and 90 years of age. At the initial assessment, 29% had signs of arterial injury with active extravasation in 5%. The most common site of injury was in the diaphysis (87.5%), and the commonest mechanism was a road traffic accident. We found no significant relation between occult vascular injury and non-union (p > 0.05). CONCLUSION: The incidence of vascular injury in open tibial fractures is 29%, and CTA is therefore a useful test in identifying vascular injuries that may require vascular intervention