Anticoagulation therapy and proximal femoral fracture treatment: An update

Hip fractures in the elderly population have become a ‘disease’ with increasing incidence. Most of the geriatric patients are affected by a number of comorbidities. Coagulopathies continue to be a special point of interest for the orthopaedic trauma surgeon, with the management of this high-risk group of patients a hot topic of debate among the orthopaedic community. While a universal consensus on how to manage thromboprophylaxis for this special cohort of patients has not been reached, multiple attempts to define a widely accepted protocol have been published

Articular impaction injuries in the lower limb

The effective management of articular impacted fractures requires the successful elevation of the osteochondral fragment to eliminate joint incongruency and the stable fixation of the fragments providing structural support to the articular surface.The anatomical restoration of the joint can be performed either with elevation through a cortical window, through balloon-guided osteoplasty or direct visualisation of the articular surface.Structural support of the void created in the subchondral area can be achieved through the use of bone graft materials (autologous tricortical bone), or synthetic bone graft substitutes.In the present study, we describe the available techniques and materials that can be used in treating impacted osteochondral fragments with special consideration of their epidemiology and treatment options

Chronic osteomyelitis: what the surgeon needs to know

Chronic osteomyelitis represents a progressive inflammatory process caused by pathogens, resulting in bone destruction and sequestrum formation. It may present with periods of quiescence of variable duration, whereas its occurrence, type, severity and prognosis is multifactorial. The ‘gold standard’ for the diagnosis of chronic osteomyelitis is the presence of positive bone cultures and histopathologic examination of the bone. Its management remains challenging to the treating physician, with a multidisciplinary approach involving radiologists, microbiologists with expertise in infectious diseases, orthopaedic surgeons and plastic surgeons. Treatment should be tailored to each patient according the severity and duration of symptoms, as well as to the clinical and radiological response to treatment. A combined antimicrobial and surgical treatment should be considered in all cases, including appropriate dead space management and subsequent reconstruction. Relapse can occur, even following an apparently successful treatment, which has a major impact on the quality of life of patients and is a substantial financial burden to any healthcare system

The ‘diamond concept’ for long bone non-union management

Long bone non-union continues to be a significant worldwide problem. Since its inception over a decade ago, the ‘diamond concept’, a conceptual framework of what is essential for a successful bone healing response, has gained great acceptance for assessing and planning the management of fracture non-unions. Herein, we discuss the epidemiology of non-unions, the basic science of bone healing in the context of the diamond concept, the currently available results and areas for future research

Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation

Aim of the study The aim of this case–control study was to develop a clinical decision rule to support assessment of the risk of long-bone non-union and plan for appropriate early intervention. Methods Two hundred patients (100 cases and 100 controls) were recruited. Risk factors identified to contribute to the development of non-union were recorded and analysed with a multivariable logistic regression model. Tabulation of the outcome (non-union/union) against each risk factor in turn (univariable analysis) was carried out. Odds ratios and confidence intervals were derived using Wald’s method. A receiver–operator curve was calculated and the area under the curve was computed. Having established the eight most important risk factors, a non-union risk index was developed as the count of the risk factors present in each patient. Results The five risk factors for non-union with greater effect size were post-surgical fracture gap > 4 mm (odds ratio (OR) = 11.97 95% CI (4.27, 33.53)), infection superficial/deep (OR 10.16 (2.44, 42.36)), not optimum mechanical stability (OR 10.06 (3.75, 26.97)), displacement > 75% of shaft width (OR 6.81 (2.21, 20.95)), and site of fracture—tibia (OR 4.33 (1.32, 14.14)). The ROC curve for the non-union index was 0.924, sensitivity 91%, specificity 77%. Conclusions The non-union index derived from counting risk factors predicts union for 0–4 risk factors and non-union for 5–8 risk factors. It can be readily applied and can guide clinicians about the risk of development of long-bone non-union. It can become a powerful aid for assessing fracture fixation outcome and to support early intervention

The Effect of an Abnormal BMI on Orthopaedic Trauma Patients: A Systematic Review and Meta-Analysis

Aims: The aim of this systemic review is to identify the complications that arise in operating on orthopaedic trauma patients with an abnormal body mass index (BMI). Materials and Methods: Systematic literature search using a combination of MESH subject headings and free text searching of Medline, Embase, SCOPUS and Cochrane databases in August 2019. Any orthopaedic injury requiring surgery was included. Papers were reviewed and quality assessed by two independent reviewers to select for inclusion. Where sufficiently homogenous, meta-analysis was performed. Results: A total of 26 articles (379,333 patients) were selected for inclusion. All complications were more common in those with a high BMI (>30). The odds ratio (OR) for high BMI patients sustaining post-operative complication of any type was 2.32 with a 23% overall complication rate in the BMI > 30 group, vs. 14% in the normal BMI group (p < 0.05). The OR for mortality was 3.5. The OR for infection was 2.28. The OR for non-union in tibial fractures was 2.57. Thrombotic events were also more likely in the obese group. Low BMI (<18.5) was associated with a higher risk of cardiac complications than either those with a normal or high BMI (OR 1.56). Conclusion: Almost all complications are more common in trauma patients with a raised BMI. This should be made clear during the consent process, and strategies developed to reduce these risks where possible. Unlike in elective surgery, BMI is a non-modifiable risk factor in the trauma context, but an awareness of the complications should inform clinicians and patients alike. Underweight patients have a higher risk of developing cardiac complications than either high or normal BMI patient groups, but as few studies exist, further research into this group is recommende

Femoral non-union above a fused knee: Successful treatment with exchange nailing and intramedullary delivery of bone morphogenetic protein

Bone healing is a complex and well-orchestrated physiological process, in which bone repairs and regenerates regaining its original biomechanical and biochemical properties. It is estimated that 5 to 10% of all fractures are complicated by delayed union or non-union. Progression to non-union is thought to be multifactorial, even though the exact biological sequence remains obscure. Treatment should aim to addressing deficiencies in both the mechanical and biological components, along with eliminating co-factors that could negatively affect the locally induced fracture healing response. We report a case of a 78-year-old patient who presented with a distal femoral non-union above a previously fused knee, which was successfully managed with exchange nailing and intramedullary delivery of recombinant human bone morphogenetic protein-7 (rhBMP-7)