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Elizabeth K Tissingh, Leonard Marais, Antonio Loro, Deepa Bose, Nilo T Paner, Jamie Ferguson, Mario Morgensten, and Martin McNally

  • The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings.

  • Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers.

  • The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English.

  • The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work.

  • The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.

Mario Herrera-Pérez, Pablo Martín-Vélez, David González-Martín, Miguel Domínguez-Meléndez, Ahmed E Galhoum, Victor Valderrabano, and Sergio Tejero

  • Osteoporotic ankle fractures result from mechanical forces that would not ordinarily result in fracture, known as ‘low-energy’ trauma, such as those equivalent to a fall from a standing height or less.

  • Osteoporotic ankle fractures in frail patients are becoming more and more frequent in daily practice and represent a therapeutic challenge for orthopaedic surgeons.

  • The main problems with frail patients are the poor condition of the soft tissues around the ankle, dependence for activities of daily living and high comorbidity.

  • The decision to operate on these patients is complex because conservative treatment is poorly tolerated in unstable fractures and conventional open reduction and internal fixation is associated with a high rate of complications.

  • The authors conducted a narrative review of the literature on primary tibiotalocalcaneal nailing of ankle fractures in frail patients and categorized the different factors to consider when treatment is indicated for this conditon. Difficulty of ambulation, age over 65 years old, deteriorated baseline state and instability of the fracture were the most frequently considered factors.

  • Finally, the authors propose an easy and quick clinical scoring system to help in the decision-making process, although further comparative studies are required to explore its validity.

Karl Stoffel, Christoph Sommer, Mark Lee, Tracy Y Zhu, Karsten Schwieger, and Christopher Finkemeier

  • For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.

  • Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.

  • Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.

  • A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.

  • In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

Rui Zhang, Xiaoyu Wang, Jia Xu, Qinglin Kang, and Reggie C Hamdy

  • Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture.

  • If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. When the radial head is not reduced, several deformities develop at the humeroradial joint, including cubitus valgus and osteoarthritis.

  • Adequate radiographs are crucial when the surgeons deal with forearm injuries.

  • At present, proximal ulnar osteotomy and open reduction of chronic radial head dislocation provides satisfactory functional outcomes because of anatomic alignment reconstruction.

  • Supplementary procedures, including transcapitellar pinning and repair or reconstruction of the annular ligament, which are performed in order to enhance stability of the humeroradial joint, should be thoroughly assessed based on joint rotational stability after reduction and on potential complications.

Maria Anna Smolle, Sandra Bösmüller, Paul Puchwein, Martin Ornig, Andreas Leithner, and Franz-Josef Seibert

  • The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures.

  • A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes.

  • Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P  = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P  = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P  = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P  < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P  = 0.997), or approaches (two studies; RR: 0.36; P  = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P  = 0.004) but not different between approaches (2 studies; RR: 0.95; P  = 0.960).

  • Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

Christof Audretsch, Alexander Trulson, Andreas Höch, Steven C Herath, Tina Histing, Markus A Küper, and Working Group on Pelvic Fractures of the German Trauma Society

  • Treatment of acetabular fractures is challenging and risky, especially when surgery is performed. Yet, stability and congruity of the hip joint need to be achieved to ensure early mobilization, painlessness, and good function. Therefore, coming up with an accurate decision, whether surgical treatment is indicated or not, is the key to successful therapy.

  • Data from the German pelvic Trauma Registry (n  = 4213) was evaluated retrospectively, especially regarding predictors for surgery. Furthermore, a logistic regression model with surgical treatment as the dependent variable was established.

  • In total, 25.8% of all registered patients suffered from an acetabular fracture and 61.9% of them underwent surgery. The fracture classification is important for the indication of surgical therapy. Anterior wall fractures were treated surgically in 10.2%, and posterior column plus posterior wall fractures were operated on in 90.2%. Also, larger fracture gaps were treated surgically more often than fractures with smaller gaps (>3 mm 84.4%, <1 mm 20%). In total, 51.4% of women and 66.0% of men underwent surgery. Apart from the injury severity score (ISS), factors that characterize the overall picture of the injury were of no importance for the indication of a surgical therapy (isolated pelvic fracture: 62.0%, polytrauma: 58.8%). The most frequent reason for non-operative treatment was ‘minimal displacement’ in 42.2%.

  • Besides fracture classification and fracture characteristics, no factors characterizing the overall injury, except for the ISS, and unexpectedly gender, are important for making a treatment decision. Further studies are needed to determine the relevance of these factors, and whether they should be used for the decision-making process, in particular surgeons with less experience in pelvic surgery, can orient themselves to.

Maximilian M. Menger, Benedikt J. Braun, Steven C. Herath, Markus A. Küper, Mika F. Rollmann, and Tina Histing

  • Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.

  • The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.

  • The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.

  • Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.

  • There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.

  • Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome.

Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034

Andreas Frodl, Benjamin Erdle, and Hagen Schmal

  • Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

  • We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

  • A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

  • Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Patrick Pflüger, Karl-Friedrich Braun, Olivia Mair, Chlodwig Kirchhoff, Peter Biberthaler, and Moritz Crönlein

  • A trimalleolar ankle fracture is considered unstable and treatment is generally performed operatively. Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus.

  • Trimalleolar ankle fractures have a rising incidence in the last decade with up to 40 per 100,000 people per year. With a growing number of elderly patients, trimalleolar ankle injuries will become more relevant in the form of fragility fractures, posing a particular challenge for trauma surgeons.

  • In patients with osteoporotic trimalleolar ankle fractures and relevant concomitant conditions, further evidence is awaited to specify indications for open reduction and internal fixation or primary transfixation of the ankle joint.

  • In younger, more demanding patients, arthroscopic-assisted surgery might improve the outcome, but future research is required to identify patients who will benefit from assisted surgical care.

  • This review considers current scientific findings regarding all three malleoli to understand the complexity of trimalleolar ankle injuries and provide the reader with an overview of treatment strategies and research, as well as future perspectives.

Cite this article: EFORT Open Rev 2021;6:692-703. DOI: 10.1302/2058-5241.6.200138

Mabua A. Chuene, Jurek R.T. Pietrzak, Allan R. Sekeitto, and Lipalo Mokete

  • Elderly hip fracture patients are at risk of stress-related gastric mucosal damage, and upper gastrointestinal bleeding is one of the underrecognized but devastating complications.

  • Proton pump inhibitors (PPIs) offer effective prophylaxis against stress-related gastric mucosal damage.

  • Systematic analysis of the literature revealed numerous articles on PPIs and hip fractures, but only three articles dedicated to the analysis of prophylactic use of PPIs in patients with a hip fracture.

  • There is significant reduction in upper gastrointestinal bleeding following PPI prophylaxis and reduced 90-day mortality in elderly hip fracture patients on prophylaxis.

  • PPIs are generally safe, cost-effective and based on available evidence. Their prophylactic use is justifiable in elderly patients with hip fractures.

  • We suggest that PPIs be prescribed routinely peri-operatively in elderly hip fracture patients. Further level-one studies on the subject will allow for firmer recommendations.

Cite this article: EFORT Open Rev 2021;6:686-691. DOI: 10.1302/2058-5241.6.200053