Trauma

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Elena Gálvez-Sirvent Department of Orthopaedic Surgery, ‘Infanta Elena’ University Hospital, Valdemoro, Madrid, Spain

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Aitor Ibarzábal-Gil Department of Orthopaedic Surgery, ‘La Paz’ University Hospital-IdiPaz, Madrid, Spain

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E. Carlos Rodríguez-Merchán Department of Orthopaedic Surgery, ‘La Paz’ University Hospital-IdiPaz, Madrid, Spain

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  • In aseptic tibial diaphyseal nonunions after failed conservative treatment, the recommended treatment is a reamed intramedullary (IM) nail.

  • Typically, when an aseptic tibial nonunion previously treated with an IM nail is found, it is advisable to change the previous IM nail for a larger diameter reamed and locked IM nail (the rate of success of renailing is around 90%).

  • A second change after an IM nail failure is also a good option, especially if bone healing has progressed after the first change.

  • Fibular osteotomy is not routinely advised; it is only recommended when it interferes with the nonunion site.

  • In delayed unions before 24 weeks, IM nail dynamization can be performed as a less invasive option before deciding on a nail change.

  • If there is a bone defect, a bone graft must be recommended, with the gold standard being the autologous iliac crest bone graft (AICBG).

  • A reamer-irrigator-aspirator (RIA) system might also obtain a bone autograft that is comparable to AICBG.

  • Although the size of the bone defect suitable to perform bone transport techniques is a controversial issue, we believe that such techniques can be considered in bone defects > 3 cm.

  • Non-invasive therapies and biologic therapies could be applied in isolation for patients with high surgical risk, or could be used as adjuvants to the aforementioned surgical treatments.

Cite this article: EFORT Open Rev 2020;5:835-844. DOI: 10.1302/2058-5241.5.190077

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Gerhard M. Hobusch Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Vienna, Austria

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Kevin Döring Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Vienna, Austria

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Rickard Brånemark Gothenburg University, Gothenburg, Sweden
Biomechatronics Group, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA

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Reinhard Windhager Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Vienna, Austria

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  • Bone-anchored implants give patients with unmanageable stump problems hope for drastic improvements in function and quality of life and are therefore increasingly considered a viable solution for lower-limb amputees and their orthopaedic surgeons, despite high infection rates.

  • Regarding diversity and increasing numbers of implants worldwide, efforts are to be supported to arrange an international bone-anchored implant register to transparently overview pros and cons.

  • Due to few, but high-quality, articles about the beneficial effects of targeted muscle innervation (TMR) and regenerative peripheral nerve interface (RPNI), these surgical techniques ought to be directly transferred into clinical protocols, observations and routines.

  • Bionics of the lower extremity is an emerging cutting-edge technology. The main goal lies in the reduction of recognition and classification errors in changes of ambulant modes. Agonist–antagonist myoneuronal interfaces may be a most promising start in controlling of actively powered ankle joints.

  • As advanced amputation surgical techniques are becoming part of clinical routine, the development of financing strategies besides medical strategies ought to be boosted, leading to cutting-edge technology at an affordable price.

  • Microprocessor-controlled components are broadly available, and amputees do see benefits. Devices from different manufacturers differ in gait kinematics with huge inter-individual varieties between amputees that cannot be explained by age. Active microprocessor-controlled knees/ankles (A-MPK/As) might succeed in uneven ground-walking. Patients ought to be supported to receive appropriate prosthetic components to reach their everyday goals in a desirable way.

  • Increased funding of research in the field of prosthetic technology could enhance more high-quality research in order to generate a high level of evidence and to identify individuals who can profit most from microprocessor-controlled prosthetic components.

Cite this article: EFORT Open Rev 2020;5:724-741. DOI: 10.1302/2058-5241.5.190070

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Tim Pohlemann Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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Steven C. Herath Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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Benedikt J. Braun Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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Mika F. Rollmann Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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Tina Histing Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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Antonius Pizanis Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany

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  • Surgical treatment of acetabular fractures remains challenging even for experienced surgeons.

  • Whilst the ilioinguinal and the Kocher-Langenbeck approach remain the standard procedures to expose the anterior or posterior aspects of the acetabulum, some modified anterior approaches for the stabilization of the acetabulum have been introduced.

  • This article will provide an overview of approaches to the anterior aspect of the acetabulum and explain the efforts that have been made to improve the surgeon’s options for certain fracture modifications, such as fractures with separation of the quadrilateral surface.

Cite this article: EFORT Open Rev 2020;5:707-712. DOI: 10.1302/2058-5241.5.190061

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Thomas Tampere Department of Orthopaedic Surgery, Ghent University Hospital, Ghent, Belgium

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Matthieu Ollivier Institute for Locomotion, Aix-Marseille University, St. Marguerite Hospital, Marseille, France

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Christophe Jacquet Institute for Locomotion, Aix-Marseille University, St. Marguerite Hospital, Marseille, France

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Maxime Fabre-Aubrespy Institute for Locomotion, Aix-Marseille University, St. Marguerite Hospital, Marseille, France

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Sébastien Parratte Institute for Locomotion, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
Department of Orthopaedic Surgery, International Knee and Joint Centre, Abu Dhabi, UAE

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  • Results of open reduction and internal fixation for complex articular fractures around the knee are poor, particularly in elderly osteoporotic patients.

  • Open reduction and internal fixation may lead to an extended hospital stay and non-weight-bearing period.

  • This may lead to occurrence of complications related to decubitus such as thrombo-embolic events, pneumonia and disorientation.

  • Primary arthroplasty can be a valuable option in a case-based and patient-specific approach. It may reduce the number of procedures and allow early full weight-bearing, avoiding the above-mentioned complications.

  • There are four main indications:

    • 1) Elderly (osteoporotic) patients with pre-existing (symptomatic) end-stage osteoarthritis.

    • 2) Elderly (osteoporotic) patients with severe articular and metaphyseal destruction.

    • 3) Pathological fractures of the distal femur and/or tibia.

    • 4) Young patients with complete destruction of the distal femur and/or tibia.

  • The principles of knee (revision) arthroplasty should be applied; choice of implant and level of constraint should be considered depending on the type of fracture and involvement of stabilizing ligaments. The aim of treatment is to obtain a stable and functional joint.

  • Long-term data remain scarce in the literature due to limited indications.

Cite this article: EFORT Open Rev 2020;5:713-723. DOI: 10.1302/2058-5241.5.190059

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Ioannis V. Papachristos Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK

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Peter V. Giannoudis Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK

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  • Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs.

  • Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed.

  • Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios.

  • Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days.

  • Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended.

  • There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.

Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

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Logan Petit Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA

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Theodore Zaki Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA

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Walter Hsiang Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA

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Michael P. Leslie Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA

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Daniel H. Wiznia Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA

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  • Injuries sustained in motorcycle collisions can be organized into distinct patterns to improve recognition and treatment.

  • Lowside, highside, topside, and collision are the four main categories of motorcycle crash types.

  • Within those four crash types, mechanisms of injury include head-leading collisions, direct vertical impact, motorcycle radius, motorcycle thumb, fuel tank injures, limb entrapment, tyre-spoke injury, and crash modifying manoeuvre.

Cite this article: EFORT Open Rev 2020;5:544-548. DOI: 10.1302/2058-5241.5.190090

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Emmanuele Santolini Academic Unit of Trauma and Orthopaedics, University of Genoa, Italy
Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK

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Nikolaos K. Kanakaris Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK

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Peter V. Giannoudis Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK
NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK

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  • Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.

  • This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.

  • Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.

  • Herein, we present issues, challenges and solutions related to the management of sacral fractures.

Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064

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Carlos A. Encinas-Ullán Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain

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José M. Martínez-Diez Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain

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E. Carlos Rodríguez-Merchán Department of Orthopaedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain

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  • The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.

  • Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.

  • Patients with multiple trauma should be stabilized quickly with EF.

  • The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.

  • Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).

  • Planning the type of framework to be used is crucial.

  • Avoid mistakes in the placement of EF.

Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029

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Maria Tennyson Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK

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Matija Krkovic Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK

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Mary Fortune The Department of Public Health & Primary Care, Strangeways Research Laboratory, Cambridge, UK

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Ali Abdulkarim Department of Trauma & Orthopaedic Surgery, Cambridge University Hospital, Cambridge, UK

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  • Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.

  • We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.

  • Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.

  • The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18).

  • When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.

Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040

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Faustine Vallon Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, Switzerland

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Axel Gamulin Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, Switzerland

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  • Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.

  • The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.

  • An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.

  • A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.

  • An intramedullary device is recommended for all other extra-capsular proximal femoral fractures.

Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020

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