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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.
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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.
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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.
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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.
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Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended.
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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
Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
Search for other papers by Marilena Giannoudi in
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NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
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With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy.
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Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents.
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Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.
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Hip fractures in the elderly population have become a ‘disease’ with increasing incidence.
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Most of the geriatric patients are affected by a number of comorbidities.
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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.
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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.
Cite this article: Ktistakis I, Giannoudis V, Giannoudis PV. Anticoagulation therapy and proximal femoral fracture treatment: an update. EFORT Open Rev 2016;1:310-315. DOI: 10.1302/2058-5241.1.160034.
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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.
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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.
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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.
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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.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160072. Originally published online at www.efortopenreviews.org
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Chronic osteomyelitis represents a progressive inflammatory process caused by pathogens, resulting in bone destruction and sequestrum formation.
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It may present with periods of quiescence of variable duration, whereas its occurrence, type, severity and prognosis is multifactorial.
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The ‘gold standard’ for the diagnosis of chronic osteomyelitis is the presence of positive bone cultures and histopathologic examination of the bone.
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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.
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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.
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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.
Cite this article EFORT Open Rev 2016;1:128–135. DOI: 10.1302/2058-5241.1.000017.
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Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.
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This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.
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The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.
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Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.
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Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.
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Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072
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Department of Trauma & Orthopaedics, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
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The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss.
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Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth.
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Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft.
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Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties.
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Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role.
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For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.
Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors.
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The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature.
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What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review.
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Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented.
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A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented.
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As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic.
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Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.
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NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors.
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Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries.
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Preoperative confirmation of the THA (total hip arthroplasty) stability is sometimes challenging. The most reliable method remains intraoperative assessment during surgical exploration of the hip joint.
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Certain B1 fractures will benefit from revision surgery, whilst some B2 fractures can be effectively managed with osteosynthesis, especially in frail patients.
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Less invasive osteosynthesis, balanced plate–bone constructs, composite implant solutions, together with an appropriate reduction of the limb axis, rotation and length are critical for a successful fixation and uneventful fracture healing.
Cite this article: EFORT Open Rev 2021;6:75-92. DOI: 10.1302/2058-5241.6.200050
Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK
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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.
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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.
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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.
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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
