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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
Search for other papers by Vasileios P Giannoudis in
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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
Search for other papers by Nikolaos K Kanakaris in
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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.
Orthopaedic Surgery Working Group, Society of Junior Doctors, Athens, Greece
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University of Patras, School of Medicine, Patras, Greece
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NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term ‘Jones’ fracture has been used inconsistently in the literature.
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In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes.
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Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient’s needs and the ‘personality’ of the fracture.
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If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the ‘gold standard’ of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems.
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Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain.
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Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.
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Patients undergoing planned or unplanned orthopaedic procedures involving their upper or lower extremity can prevent them from safe and timely return to driving, where they commonly ask, ‘Doctor, when can I drive?’ Driving recommendations after such procedures are varied. The current evidence available is based on a heterogenous data set with varying degrees of sample size and markedly differing study designs.
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This instructional review article provides a scoping overview of studies looking at return to driving after upper or lower extremity surgery in both trauma and elective settings and, where possible, to provide clinical recommendations for return to driving.
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Medline, EMBASE, SCOPUS, and Web of Science databases were searched according to a defined search protocol to elicit eligible studies. Articles were included if they reviewed adult drivers who underwent upper or lower extremity orthopaedic procedures, were written in English, and offered recommendations about driving.
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A total of 68 articles were included in the analysis, with 36 assessing the lower extremity and 37 reviewing the upper extremity. The evidence available from the studies reviewed was of poor methodological quality. There was a lack of adequately powered, high quality, randomised controlled trials (RCTs) with large sample sizes to assess safe return to driving for differing subset of injuries.
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Many articles provide generic guidelines on return to driving when patients feel safe to perform an emergency stop procedure with adequate steering wheel control.
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In future, RCTs should be performed to develop definitive return to driving protocols in patients undergoing upper and lower extremity procedures.
