Aim: To compare outcomes between total elbow replacement (TER), distal humerus hemiarthroplasty (DHH) and open reduction internal fixation (ORIF) for AO type-C (AOC) fractures of the distal humerus. Methods: Retrospective analysis of acute AOC distal humerus fractures in patients ≥50 years treated surgically in our Major Trauma Centre between 2016 and 2022. We evaluated the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), range of movement (ROM), complication rate and re-operation rate. Results: 65 patients met the inclusion criteria. 22 patients were excluded (11 uncontactable, 10 deaths, 1 declined to take part). Mean age was 77.1, 61.3 and 64.4 years old for TER, DHH and ORIF respectively. OES were comparable in TER and DHH but lower in the ORIF group (TER 41.3, DHH 42.1, ORIF 37.6, p = 0.55). MEPS were highest in the DHH group followed by TER and ORIF respectively (TER 86.3, DHH 88.2, ORIF 84.4, p = 0.78). Re-operation rates were higher in the ORIF group (TER 3.9%; DHH 11.8%; ORIF 31.8%, p = 0.03). Complication rates were higher in the ORIF group (TER 11.5%; DHH 23.5%; ORIF 54.6%, p = 0.02). Greater than 100 degrees flexion / extension ROM was achieved in 90.1%, 81.3% and 66.7% for TER, DHH and ORIF respectively. Discussion: There is variability in surgical management for AOC distal humerus fractures for patients ≥50 years. OES, MEPS, re-operation rates and complication rates all favour arthroplasty over fixation (although PROMs were not statistically significant). We propose a prospective randomised control trial.

Introduction: Complex proximal humerus fractures are difficult to treat because of osteoporosis or bone loss due to the magnitude of injury. Treatment of non-union or osteolytic lesions of proximal humerus are also technically demanding because of the bone quality and loss of bone continuity. In these situations lateral locking PHILOS plating is the treatment of choice which will give an expected result if the medial continuity is maintained. When medial void is not addressed, the chances of loss of reduction, articular penetration of screws and implant failure are highly possible. This study is aimed at analysing the results of complex proximal humerus fractures treated with PHILOS plating and medial fibular allograft (PHILOSMFA). Patients and methods: In our institute, 11 patients were treated using PHILOSMFA in the 2012 to 2022. In these non-union proximal humerus was 6, pathological fracture proximal humerus was 3 and malunion proximal humerus was 2. Results: Though minor complications like superficial infections were encountered in 3 patients, all had good results in regard to bony union and functional outcome using DASH score except 2 (one patient lost to follow up and other patient had brachial plexus injury on the same side. There was no implant failure or screw cut out. Conclusion: Using fibular strut allograft is an excellent option for special situations like bone loss in proximal humerus in which functional outcome of osteosynthesis is better than replacement.

Trauma and injury care is one of the most challenging situation a surgeon could face. The most recent estimates show that injuries are among the leading causes of death and disability in the world. They affect all populations, regardless of age, sex, income, or geographic region.. According to the World Health Organization, about 55.4 million people died worldwide in 2019. Of this total 3,159,000 died from preventable injuries, making it the world’s fifth leading cause of death. Motor-vehicle injuries accounted for nearly 1.3 million of the total mortality, nearly twice the number of deaths than the second leading cause, falls. Furthermore, two billion people or a quarter of the world’s population, now lives in conflict-affected areas, according to the United Nations report in May, 2022. Trauma has become an integral part of society. Most deaths could have been prevented if proper management was instituted early on. The involvement of the civil sector as well as the private sector is paramount to the development of trauma systems that would mitigate the effects of trauma after injury. In order to address these needs, collaboration of all stakeholders are needed to strengthen national injury-related data system development, including injury surveillance, health information systems and vital registration. Finally, there is a need to enhance trauma management globally through multidisciplinary and inter-professional collaboration in Education, Training and Research.

INTRODUCTION:Pelvic fractures are common in the elderly and these injuries are associated with high mortality rates, especially in polytrauma. Treatment strategies differ between institutions and novel guidelines are mandated as incidences of geriatric pelvic trauma will rise in the nearby future. The aim of the current multicenter study is to identify predictive factors for mortality in geriatric patients with pelvic trauma.

METHODS:All geriatric trauma patients with pelvic fractures were selected form our prospective multicenter geriatric trauma database. Patient (incl. co-morbidities and medication) and trauma characteristics as well as treatment data were studied for both mono- and polytrauma (ISS>16)-cases. Thereafter, independent predictors for mortality were identified by a stepwise multivariable regression analysis.

RESULTS:352 geriatric patients with a mean age of 79.8 years were included. A total of 126 Tile-A fractures were diagnosed, 171 patients had a B-type fracture, the others suffered C-type injuries. A mortality rate of 9.7 percent was found. Polytraumatized patients had higher mortality rates (26.2% vs. 2.8%, P<0.001) than monotrauma cases. 76.5 percent of patients died within the first 2 days after admission. The multivariable logistic regression analysis showed that both fracture type and ISS are independent predictors for mortality.

CONCLUSION:This study demonstrates that higher ISS and fracture type are the only independent predictive factors for mortality. Patients age, co-morbidities such as osteoporosis and medication including anticoagulation are factors of no prognostic relevance for mortality in this dataset. These insights are key for the development of novel standardized treatment guidelines when defining priorities of care.

Background: Hardware removal after acetabular fractures fixation has its indications and technical difficulties; however, this was rarely investigated after acetabular fractures fixation through anterior approaches.
Purpose: To investigate the indications and complications associated with acetabular fractures hardware removal in a cohort of patients operated upon through anterior approaches. Methods: We retrospectively reviewed all patients admitted for hardware removal after acetabular fracture fixation to our specialized pelvis and acetabulum trauma unit from 2014 to 2022. Ten of the 85 patients admitted in this period had their hardware removed through anterior approaches. Eight were operated upon through a modified Stoppa, one ilioinguinal, and one pararectus approach. Results: Seven males and three females, having a mean age of 41.1±14.8 years. The interval between index surgery and hardware removal surgery was 2.3±1.3 years. The indications for hardware removal were 6 cases (60%) for infections and 4 cases (40%) for hip arthritis. The mean operative time was 144.5±58.4 minutes. The mean blood loss was 1780±857.4 cc, and all patients required blood transfusion (mean 1.5±0.7 units). Complications were reported in 4 patients (40%), one L5 nerve injury , one external iliac artery injury , one external iliac vein injury with subsequent DVT, and one patient had urinary bladder injury .Conclusions: Hardware removal from anterior approaches after acetabular fractures could be challenging, carrying a high risk of complications. Clear indications for hardware removal need to be determined, and working in a multidisciplinary team, including general, vascular, and urosurgery, is mandatory.

Introduction:

Trans sacral trans iliac screw insertion TSTI in pelvic fractures requires an understanding of osseous fixation pathway and it’s intraoperative imaging. The technique is complicated by fracture displacement as the entry point and the trajectory of wire is planned factoring in the displacement and the predicted position after reduction. We describe a modification of the technique named the railroad technique which improves the accuracy, flow and efficiency of the procedure.

Technical description:

The guidewire is started from the uninjured side from an appropriate entry point and trajectory and parked medial to the injury. Reduction is carried out by surgeon standing on injured side and wire is advanced by assistant from contralateral side. The wire is delivered from injured side and the TSTI screw is inserted from injured to uninjured side.

Discussion:

The modification carries several advantages. Firstly, it allows the surgeon to focus solely on the reduction, as wire entry and trajectory is performed ahead. It decreases the time between achieving reduction and preliminary fixation. It decreases the need to reposition the wire improving theatre efficiency. Lastly the assistant passing the wire is on contralateral side avoiding overcrowding on injured side and providing a clear view of image intensifier screen to surgeon. In our institute we routinely use this technique in vertical shear fractures, APC III and LCIII

Conclusion:

The railroad technique for TSTI screw fixation is a simple modification that should be part of every pelvic surgeon armamentarium.

Interlocking nails are considered gold standard for the treatment of femoral shaft fractures. However, long surgical time, high radiation exposure, difficulty in nail insertion without reaming, per-operative bleeding etc. are matters of concern. On the other hand, flexible expandable nails have shown some promise to overcome the above-mentioned difficulties. But comparative studies are essential to establish any significant advantages or disadvantages. A retrospective comparative study was conducted between two groups comprising of 69 femur fractures operated with interlocking nails and 47 patients treated with expandable femoral nails at a tertiary care hospital in India. Variables such as duration of surgery, reaming, fluoroscopy exposure, blood loss, time for union, time for weight bearing and functional outcome scores were compared. Lower limb functional scale (LEFS) score was used to assess functional outcome after one year, two years and three years follow-up. It was observed that, duration of surgery, radiation exposure, blood loss and need for reaming were significantly reduced in the expandable nailing group. But there was no significant difference in time of union, weight bearing and functional outcome. The most important limiting factor for the expandable nail was the cost of the implant which was significantly higher than the standard interlocking nail. The expandable nail was very useful in minimizing the per-operative complications and problems, however, there was no difference in the long term outcome compared to interlocking nails.

Introduction:
In our previous series study, ankle joint osteoarthritis was related to the type of internal fixator when it comes to ankle fracture involving posterior malleolar. Reduction quality, dislocation, and open or close fracture failed to achieve statistical significance in the aspect of osteoarthritis development S/P ORIF. In this study, we aimed to investigate the risk factors of ankle joint osteoarthritis of trimalleolar fracture post ORIF.
Method:
132 patients underwent surgery of open reduction and plate fixation for trimalleolar fracture between 2015 and 2021. Image follow-up was performed for at least 1 year. Results were assessed according to the Kellgren and Lawrence system for classification of osteoarthritis. Factors inckuding age, sex, body mass idex, open fracture, dislocation, smoking, operation time,blood loss, and reduction quality were gathered.
Result:
Upon factors listed, only reduction quality had statistical significance when correlated with extent of ankle joint osteoarthritis of trimalleolar fracture post ORIF.
Discussion:
Early reduction of dislocation joint and staging surgery including ESF fixation may reduce the risk of subsequent OA change. Besides, most open trimalleolar ankle fractures were Gustilo type I with limited soft tissue compromise, causing less contribution to the development of osteoarthritis. On the contrary, reduction quality directly influences ankle joint congruency and has a direct impact on the development of osteoarthritis.
Conclusions:
Reduction quality remains the most direct risk factor of ankle joint osteoarthritis of trimalleolar fracture post ORIF.

Comminuted subtrochanteric fractures of femur often occur due to high-energy injuries. These are challenging fractures and pose difficulty in reduction and alignment of the fracture fragments. Aggressive open reduction for anatomic reconstruction of subtrochanteric fractures may lead to extensive soft-tissue and periosteal stripping and lead to complications like nonunion, delayed-union, implant failures and infections. More and more comparative studies are necessary to understand these fractures, implant selection and their proper treatment. Ninety-five cases of comminuted subtrochanteric fractures were retrospectively analyzed; out of them 53 fractures were managed with intra-medullary nailing following either open or closed reduction maneuver and 42 were treated with minimal invasive biological plating technique between March 2014 to January 2021 at a tertiary care hospital. Factors like duration of surgery, blood loss, time to union and weight-bearing, complications and functional outcomes of both groups were studied and compared. Eighty-six patients were available for outcome evaluation with a minimum two-year's follow-up. The functional evaluation was done by LEFS scoring system. The nailing group was found to have significantly greater incidences of delayed union, nonunion, implant failure and secondary surgeries like bone grafting and re-fixation. But there was no significant difference in the functional outcome score between the two groups after follow-up of two-years and four-years duration. Intra-medullary nailing, although considered gold standard, may not always yield desirable results in comminuted subtrochanteric fractures. Closed reduction followed by biological plating has shown promising results and helps in minimizing the post-operative complications in these complex fractures.