Innovations in osteosynthesis and fracture care

Polytherapy versus monotherapy in the treatment of tibial non-unions: a retrospective study

BACKGROUND

Treating tibial non-unions efficiently presents a challenge for orthopaedic trauma surgeons. The established gold standard involves implanting autologous bone graft with adequate fixation, but the addition of biologicals according to the so-called diamond concept has become increasingly popular in the treatment of non-unions. Previous studies have indicated that polytherapy, which involves implanting mesenchymal stem cells, bioactive factors and osteoconductive scaffolds, can improve bone healing. This study aims to evaluate the efficacy of polytherapy compared with monotherapy in treating tibial non-unions of varying severity.

MATERIALS AND METHODS

Data from consecutive tibial non-unions treated between November 2014 and July 2023 were retrospectively analysed. The Non Union Scoring System (NUSS) score before non-union surgery, and the Radiographic Union Score for Tibial fractures (RUST), scored at 1, 3, 6, 9, 12 and 18 months post-surgery, were recorded. Initially, a comparison was made between the polytherapy and monotherapy groups. Subsequently, patients receiving additional surgical non-union treatment were documented, and the frequency of these treatments was tallied for a subsequent per-treatment analysis.

RESULTS

A total of 34 patients were included and divided into a polytherapy group (n = 15) and a monotherapy group (n = 19). The polytherapy group demonstrated a higher NUSS score (44 (39, 52) versus 32 (29, 43), P = 0.019, z = -2.347) and a tendency towards a higher success rate (93% versus 68%, P = 0.104) compared with the monotherapy group. For the per-treatment analysis, 44 treatments were divided into the polytherapy per-treatment group (n = 20) and the monotherapy per-treatment group (n = 24). The polytherapy per-treatment group exhibited a higher NUSS score (48 (43, 60) versus 38 (30, 50), P = 0.030, z = -2.173) and a higher success rate (95% versus 58%, P = 0.006) than the monotherapy per-treatment group. Within the monotherapy per-treatment group, the NUSS score displayed excellent predictive performance (AUC = 0.9143). Setting the threshold value at 48, the sensitivity and specificity were 100.0% and 70.0%, respectively.

CONCLUSIONS

Polytherapy is more effective than monotherapy for severe tibial non-unions, offering a higher success ratio. The NUSS score supports decision-making in treating tibial non-unions.

LEVEL OF EVIDENCE

Level III.

The application of a hollow trephine in femoral retrograde intramedullary nailing technique

PURPOSE

The purpose of this study was to describe and evaluate the use of a specially designed hollow trephine to create the entry point through the femoral condyle during retrograde interlocking intramedullary nailing for femoral fractures.

METHODS

From June 2019 to December 2021, we treated 11 patients (5 men, 6 women; mean age, 64 years; age range 40-77 years) with mid-distal femoral fractures by retrograde intramedullary femoral nailing using a self-designed hollow trephine for femoral condyle reaming and cancellous bone harvesting. The mode of all the nails is static. Patients were followed up at 1, 4, 8, and 12 weeks and for at least 6 months after surgery. The healing process and heterotopic ossification were evaluated by imaging. Partial weight bearing was permitted during the recovery period and complete weight bearing was permitted after clinical healing of the fracture displayed by X-ray.

RESULTS

The operation was successful in all patients. Over mean follow-up of 9.3 months (range, 6.0-12.0 months), all patients achieved clinical healing within three months. There were no complications such as knee joint infection, heterotopic ossification, knee joint adhesion and wedge effect.

CONCLUSION

The use of the hollow trephine during femoral retrograde intramedullary nailing helps avoid postoperative complications such as heterotopic ossification, knee joint adhesions, and wedge effect. It also facilitates bone graft harvesting.

Trends in Orthopedic Surgery in Chile: Analysis Between 2004 and 2020

Purpose To describe the trends of orthopedic surgery in Chile since 2004 in terms of the number and gender of surgeons, the incidence of procedures per 100,000 inhabitants (IR), and access by health insurance and type of health center. Methods A cross-sectional study was designed. Three databases were analyzed: the free access database of the Chilean Department of Statistics and Health Information (DEIS), which had information on all procedures performed in health institutions in Chile from 2004 to 2020. Then, the orthopedic surgeon registry was requested from the National Superintendence of Health (NSH). Finally, the database of the Chilean Society of Orthopaedic Surgeons (SCHOT) was analyzed. Spearman's correlation was used to determine significant trends during the analyzed period. Results The NSH reported 1770 orthopedic surgeons in 2020; 56% were affiliated with SCHOT. An upward trend in the proportion of female orthopedic surgeons was found, from 4.8% in 2004 to 7.6% in 2020. Since 2004, the IR of orthopaedic surgeries has been increasing significantly in both health insurances; the growth in public insurance follows a linear model (R2 = 0.970) of parameters β0 = - 55982.6 (p <0.000) and β1 = 28.02 (p <0.000) while in private insurance, the growth is also linear (R2 = 0.890) but with a greater slope: β0 = - 104136 (p <0.000) and β1 = 52.15 (p <0.000). A significant downward trend was found in the proportion of surgeries performed in the public health network (rho = -0.797, p = 0.0002). Conclusions There is a significant increase in the number of orthopedic surgeons and the number of procedures per 100,000 inhabitants. Nevertheless, there is evident inequity in access to orthopedic surgery in Chile and low gender diversity.

Reaming of femoral fractures with different reaming irrigator aspirator systems shows distinct effects on cardiac function after experimental polytrauma

Cardiac injuries are recorded after multiple trauma and are associated with a poor patient outcome. Reaming prior to locked intramedullary nailing is a frequently used technique to stabilize femoral diaphysis fractures. However, in polytraumatized patients, complications such as fat emboli and acute respiratory distress syndrome have been associated with reaming. The reaming irrigator aspirator (RIA) system provides concomitant irrigation and suction of the intramedullary contents, and should, therefore, reduce reaming-associated complications. The aim of the study was to investigate cardiac function after multiple trauma with regard to two different RIA devices (RIAI vs RIAII). 15 male pigs were included in the study. Pigs received either sham treatment or multiple trauma (chest trauma, femur fracture, liver laceration, and hemorrhagic shock), followed by intramedullary nailing after reaming with either the RIAI or RIAII system (RIAII: reduced diameter of the reamer, improved control of irrigation and suction). Cardiac function was assessed by transesophageal echocardiography and systemic inflammation as well as local cardiac damage examined. Pigs of both treatment groups showed impaired cardiac function, valvular insufficiency, and cardiac damage. Systemic inflammation and local cardiac alterations were observed which might contribute to early myocardial damage in vivo. Multiple trauma including long-bone fracture and subsequent intramedullary reaming induces cardiac dysfunction and valvular insufficiency, which might be linked to both mechanical cardiac injury and increased systemic inflammation. 6 hours after trauma there are less differences between RIAI and RIAII treatment with regard to post-traumatic cardiac consequences in multiple injured pigs, indicating no beneficial effect of RIAII over RIAI.

Complement Activation and Organ Damage After Trauma-Differential Immune Response Based on Surgical Treatment Strategy

Background: The complement system is part of the innate immunity, is activated immediately after trauma and is associated with adult respiratory distress syndrome, acute lung injury, multiple organ failure, and with death of multiply injured patients. The aim of the study was to investigate the complement activation in multiply injured pigs as well as its effects on the heart in vivo and in vitro. Moreover, the impact of reamed vs. non-reamed intramedullary nailing was examined with regard to the complement activation after multiple trauma in pigs.

Materials and Methods: Male pigs received multiple trauma, followed by femoral nailing with/without prior conventional reaming. Systemic complement hemolytic activity (CH-50 and AH-50) as well as the local cardiac expression of C3a receptor, C5a receptors1/2, and the deposition of the fragments C3b/iC3b/C3c was determined in vivo after trauma. Human cardiomyocytes were exposed to C3a or C5a and analyzed regarding calcium signaling and mitochondrial respiration.

Results: Systemic complement activation increased within 6 h after trauma and was mediated via the classical and the alternative pathway. Furthermore, complement activation correlated with invasiveness of fracture treatment. The expression of receptors for complement activation were altered locally in vivo in left ventricles. C3a and C5a acted detrimentally on human cardiomyocytes by affecting their functionality and their mitochondrial respiration in vitro.

Conclusion: After multiple trauma, an early activation of the complement system is triggered, affecting the heart in vivo as well as in vitro, leading to complement-induced cardiac dysfunction. The intensity of complement activation after multiple trauma might correlate with the invasiveness of fracture treatment. Reaming of the femoral canal might contribute to an enhanced “second hit” response after trauma. Consequently, the choice of fracture treatment might imply the clinical outcome of the critically injured patients and might be therefore crucial for their survival.

A Biomechanical Comparison between Taylor's Spatial Frame and Ilizarov External Fixator

ABSTRACT

Taylor's spatial frame (TSF) and Ilizarov external fixators (IEF) are two circular external fixator commonly used to address complex deformity and fractures. There is currently no data available comparing the biomechanical properties of these two external fixators. This study looks into the mechanical characteristics of each system. TSF rings with 6 oblique struts, 4 tube connectors, 4 threaded rods, and 6 threaded rods were compared to a standard IEF rings with 4 threaded rods. Compression and torsional loading was performed to the frame as well as construct with Polyvinylchloride tubes. TSF rings with 4 tube connectors had the highest stiffness (3288 N/mm) while TSF rings with 6 struts was the least stiff. The situation was reversed for torsion where TSF rings with 6 oblique struts had the highest torsional stiffness (82.01 Nm/Degree) and frame Ilizarov rings with 4 threaded rods the least. Standard TSF construct of two ring with 6 oblique struts have better torsional stiffness and lower axial stiffness compared to the standard IEF.

KEY WORDS

Taylor's Spatial Frame, Ilizarov External Fixator, Biomechanical properties.

Monotherapy vs. polytherapy in the treatment of forearm non-unions and bone defects

OBJECTIVE

To determinate the efficacy of "polytherapy", a surgical technique that utilize all the components of the diamond concept (mesenchymal stem cells, bone morphogenetic proteins and scaffold) versus a "monotherapy", a surgical technique that utilize only one component of the diamond conceptin the treatment of severe forearm non-unions.

METHODS

We studied a database of 52 patients with 52 forearm non-unions; we classified the patients with the NUSS SCORE and we divided the patients in two group according to the treatment received. So we distinguished a group of patients treated according to the principles of "monotherapy" (33 patients) and a group of patients treated according to the principles of "polytherapy" (19 patients). The minimum follow up was 12 months.

RESULTS

In the monotherapy group 21/33 non-unions (63.64%) went on to develop a radiographic and clinical healing within a period of 12 months, the calculated DASH SCORE showed a mean value of 55.15 points. In the polytherapy group 17/19 (89.47%) nonunions went on to develop clinical and radiographic healing within 12 months, and the average DASH score showed a mean value of 45.47 points.

CONCLUSION

The polytherapy technique with the use of recombinant morphogenetic proteins, autologous MSCs and scaffold in the same surgical time appears to be an effective treatment for patients with severe forearm non-unions.

Treatment of long bone non-unions with polytherapy: indications and clinical results

The incidence of long bone non-unions has been estimated to range between 5 and 10%. Autologous bone graft usually harvested from the iliac crest continues to be the gold standard for biological enhancement of atrophic non-unions. However, its use has been hampered by minor and major donor site complications. Moreover despite possessing the properties of osteogenecity, osteoconductivity and some osteoinductivity the overall results of treatment have not been consistent with disappointing success rates at times. The concept of polytherapy for the treatment of non-unions, namely the simultaneous application of the three fundamental elements of the diamond concept, osteoprogenitor cells, growth factor and osteoconductive scaffold, appears to be an attractive alternative but more studies are desirable to validate this strategy.

Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today

Despite the remarkable advances achieved within the boundaries of the new discipline of Pelvic surgery, pelvic ring disruptions remain challenging and complex problems in orthopaedics. The long-term complications related to reconstruction techniques of these injuries have motivated researchers and surgeons to explore various alternative treatment modalities. Several biomechanical studies have addressed these issues. We performed a medline search including studies published during the last 30 years. Our search yielded 114 studies, 39 of which met the pre-specified inclusion criteria and were further critically analysed and discussed regarding the biomechanical aspects of pelvic ring reconstruction techniques. Based on observational approach and evaluation of the studies specific keypoints are highlighted comprising the clinical translation of the biomechanical supported findings.

Pattern of release and relationship between HMGB-1 and IL-6 following blunt trauma

BACKGROUND

High mobility group box-1 (HMGB-1), a recently identified inflammatory cytokine, is implicated in the pathogenesis of several inflammatory, infective and neoplastic processes. Patterns of expression following blunt trauma have not been adequately reported in the literature. This study aimed to quantify the serum concentrations of HMGB-1 following blunt trauma, and assess its relationship with the more established interleukin 6 (IL-6).

PATIENTS AND METHODS

20 patients with median injury severity score 17 (range 9-36) sustaining closed diaphyseal fractures of the femur treated by intramedullary nailing were included in the study. Serum concentrations of HMGB-1 and IL-6 were measured at several time points during their treatment.

RESULTS

A strong correlation was observed between admission and day 1 post-op concentrations of IL-6 and both the injury severity score (ISS) and the requirement for intensive care unit treatment. Serum concentrations of HMGB-1 did not demonstrate such a correlation. Around day 3 when IL-6 concentrations begin to fall, serum HMGB-1 concentrations were observed to increase.

CONCLUSIONS

IL-6 concentration measured early after admission is again shown to be strongly associated with overall injury severity and requirement for intensive care unit treatment. In contrast, HMGB-1 appears to be a late inflammatory mediator with levels becoming elevated once serum concentrations of IL-6 begin to fall. However, we were unable to demonstrate any relationship with injury severity or requirement for ICU care at any stage. These preliminary findings may form the basis for future research in this area.

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing

We studied 80 patients (56 females) with an average age of 84 years (range 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.

Matrix metalloproteases MMP-2 and MMP-9: are they early biomarkers of bone remodelling and healing after arthroscopic acromioplasty?

Arthroscopic acromioplasty, one of the most frequent procedures in shoulder surgery, can promote tissue healing process by the release of growth/angiogenic factors from the acromion. Matrix metalloproteinases MMP-2 and MMP-9 are involved in such process. The purpose of this study was to measure MMP-2 and MMP-9 levels in the articular fluid and in the peripheral blood of patients undergoing arthroscopic acromioplasty in order to better understand the local involvement of such factors in the healing process after surgical procedures. Concentrations of MMP-2 and MMP-9 in the subacromial space and peripheral blood collected shortly after surgery were determined by ELISA. MMP-2 and MMP-9 concentrations were measured in the subacromial fluid of 23 patients. In subacromial fluid, the levels between MMP-2 and MMP-9 did not reach statistical significance (127.15±45.56 vs 149.41±53.61 pg/ml, respectively, p>0.05). Peripheral blood levels of MMP-2 (130.75±47.48 pg/ml) were comparable to the subacromial fluid ones (127.15±45.56 pg/ml) whereas MMP-9 level was higher in the subacromial space (149.41±53.61 pg/ml) than in the peripheral blood (67.61±12.62 pg/ml, p<0.001). This work suggests that the measurement of bone specific MMPs (MMP-2 and MMP-9) can be an useful tool to be monitored in parallel with growth factor levels and other bone turnover markers in order to evaluate the bone remodelling and tissue healing processes. This study suggests that the measurement of bone specific MMPs levels, in particular MMP-9, may evaluate the bone remodelling and healing after arthroscopic shoulder acromioplasty.

The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device

We evaluated the peripheral release of inflammatory mediators after femoral fracture and subsequent intramedullary reaming using the RIA reamers. IL-6 was elevated after trauma, and reaming with RIA induced a measurable second hit response. However, despite a higher ISS, the levels of IL-6 in the RIA group were similar to the levels measured in a group of patients where reaming of the femoral canal was performed using conventional reamers. There was one death related to fat embolism syndrome in the conventional reamers group. However, the overall incidence of complications was low and similar between the 2 groups of studied patients. In polytrauma patients, large scale studies are desirable to evaluate further the immuno-inflammatory response using the RIA reamers prior to the instrumentation of the femoral canal.

Cartilage repair evolution in post-traumatic osteochondral lesions of the talus: from open field autologous chondrocyte to bone-marrow-derived cells transplantation

The aims of this study are to describe evolution in cartilage repair from open field autologous chondrocyte implantation to regeneration by arthroscopic bone-marrow-derived cells (BMDCs) "one step" technique; to present the results of a series of patients consecutively treated and to compare in detail the different techniques used in order to establish the advantages obtained with the evolution in cartilage regenerative methods. 81 patients (mean age 30±8 years) were evaluated in this study. Patient assessment included clinical AOFAS score, X-rays and MRI preoperatively and at different established follow-ups. All the lesions were >1.5 cm(2) and received open autologous chondrocyte implantation (10 cases), arthroscopic autologous chondrocyte implantation (46 cases), and "one step" arthroscopic repair by BMDC transplantation (25 cases). For arthroscopic repair techniques a hyaluronic acid membrane was used to support cells and specifically designed instrumentation was developed. Patients of all the three groups underwent a second arthroscopy with a bioptic cartilage harvest at 1 year follow-up. Mean AOFAS score before surgery was 57.1±17.2 and 92.6±10.5 (P<0.0005) at mean 59.5±26.5 months. A similar pattern of AOFAS improvement in results was found in the three different techniques. Histological evaluations highlighted collagen type II and proteoglycan expression. The cartilage repair techniques described were able to provide a repair tissue which closely approximates the characteristics of the naive hyaline cartilage. Evolution in surgical technique, new biomaterials and more recently the use of BMDCs permitted a marked reduction in procedure morbidity and costs up to a "one step" technique able to overcome all the drawbacks of previous repair techniques.

Management of distal radius fractures: treatment protocol and functional results

Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment is controversial and still debated in the literature. For a correct management of these lesions many authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint mobilisation. We report our experience in the daily management of these lesions. The fractures are evaluated considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture stability. The best treatment option must be decided in accordance to the type of fracture, the extent of metaphyseal comminution, the quality of the bone and the medical condition of the patient.

Percutaneous techniques in the treatment of osteoporotic, traumatic and neoplastic fractures of thoraco-lumbar spine: our institutional experience

Fifty-eight (30 females) patients with a mean age of 55 were treated in our institution with minimal invasive surgery techniques for osteoporotic, traumatic and neoplastic fractures of the thoraco-lumbar spine. All patients completed pre-operatively and post-operatively the VAS score (0-10, 10 being the worst state for pain) as well as the Oswestry low back pain disability questionnaire at 3, 12, 24 and 36 months intervals. Overall the VAS score was reduced from 7.8 points pre-operatively, to 2.1 points at the 36 month follow up. Oswestry disability score improved from a pre-operative severe disability to moderate disability at 3 months up to a minimum disability at 36 months. The minimally invasive surgical techniques can significantly improve clinical outcomes by preventing many of the drawbacks associated with open approaches whilst also allowing to associate other methods such as coblation, vertebroplasty, interbody fusion that can be complementary to vertebral fixation.

Articular step-off and risk of post-traumatic osteoarthritis. Evidence today

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

"No one has ever asked for it back!" A survey assessing the fate of reusable external fixation equipment in mortuaries

Technicians from one hundred and eighteen Human Tissue Authority (HTA) approved mortuaries licensed to perform post-mortems in England completed a telephone interview. All were questioned on whether they had contact with reusable external fixators, who was responsible for the removal, the number removed annually, and the destination of the fixator post-removal. Opinion was sought on how the return of the equipment could be better facilitated. Seventy-four of the technicians interviewed could remember seeing external fixation devices, but were unable to quantify how many were removed annually. Sixty-one of those questioned stated that they personally removed the fixator, three always requested an Orthopaedic surgeon to remove the device and five contacted a Nurse Specialist. Forty-eight stated that they returned the devices to their local Sterile Services Department or Orthopaedic department. Nine technicians always discarded the fixators, eight always left them with the body and two stored them in the mortuary. Many reusable external fixation devices are inappropriately disposed of each year due to a lack of knowledge and communication with Orthopaedic departments. Confusion also exists among some technicians over whether external fixation components should be treated as 'implants'. There is a need for clear guidelines to raise awareness and ensure the appropriate return of these high cost devices.

Bone morphogenetic proteins in musculoskeletal medicine

Ongoing research at the molecular level has expanded our understanding of the physiological processes that regulate the complex phenomena of fracture healing and bone regeneration. A number of key molecules have been identified and shown to facilitate the progression of healing from one stage to another, leading to an uneventful outcome. Among these candidate molecules, bone morphogenetic proteins (BMPs) possess potent osteoinductive properties. They interact with osteoprogenitor cells, regulating both mitogenesis and differentiation potential. Since the discovery of BMPs, a number of experimental and clinical trials have supported their safety and efficacy of their use in therapy. Nonetheless, at times their efficacy falls short of expectations. Several factors have been identified as contributing to this result. It is anticipated that, as our knowledge expands and we understand better the complex pathways and cascades of molecular events attributable to BMPs, the application of these molecules in the clinical setting will continue to increase and to show more favourable outcomes.

Surgical techniques: how I do it? The Reamer/Irrigator/Aspirator (RIA) system

Although reamed intramedullary nailing has long been considered a safe procedure, pulmonary complications have been reported in some groups of patients. Concerns over fat embolisation, adult respiratory distress syndrome (ARDS), and sudden intraoperative death have prompted some authors to question whether the benefits of reaming are outweighed by its potential adverse effects to the patient. In response to these complications, recent evaluations have focused on alternative systems that reduce intramedullary pressure during reaming. The Reamer/Irrigator/Aspirator (RIA) system (Synthes, Inc., West Chester, PA) was developed as a simultaneous reaming and aspiration system to reduce the intramedullary pressure, heat generation, operating time, and systemic effects of reaming. It was designed with an aggressive one-pass reamer head which is connected to a hand-held reamer via a drive shaft, simultaneously irrigating and aspirating femoral canal contents during reaming, thus preventing thermal necrosis and fat embolisation. After its early use, investigators examined the "aspirate" captured by the RIA which appeared to be loaded with osteogenic substrates. This discovery revealed a second potential use for the RIA-a bone graft harvester. The different design characteristics and technicalities of the RIA system necessitate a deep and clear understanding of its technique, a meticulous preoperative planning and a strict adherence to its principles intraoperatively. We present our current approach to the use of the RIA system, including the preoperative planning, the details of the operative procedure, the pitfalls and the potential complications that could be encountered.

Damage control orthopaedics: lessons learned

Damage control orthopaedics (DCO) is a staged approach for the management of multiply injured patients. It is ideal for trauma patients presenting in an unstable or extremis physiological state. It focuses on the rapid resuscitation of these patients by providing temporary stabilisation of fractures while at the same time reducing the biological load of surgery. Early findings support its usefulness in controlling the lethal triad of hypothermia, acidosis and coagulopathy. Furthermore, recent evidence indicates that it regulates the evolving systemic inflammatory response, reducing the detrimental complications of adult respiratory distress syndrome, multiple organ dysfunction and subsequent mortality. Although DCO has been proven a useful surgical strategy for efficiently managing patients with multiple trauma, further work is required to establish fully its indications, results and cost implications.

Bilateral femoral fractures: does intramedullary nailing increase systemic complications and mortality rates?

In order to evaluate the impact of simultaneous intramedullary nailing in patients with bilateral femoral fractures on systemic complications a comprehensive review of the literature was performed. Four studies reporting the results of 197 patients following trauma were analysed. The mean Injury Severity Score was 20.6 (range, 9-75). According to the data available, reamed intramedullary nailing was performed in 96% of the cases. The incidence of fat embolism was 4.1%, ARDS 14.6% and pulmonary embolism 6.9%. The overall mortality was 6%. The mean hospital stay was 17.9 days (range, 4-108). Bilateral femoral fractures have a high risk of complications and mortality. Damage control surgery should be considered in these cases where the clinician anticipates the development of systemic complications.