Can the Clinical Frailty Scale on admission predict 30-day survival, postoperative complications, and institutionalization in patients with fragility hip fracture? : a cohort study of 1,255 patients

AIMS

We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

METHODS

Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis.

RESULTS

Significant non-linear associations between CFS and outcomes were observed. Risk of death within 30 days rose linearly for CFS 1 to 5, but plateaued for CFS > 5. The incidence of complications and length of stay rose linearly for CFS 1 to 4, but plateaued for CFS > 4. In contrast, the risk of new institutionalization rose linearly for CFS 1 to 8. The AUCs for 30-day mortality for the CFS and NHFS were very similar: CFS AUC 0.63 (95% CI 0.57 to 0.69) and NHFS AUC 0.63 (95% CI 0.57 to 0.69).

CONCLUSION

Use of the CFS may provide useful information on outcomes for fitter patients presenting with hip fracture, but completion of the CFS by the admitting orthopaedic team does not appear successful in distinguishing between higher CFS categories, which define patients with frailty. This makes a strong case for the role of the orthogeriatrician in the early assessment of these patients. Further work is needed to understand why patients assessed as being of mild, moderate, and severe frailty do not result in different outcomes. Cite this article: Bone Joint J 2022;104-B(8):980-986.

Interventions for treating supracondylar elbow fractures in children

BACKGROUND

Elbow supracondylar fractures are common, with treatment decisions based on fracture displacement. However, there remains controversy regarding the best treatments for this injury.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating supracondylar elbow fractures in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in March 2021. We also searched trial registers and reference lists. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing different interventions for the treatment of supracondylar elbow fractures in children. We included studies investigating surgical interventions (different fixation techniques and different reduction techniques), surgical versus non-surgical treatment, traction types, methods of non-surgical intervention, and timing and location of treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data and conducted GRADE assessment for five critical outcomes: functional outcomes, treatment failure (requiring re-intervention), nerve injury, major complications (pin site infection in most studies), and cosmetic deformity (cubitus varus).  MAIN RESULTS: We included 52 trials with 3594 children who had supracondylar elbow fractures; most were Gartland 2 and 3 fractures. The mean ages of children ranged from 4.9 to 8.4 years and the majority of participants were boys. Most studies (33) were conducted in countries in South-East Asia. We identified 12 different comparisons of interventions: retrograde lateral wires versus retrograde crossed wires; lateral crossed (Dorgan) wires versus retrograde crossed wires; retrograde lateral wires versus lateral crossed (Dorgan) wires; retrograde crossed wires versus posterior intrafocal wires; retrograde lateral wires in a parallel versus divergent configuration; retrograde crossed wires using a mini-open technique or inserted percutaneously; buried versus non-buried wires; external versus internal fixation; open versus closed reduction; surgical fixation versus non-surgical immobilisation; skeletal versus skin traction; and collar and cuff versus backslab. We report here the findings of four comparisons that represent the most substantial body of evidence for the most clinically relevant comparisons.  All studies in these four comparisons had unclear risks of bias in at least one domain. We downgraded the certainty of all outcomes for serious risks of bias, for imprecision when evidence was derived from a small sample size or had a wide confidence interval (CI) that included the possibility of benefits or harms for both treatments, and when we detected the possibility of publication bias.  Retrograde lateral wires versus retrograde crossed wires (29 studies, 2068 children) There was low-certainty evidence of less nerve injury with retrograde lateral wires (RR 0.65, 95% CI 0.46 to 0.90; 28 studies, 1653 children). In a post hoc subgroup analysis, we noted a greater difference in the number of children with nerve injuries when lateral wires were compared to crossed wires inserted with a  percutaneous medial wire technique (RR 0.41, 95% CI 0.20 to 0.81, favours lateral wires; 10 studies, 552 children), but little difference when an open technique was used (RR 0.91, 95% CI 0.59 to 1.40, favours lateral wires; 11 studies, 656 children). Although we noted a statistically significant difference between these subgroups from the interaction test (P = 0.05), we could not rule out the possibility that other factors could account for this difference. We found little or no difference between the interventions in major complications, which were described as pin site infections in all studies (RR 1.08, 95% CI 0.65 to 1.79; 19 studies, 1126 children; low-certainty evidence). For functional status (1 study, 35 children), treatment failure requiring re-intervention (1 study, 60 children), and cosmetic deformity (2 studies, 95 children), there was very low-certainty evidence showing no evidence of a difference between interventions. Open reduction versus closed reduction (4 studies, 295 children) Type of reduction method may make little or no difference to nerve injuries (RR 0.30, 95% CI 0.09 to 1.01, favours open reduction; 3 studies, 163 children). However, there may be fewer major complications (pin site infections) when closed reduction is used (RR 4.15, 95% CI 1.07 to 16.20; 4 studies, 253 children). The certainty of the evidence for these outcomes is low. No studies reported functional outcome, treatment failure requiring re-intervention, or cosmetic deformity. The four studies in this comparison used direct visualisation during surgery. One additional study used a joystick technique for reduction, and we did not combine data from this study in analyses. Surgical fixation using wires versus non-surgical immobilisation using a cast (3 studies, 140 children) There was very low-certainty evidence showing little or no difference between interventions for treatment failure requiring re-intervention (1 study, 60 children), nerve injury (3 studies, 140 children), major complications (3 studies, 126 children), and cosmetic deformity (2 studies, 80 children). No studies reported functional outcome. Backslab versus sling (1 study, 50 children) No nerve injuries or major complications were experienced by children in either group; this evidence is of very low certainty. Functional outcome, treatment failure, and cosmetic deformity were not reported.  AUTHORS' CONCLUSIONS: We found insufficient evidence for many treatments of supracondylar fractures. Fixation of displaced supracondylar fractures with retrograde lateral wires compared with crossed wires provided the most substantial body of evidence in this review, and our findings indicate that there may be a lower risk of nerve injury with retrograde lateral wires. In future trials of treatments, we would encourage the adoption of a core outcome set, which includes patient-reported measures. Evaluation of the effectiveness of traction compared with surgical fixation would provide a valuable addition to this clinical field.

Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales

AIMS

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

METHODS

A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.

RESULTS

A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001).

CONCLUSION

SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.

Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments

AIMS

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

METHODS

Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year.

RESULTS

A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection.

CONCLUSION

Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958-965.

Are facemasks a priority for all staff in theatre to prevent surgical site infections during shortages of supply? A systematic review and meta-analysis

BACKGROUND

The provision of facemasks must be prioritised when supplies are interrupted. These include supplies to operating rooms. The aim of this review is to evaluate the available evidence to determine the relative priority for the provision of facemasks in operating rooms to prevent surgical site infection.

METHODS

A systematic search of OVID Medline, Embase & Cochrane Central was completed. Candidate full-text articles were identified and analysed by two reviewers who also assessed risk of bias.

FINDINGS

Six studies were identified that described infections with and without facemask usage. The pooled effect of not wearing facemasks was a risk ratio for infection of 0.77 (0.62-0.97) in favour of not wearing masks. Only one case-controlled study evaluated facemask usage in implant surgery and demonstrated an odds ratio for developing infection of 3.34 (95% CI 1.94-5.74) if facemasks were not worn by the operating surgeon. Four studies collected microbiological cultures during periods in surgery with or without facemasks. Two demonstrated an increase in colony forming units in surgery where the wound was directly below the surgeon. One study showed equivocal results when masks were worn, and one was terminated early limiting interpretation.

CONCLUSION

The use of facemasks by scrubbed staff during implant surgery should be mandatory to prevent infection. We recommend the use of facemasks by all scrubbed staff during other forms of surgery to protect the patient and staff, but the supporting evidence is weak. There is insufficient evidence to show that non-scrubbed staff must wear masks during surgery.

Development of the CORE-Kids core set of outcome domains for studies of childhood limb fractures

Aims

The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures.

Methods

A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders.

Results

The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively.

Conclusion

This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development.

Cite this article: Bone Joint J 2021;103-B(12):1821–1830.

Outcomes after hip fractures sustained in hospital: A propensity-score matched cohort study

AIMS

The aim of this study was to compare outcomes following hip fracture for patients who sustained their fracture whilst in hospital (inpatients) with those who sustained their fracture in the community (outpatients).

PATIENTS AND METHODS

Data on all hip fracture admissions aged 65 years or over between 1^st May 2007 and 31^st March 2018 was analysed from a prospectively collected hip fracture database. Patient demographics, co-morbidities, and discharge information were analysed. Outcome measures included mortality (inpatient, 30-day and one year), surgical site infection (SSI) rate and mean length of stay (LOS). Baseline characteristics were used to generate propensity-match scores for each patient, with inpatients matched to outpatients in a 1:1 ratio. Outcomes were compared after matching.

RESULTS

7,592 patients were included in the study. 338 were identified as having an inpatient hip fracture. There was a significantly greater level of comorbidity in the inpatient group at baseline. After propensity-score matching, there were 229 patients in the inpatient group and 222 in the outpatient group, with no significant difference in baseline co-morbidities. In this propensity score matched cohort, 30-day mortality was significantly higher in the inpatient group (16%) compared to the outpatient group (10%), P = 0.049. 1-year mortality was also significantly higher in the inpatient group (44%) compared to the outpatient group (34%), P = 0.03. There was no significant difference in inpatient mortality, mean LOS and SSI rates between the two groups.

CONCLUSION

Patients who suffer a hip fracture whilst in hospital have significantly poorer outcomes than those who suffer a hip fracture whilst an outpatient, even after adjusting for co-morbidities. Dedicated guidelines are needed for this particularly vulnerable group.

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia

AIMS

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of 'off-ended' fractures in children with at least two years of potential growth remaining.

METHODS

A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires.

RESULTS

Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections.

CONCLUSION

Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902-907.

Developing a core outcome set for hand fractures and joint injuries in adults: a systematic review

This study identifies the treatment outcome domains used in recently published studies on the treatment of hand fractures and joint injuries with the aim to inform development of a core outcome set. Seven databases were searched from January 2014 to March 2019 for randomized and quasi-randomized studies and large prospective observational studies. We identified 1777 verbatim outcomes in 160 eligible studies. From the verbatim outcomes we distinguished 639 unique outcomes, which we categorized into 74 outcome domains based on the World Health Organization International Classification of Functioning, Disability, and Health framework. The primary outcome was appropriately identified in only 65% (72/110) of randomized and quasi-randomized controlled trials. Of the 72 studies with a primary outcome identified, 74% (53/72) had an appropriate power calculation. The vast heterogeneity in outcome selection across studies highlights the need for a core outcome set of what outcomes to measure in future clinical research on hand fractures and joint injuries.

Quality of patient-reported outcomes used for quality of life, physical function, and functional capacity in trials of childhood fractures

AIMS

This study evaluates the quality of patient-reported outcome measures (PROMs) reported in childhood fracture trials and recommends outcome measures to assess and report physical function, functional capacity, and quality of life using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of OVID Medline, Embase, and Cochrane CENTRAL was performed to identify all PROMs reported in trials. A search of OVID Medline, Embase, and PsycINFO was performed to identify all PROMs with validation studies in childhood fractures. Development studies were identified through hand-searching. Data extraction was undertaken by two reviewers. Study quality and risk of bias was evaluated by COSMIN guidelines and recorded on standardized checklists.

RESULTS

Searches yielded 13,672 studies, which were screened to identify 124 trials and two validation studies. Review of the 124 trials identified 16 reported PROMs, of which two had validation studies. The development papers were retrieved for all PROMs. The quality of the original development studies was adequate for Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility and Upper Extremity and doubtful for the EuroQol Five Dimension Youth questionnaire (EQ-5D-Y). All other PROMs were found to have inadequate development studies. No content validity studies were identified. Reviewer-rated content validity was acceptable for six PROMs: Activity Scale for Kids (ASK), Childhood Health Assessment Questionnaire, PROMIS Upper Extremity, PROMIS Mobility, EQ-5D-Y, and Pediatric Quality of Life Inventory (PedsQL4.0). The Modified Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was shown to have indeterminate reliability and convergence validity in one study and PROMIS Upper Extremity had insufficient convergence validity in one study.

CONCLUSION

There is insufficient evidence to recommend strongly the use of any single PROM to assess and report physical function or quality of life following childhood fractures. There is a need to conduct validation studies for PROMs. In the absence of these studies, we cautiously recommend the use of the PROMIS or ASK-P for physical function and the PedsQL4.0 or EQ-5D-Y for quality of life. Cite this article: Bone Joint J 2020;102-B(12):1599-1607.

Outcomes reported in trials of childhood fractures: a systematic review

Aims

To analyze outcomes reported in trials of childhood fractures.

Methods

OVID MEDLINE, Embase, and Cochrane CENTRAL databases were searched on the eighth August 2019. A manual search of trial registries, bibliographic review and internet search was used to identify additional studies. 11,476 studies were screened following PRISMA guidelines. 100 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Study quality was not evaluated. Outcomes reported by trials were mapped onto domains in the World Health Organization (WHO) International Classification of Function framework.

Results

In all, 525 outcomes were identified representing 52 WHO domains. Four domains were reported in more than 50% of trials: structure of upper/lower limb, sensation of pain, mobility of joint function, and health services, systems and policies. The Activities Scale for Kids performance (ASK-p) score was the most common outcome score reported in 6/72 upper limb and 4/28 lower limb trials.

Conclusion

There is a diverse range of outcomes reported in trials of childhood fractures covering all areas in the International Classification of Functioning, Disability and Health (ICF) framework. There were three common upper limb and three common lower limb outcomes. In the absence of a core outcome set, we recommend that upper limb trials report pain, range of movement and radiograph appearance of the arm and lower limb trials report pain, radiograph appearance of the leg and healthcare costs to improve consistency of reporting in future trials.

Cite this article: Bone Joint Open 2020;1-5:167–174.

Is it safe for extended-role radiographers to measure migration percentage in children with cerebral palsy?

INTRODUCTION

In the surveillance of children with cerebral palsy, the measurement of migration percentage is used to identify children at risk of hip dislocation. Early identification of children at risk facilitates early intervention with less invasive surgical procedures to prevent further deterioration. The aim of this study is to evaluate the safety of the measurements of migration percentage for surveillance in cerebral palsy by extended-role radiographers by evaluating the reliability and validity of measurements performed by these professionals.

METHODS

A sample of thirty pelvic x-rays were selected from the local cerebral palsy database. A range of hip displacement was selected including some challenging borderline x-rays. All ten extended-role radiographers completed measurements using TraumaCAD which were repeated at a minimum of 4 weeks. Inter-rater and intra-rater reliability was calculated using intraclass correlation coefficients. The accuracy and safety of the system was evaluated by converting measurements into referral categories (red, amber or green) and cohen's kappa was calculated when categories were compared to measurements to orthopaedic surgeon RESULTS: The inter-rater reliability between radiographers was 0.938 (95% CI 0.914-0.991). The intra-rater reliability was 0.941 (95% CI 0.931-0.949). The percentage agreement was 94.8% for green, 93.8% for amber and 98.2% for red hips. The weighted kappa value was 0.923 (95% CI 0.889-0.957).

CONCLUSION

The reliability and accuracy of radiographer measurement of migration percentage is excellent. It is safe for radiographers to calculate the migration percentage using semi-automated software for the surveillance of children with cerebral palsy.

IMPLICATIONS FOR PRACTICE

We recommend the measurement of migration percentage may be performed by extended-role radiographers to deliver accurate and reliable measurements for use in cerebral palsy surveillance.

Value of the 'clicky hip' in selective screening for developmental dysplasia of the hip

AIMS

The aim of this study was to review the value of accepting referrals for children with 'clicky hips' in a selective screening programme for hip dysplasia.

PATIENTS AND METHODS

A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant.

RESULTS

There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to 'clicky hip' with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with 'clicky hip' and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a 'clicky hip' and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips.

CONCLUSION

There is significant value in reviewing children with an isolated 'clicky hip'. Many children who require treatment are referred to the orthopaedic service as 'clicky hip' with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, 'clicky hip' is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635-638.

Management of ankle fractures in children

Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.

Management of 'low-risk' ankle fractures in children: a systematic review

INTRODUCTION

This study aimed to review the literature to establish whether there is a best treatment for low-risk ankle fractures in children.

MATERIALS AND METHODS

A systematic review and meta-analysis of trials was undertaken, which compared interventions for 'low-risk' ankle fractures in children. A meta-analysis was performed using a random effects model.

RESULTS

Four trials were identified reporting outcomes from 256 patients. All trials reported results using a device that permitted ankle motion compared with more rigid immobilisation. Overall risk of bias was low for three trials and high for one trial. Two trials assessed time to return to normal function. Patients treated in a splint or with a bandage recovering 6-7.5 days sooner than those treated with rigid immobilisation. One trial demonstrated that children returned to school sooner if treated in a bandage rather than in a cast. Two trials found a higher Activity Scale for Kids performance score at four weeks for children treated with splint compared with rigid immobilisation. There was no clear advantage to any device in patient satisfaction, quality of life or total costs.

DISCUSSION

There is no clear best treatment for these injuries. Studies had significant limitations and outcomes were heterogeneous, limiting meta-analysis.

CONCLUSION

There is a need for a definitive trial to establish the best treatment for ankle fractures and a core outcome set to ensure study findings are consistent and can be analysed in future meta-analyses.

A systematic review of local antibiotic devices used to improve wound healing following the surgical management of foot infections in diabetics

AIMS

Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery.

MATERIALS AND METHODS

Databases were searched to identify eligible studies and 13 were identified for inclusion.

RESULTS

Overall, the quality of the studies was poor. A single trial suggested that wound healing is quicker when a gentamicin-impregnated collagen sponge was implanted at time of surgery, with no difference in length of stay or rate of amputation. Results from studies with high risk of bias indicated no change in wound healing when a gentamicin-impregnated sponge was implanted during transmetatarsal amputation, but a reduction in the incidence of wound breakdown (8% vs 25%, not statistically significant) was identified. A significant cost reduction was identified when using an antimicrobial gel to deliver antibiotics and anti-biofilm agents (quorum-sensing inhibitors) compared with routine dressings and systemic antibiotics. Analyses of case series identified 485 patients who were treated using local antibiotic delivery devices. The rates of wound healing, re-operation, and mortality were comparable to those that have been previously reported for the routine management of these infections.

CONCLUSION

There is a lack of good-quality evidence to support the use of local antibiotic delivery devices in the treatment of foot infections in patients with diabetes. Cite this article: Bone Joint J 2018;100-B:1409-15.

Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis

Aims

The aim of this review was to evaluate the available literature and to calculate the pooled sensitivity and specificity for the different alpha-defensin test systems that may be used to diagnose prosthetic joint infection (PJI).

Materials and Methods

Studies using alpha-defensin or Synovasure (Zimmer Biomet, Warsaw, Indiana) to diagnose PJI were identified from systematic searches of electronic databases. The quality of the studies was evaluated using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) tool. Meta-analysis was completed using a bivariate model.

Results

A total of 11 eligible studies were included. The median QUADAS score was 13 (interquartile range 13 to 13) out of 14. Significant conflicts of interest were identified in five studies. The pooled sensitivity for the laboratory alpha-defensin test was 0.95 (95% confidence interval (CI) 0.91 to 0.98) and the pooled specificity was 0.97 (95% CI 0.95 to 0.98) for four studies with a threshold level of 5.2 mgl-1 The pooled sensitivity for the lateral flow cassette test was 0.85 (95% CI 0.74 to 0.92) and the pooled specificity was 0.90 (95% CI 0.91 to 0.98). There was a statistically significant difference in sensitivity (p = 0.019), but not specificity (p = 0.47).

Conclusion

Laboratory-based alpha-defensin testing remains a promising tool for diagnosing PJI. The lateral flow cassette has a significantly lower performance and pooled results are comparable to the leucocyte esterase test. Further studies are required before the widespread adoption of the lateral flow cassette alpha-defensin test. Cite this article: Bone Joint J 2018;100-B:703-11.

A case report of periprosthetic fracture left proximal humerus with radial nerve palsy following pectoralis major repair

Primary repair of pectoralis major tendon with bony tunnels and anchor sutures in the proximal humerus creates a potential weakness and stress riser leading to increased risk of periprosthetic fracture and nerve damage at the site of weakness with subsequent injury, if not allowed to heal satisfactorily with adequate period of rest.

A case report of Progressive subluxation leading to an anterior dislocation of the hip following sliding hip screw fixation for pertrochanteric Extracapsular 4 part fracture neck of femur

Unstable 4 part pertrochanteric fractures without lateral cortical support presents considerable technical problem in treatment with high risk of failure with any implant. Anatomical or slight valgus reduction and subchondral central position of the lag screw (TAD <25 mm) reduces the chance of screw cut out and other complications.

Bougie-related airway trauma: dangers of the hold-up sign

The bougie is a popular tool in difficult intubations. The hold-up sign is used to confirm tracheal placement of a bougie. This study aimed to establish the potential for airway trauma when using this sign with an Eschmann re-usable bougie or a Frova single-use bougie. Airways were simulated using a manikin (hold-up force) and porcine lung model (airway perforation force). Mean (SD) hold-up force (for airway lengths over the range 25-45 cm) of 1.0 (0.4) and 5.2 (1.1) N were recorded with the Eschmann and Frova bougies, respectively (p < 0.001). The mean (SD) force required to produce airway perforation was 0.9 (0.2) N with the Eschmann bougie and 1.1 (0.3) N with the Frova bougie (p = 0.11). It is possible to apply a force at least five times greater than the force required to produce significant trauma with a Frova single-use bougie. We recommend that the hold-up sign should no longer be used with single-use bougies. Clinicians should be cautious when eliciting this sign using the Eschmann re-usable bougie.

The Newport eye: design and initial evaluation of a novel foreign body training phantom

To improve SHO confidence in corneal foreign body removal, a novel training phantom is proposed. This phantom is a polyvinyl and gelatine-based model, easily fabricated in the emergency department (ED). Use of the phantom results in a significant improvement in SHO confidence, and therefore, makes a useful, cost-effective adjunct for ED training.