The use of locking plates in the surgical treatment of proximal humeral fractures is associated with an unexpectedly high rate of screw cutout and revision surgery, especially in patients older than sixty years who have a three or four-part fracture. The indications for open reduction and internal fixation in these patients require continued analysis.

Summary Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0.83, 95% CI 0.63–1.09; p=0.18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1.91, 1.06–3.44; p=0.0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0.82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0.41) and sepsis (seven [1%] vs six [1%]; p=0.79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated.

Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus, or a history of diabetes had a higher risk of failure of a single surgical debridement for acute septic arthritis and requiring additional surgical debridement(s).

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Removal of one centimeter from the tip of a tibial nail allows placement of two distal interlocking screws in tibial fractures located four centimeters from the tibiotalar joint. The fixation strength achieved is comparable to that of standard intramedullary nailing of tibial fractures located five centimeters from the tibiotalar joint using two distal interlocking screws. Fixation strength with these distal fractures, however, is not strong enough to resist moderate compression-bending loads. Thus, patients with distal tibia fractures treated with intramedullary nailing must follow weight-bearing restrictions until significant fracture healing occurs to prevent coronal plane malalignment of the fracture.

No abstract

Industry statistics suggest that motorcycle owners in the United States are getting older. Our objective was to analyze the effect of this demographic shift on injuries and outcomes after a motorcycle crash. Injured motorcyclists aged 17 to 89 years in the National Trauma Databank were reviewed from 1996 to 2005. Age trends and injury patterns were assessed over time. Injury Severity Score (ISS), length of stay (LOS), intensive care unit (ICU) use, comorbidities, complications, mortality, injury patterns, helmet use, and alcohol use were compared for subjects 40 and older versus those younger than 40 years old. There were 61,689 subjects included. Over the study period, the mean age increased from 33.9 to 39.1 years ( P < 0.01), and the proportion of subjects 40 years of age or older increased from 27.9 to 48.3 per cent. ISS, LOS, ICU LOS, and mortality were higher in the 40 years of age or older group ( P ≤ 0.01). The rates of admission to the ICU (32.3 vs. 27.3%), pre-existing comorbidities (20 vs. 9.7%), and complications (7.6 vs. 5.5%) were all higher in the 40 years of age and older group ( P < 0.01). The average age of the injured motorcyclist is increasing. Older riders’ injuries appear more serious, and their hospital course is more likely to be challenged by comorbidities and complications contributing to poorer outcomes. Motorcycle safety education and training initiatives should be expanded to specifically target older motorcyclists.