Publications by authors named "Theodoros Tosounidis"

56 Publications

The level of bifurcation of peroneal artery and its implications for posterolateral approach to the ankle: a CT angiography study.

Surg Radiol Anat 2021 Jul 17. Epub 2021 Jul 17.

Department of Orthopaedic Surgery, University Hospital of Heraklion, Crete, Greece.

Purpose: This study aims to provide data, with the use of computed tomography angiography, regarding the level of bifurcation of the peroneal artery to the anterior perforating branch and the lateral calcaneal branch, in relation to the osseous anatomic structures of the tibial plafond, the medial malleolus and the lateral malleolus.

Methods: The study included patients who underwent diagnostic computed tomography angiography of the lower extremities. Measurements were performed in two-dimensional reconstructions and included the perpendicular distance from peroneal artery bifurcation into anterior perforating branch and lateral calcaneal branch to the lowest level of tibial plafond (D1), medial malleolus (D2) and lateral malleolus (D3). The distances were also normalized to the length of the tibia.

Results: Sixty patients and a total of 115 limbs were enrolled in this study. The mean distance ± standard deviation from peroneal artery bifurcation to tibial plafond (D1) was 4.33 ± 1.12 cm (normalized 0.12 ± 0.03) (range 2.54-8.26 cm), to medial malleolus (D2) was 5.53 ± 1.18 cm (normalized 0.16 ± 0.03) (range 3.27-9.5 cm) and to lateral malleolus (D3) was 6.53 ± 1.17 cm (normalized 0.18 ± 0.03) (range 4.71-10.2 cm), respectively. There was no significant difference between right and left limb measurements (p > 0.05). Females presented lower, but not statistically significant (p > 0.05), D1, D2 and D3 measurements compared to males.

Conclusion: The bifurcation of the peroneal artery takes place at lower level compared to previously published studies and consequently extreme caution should be exercised when performing the posterolateral approach to the ankle. This study adds to the understanding of the relevant vascular anatomy of the region and assists in performing the posterolateral approach to the ankle with safety.
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http://dx.doi.org/10.1007/s00276-021-02800-yDOI Listing
July 2021

Can CRP Levels Predict Infection in Presumptive Aseptic Long Bone Non-Unions? A Prospective Cohort Study.

J Clin Med 2021 Jan 22;10(3). Epub 2021 Jan 22.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS2 9JT, UK.

Nonunion remains a major complication of the management of long bone fractures. The primary aim of the present study was to investigate whether raised levels of C-reactive protein (CRP) and white blood cell count (WBC), in the absence of clinical signs, are correlated with positive intraoperative tissue cultures in presumptive aseptic long-bone nonunions. Infection was classified as positive if any significant growth of microorganisms was observed from bone/tissue samples sent from the theater at the time of revision surgery. Preoperatively all patients were investigated with full blood count, white blood count differential as well as C-reactive protein (CRP). A total of 105 consecutive patients (59 males) were included in the study, with an average age of 46.76 years (range 16-92 years) at the time of nonunion diagnosis. The vast majority were femoral (56) and tibial (37) nonunions. The median time from the index surgical procedure to the time of nonunion diagnosis was 10 months (range 9 months to 10 years). Positive cultures revealed a mixed growth of microorganisms, with coagulase-negative (56.4%) being the most prevalent microorganism, followed by (20.5%). , Methicillin-Resistant Staphylococcus aureus (MRSA), coliforms and micrococcus were present in the remainder of the cases (23.1%). Overall, the risk of infection with normal CRP levels (<10 mg/L) was 21/80 = 0.26. Elevated CRP levels (≥10 mg/L) increased the risk of infection to 0.72. The relative risk given a positive CRP test was RR = 0.72/0.26 = 2.74. Overall, the WBC count was found to be an unreliable marker to predict infection. Solid union was achieved in all cases after an average of 6.5 months (3-24 months) from revision surgery. In patients with presumed aseptic long bone nonunion and normal CRP levels, the risk of underlying low-grade indolent infection can be as high as 26%. Patients should be made aware of this finding, which can complicate their treatment course and outcomes.
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http://dx.doi.org/10.3390/jcm10030425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865495PMC
January 2021

Operative treatment of acute shaft and neck lesser metatarsals fractures: a systematic review of the literature.

Eur J Orthop Surg Traumatol 2021 Jan 23. Epub 2021 Jan 23.

University Hospital of Heraklion, Crete, Greece.

Purpose: Metatarsal fractures are relatively common injuries that they might lead to significant disability and chronic pain if suboptimally treated. Operative treatment is reserved for the displaced fractures. The primary aim of the herein study is to present the union time and rate, as well as the functional outcome of the surgically treated isolated lesser metatarsal shaft and neck fractures. The secondary aim is to present the related complications of each fixation method.

Methods: The electronic databases of Pubmed, Scopus, Embase and Cochrane libraries were searched from January 1990 to December 2020. PRISMA guidelines were used for data collection. We retrieved five articles including in total 154 patients, which were compatible to our inclusion criteria and they were used for this systematic review.

Results: A total of 75 patients were treated with percutaneous antegrade pinning resulting in AOFAS score: 96.4 ± 4.8 and time to heal 7.4 ± 1 weeks, 34 patients underwent ante/retrograde pinning resulting in AOFAS score: 95.2 ± 4.75 and time to heal 6.5 ± 1 weeks, and 45 patients underwent open reduction and internal fixation with plate and screws resulting in a time to union 10.9 ± 0.5 weeks.

Conclusion: Our results demonstrate that K wire intramedullary nailing regardless of the specific technique (antegrade, retrograde, ante/retrograde) is associated with better outcomes compared to open reduction and internal fixation as it permits faster weight bearing and quicker rehabilitation. K-wire fixation is related to statistically significant shorter time for the fracture to heal, by approximately three weeks compared to open reduction and internal fixation. Future research should focus on studies directly comparing the different intramedullary K-wiring techniques and also K-wiring versus plate fixation.
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http://dx.doi.org/10.1007/s00590-020-02869-yDOI Listing
January 2021

When does hip fracture surgery delay affects the length of hospital stay?

Eur J Trauma Emerg Surg 2021 Jan 3. Epub 2021 Jan 3.

Department of Traumatology, University Medical Center Ljubljana, 1000, Ljubljana, Slovenia.

Purpose: To define factors influencing length of hospital stay (LOS) besides surgery delay.

Methods: We retrospectively analyzed 634 patients operated for hip fractures in 1-year period. Investigated characteristics were age, gender, American Society of Anesthesiologists score (ASA), time to surgery (first 48 h was considered early), type of surgery, anticoagulant therapy and non-routine pre-operative tests. Univariate and multivariable analysis were performed. p values < 0.05 were considered statistically significant.

Results: Median LOS was 12 days. Patients operated within 48 h had a LOS of 10 days, while patients operated after 48 h had 4 days longer LOS (p < 0.01). In multiple regression analyses, it was predicted that patients operated after 48 h with every 10 h delay to surgery had 7.3 h longer hospitalizations. All other factors did not influence the LOS. In early operation group, patients with hip arthroplasty had 3.3 days longer hospitalization compared to patients with osteosynthesis, every higher ASA score was associated with 1.4 days longer hospitalization, patients on anticoagulant therapy had 2.6 days longer LOS but surgery delay had no influence on LOS. Preinjury residence at a nursing home was associated with 4.4 days shorter hospitalizations compared to preinjury residence at home in both time frames.

Conclusions: In patients operated in first 48 h longer LOS is associated with ASA, anticoagulant therapy and operation type but not with delay to surgery. If patients are operated after 48 h, surgery delay is the only factor increasing LOS.
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http://dx.doi.org/10.1007/s00068-020-01565-0DOI Listing
January 2021

Anterior hip dislocation with simultaneous anterior column and anterior wall acetabular fracture: A case report.

Trauma Case Rep 2021 Feb 11;31:100391. Epub 2020 Dec 11.

Department of Orthopaedics and Traumatology, University Hospital of Heraklion, Heraklion, Greece.

Introduction: Isolated anterior column and anterior wall fractures are a relatively rare subgroup of acetabular fractures. They represent 6,3% of all acetabular fractures. Surgical treatment is indicated for fractures with displacement more than 5 mm and when incongruence of the articular surface and/or instability of the joint is evident, in order to allow early mobilization and prevent further complications, such as posttraumatic hip arthritis. Open reduction and internal fixation is the usual standard of care. Closed reduction and percutaneous fixation can be performed in minimally displaced fractures. In the herein article, we describe the unique combination of anterior hip dislocation along with anterior column and anterior wall fractures in a middle-aged patient, after a fall from small height.

Case Report: A 56-year-old female patient was brought to the emergency department after an accidental fall from height less than 2 m. Upon arrival her right hip was abducted, shortened and externally rotated. CT scan of the pelvis revealed anterior dislocation of the right hip, an impaction injury of the femoral head, and fractures of anterior column and anterior wall of the acetabulum. Closed reduction of the hip was performed. Open reduction and internal fixation of the fractures was carried out utilizing the extended Smith-Petersen approach in a scheduled manner 5 days after admission. At one-year follow-up after the injury the patient had returned to all of her pre-injury activities and she was able to walk exercising full weight bearing without residual pain.

Conclusion: Anterior hip dislocation with simultaneous isolated anterior column and anterior wall fracture is an injury of rare incidence. Orthopaedic surgeons treating fractures should be aware of this entity and the herein article can serve as a reference regarding the management of such an uncommon injury.
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http://dx.doi.org/10.1016/j.tcr.2020.100391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770966PMC
February 2021

Fracture blisters: pathophysiology and management.

Injury 2020 Dec;51(12):2786-2792

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Floor D, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, West Yorkshire, LS1 3EX, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.

Open fractures are considered an orthopaedic emergency due to the severe soft tissue disruption that might potentially lead to devastating complications. On the other hand, closed fractures, and especially those resulting from high-energy mechanisms, are also often accompanied by severe soft tissue trauma. Soft tissue envelope compromise can have a detrimental effect on the final outcome of the patients. Fracture blisters in particular, develop as a sign of significant local tissue trauma and appear in a time period between 6 to 72 hours post-injury. They can delay the definitive fracture treatment for a considerable amount of time and at the same time they also increase the risk for post-operative wound complications. Awareness of fracture blisters pathophysiology and their management options are crucial for orthopaedic surgeons, in order to achieve a favorable clinical outcome. In the herein study we present a concise synopsis of the pathophysiology pathways and management options of fracture blisters.
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http://dx.doi.org/10.1016/j.injury.2020.11.059DOI Listing
December 2020

Influence of reaming intramedullary nailing on MSC population after surgical treatment of patients with long bone fracture.

Mol Med Rep 2020 09 9;22(3):2521-2527. Epub 2020 Jul 9.

Department of Orthopedics and Traumatology, University of Crete School of Medicine, 71003 Heraklion, Greece.

Reamed intramedullary nailing (RIN) is a surgical method of choice for treatment of diaphyseal fractures. This procedure affects the biological environment of bone tissue locally and systemically. This study investigated the influence of RIN on mesenchymal stem cells (MSCs) in patients with long bone fractures. The axis of C-X-C motif chemokine receptor 4 (CXCR4)/stromal cell-derived factor 1 (SDF‑1) was selected since it is considered as major pathway for MSC homing and migration. Iliac crest bone marrow (IC‑BM) samples and blood samples were collected at two different time points. One sample was collected before the RIN (BN) and the other immediately after RIN (AN). BM‑MSCs were cultured and RT‑qPCR was performed for CXCR4 mRNA levels and ELISA for the SDF‑1 sera levels. The experimental study revealed that there was a correlation between the increase of SDF‑1 levels in peripheral blood and a decrease in the levels of CXCR4 in MSCs in the IC‑BM following RIN. The levels of SDF‑1 showed a significant increase in the sera of patients after RIN. In conclusion, the present study is the first providing evidence of the effects of RIN on MSC population via the CXCR4/SDF‑1 axis. The levels of serum SDF‑1 factor were elevated after RIN while increased levels of SDF‑1 in peripheral blood were inversely correlated with the mRNA levels of CXCR4 on BM‑MSCs after RIN. Therefore, this study contributes to enlighten the systematic effects of RIN on the population of MSCs at a cellular level.
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http://dx.doi.org/10.3892/mmr.2020.11320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411410PMC
September 2020

Post-operative outcomes of open reduction and internal fixation versus circular external fixation in treatment of tibial plafond fractures: A systematic review and meta-analysis.

Injury 2020 Jul 12;51(7):1448-1456. Epub 2020 May 12.

Orthopaedic Surgery, University of Crete School of Medicine, Heraklion, Greece. Electronic address:

Introduction: Tibial plafond fractures (TPF) are complex injuries often resulting in poor outcomes. Combination of articular impaction, metaphysealcomminution and soft-tissue injury results in a significant treatment challenge. The aim of this study was to conduct a systematic review and meta-analysis to compare post-operative complications and functional outcomes of open reduction and internal fixation (ORIF) versus circular external fixation (CEF) for treatment of TPF.

Methods: A comprehensive search of PubMed/MEDLINE, Embase, Scopus and Cochrane library was undertaken. All studies published in English language comparing ORIF with CEF for treatment of TPF were included.

Results: 5 comparative studies with 239 fractures met the inclusion criteria. Meta-analysis showed no significant difference in rates of non-union, malunion, superficial infection, deep infection, and secondary arthrodesis between the two treatment groups. Significantly higher rate of unplanned metalwork removal (RR 5.68, 95% CI 1.13 to 28.55, p = 0.04) and lower rate of post-traumatic arthritis (RR 0.48, 95% CI 0.30 to 0.78, p = 0.003) were found in patients that underwent ORIF. 1 study showed significantly lower functional outcomes scores with CEF (p< 0.05), whereas 3 studies found comparable functional outcomes between the two treatment groups. Overall, there was a preference in treating more severe injuries with CEF.

Conclusion: CEF and ORIF are both acceptable treatment options for surgical management of TPF, with comparable post-operative complication rates and functional outcomes. This study highlights paucity of high-quality evidence regarding the optimal fixation method for TPF.
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http://dx.doi.org/10.1016/j.injury.2020.04.056DOI Listing
July 2020

Acute and chronic infection: Is there a gold standard for management of the wound and bone defect?

OTA Int 2020 Mar 23;3(1):e068. Epub 2020 Mar 23.

University Hospital, Heraklion, Crete, Greece.

Acute and chronic infections with bone involvement remain a challenge to manage. They pose a significant burden to the patient, the treating surgeon, and society. Multidisciplinary team involvement is mandatory for a successful outcome. Application of a gold standard approach is not possible due to the high heterogeneous patient population and the variable degree of severity of soft tissue and bone involvement. The mainstay of treatment remains the conversion of a septic environment to an aseptic one with aggressive debridement of the affected soft tissues and bone. Reconstruction of the soft tissue defect can be achieved using modern microsurgical techniques, whereas the induced membrane and distraction osteogenesis (bone transport) are currently the 2 most commonly used treatment modalities for bone loss. The safest approach to deal successfully with this multifaceted clinical pathology is to always follow well-established principles of management and adapt treatment to the personalized needs of the patient.
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http://dx.doi.org/10.1097/OI9.0000000000000068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081461PMC
March 2020

Telomere length and telomerase activity in osteoporosis and osteoarthritis.

Exp Ther Med 2020 Mar 24;19(3):1626-1632. Epub 2019 Dec 24.

Laboratory of Toxicology, Medical School, University of Crete, 71003 Heraklion, Greece.

Osteoarthritis (OA) and osteoporosis (OP) are associated skeletal pathologies and have as a distinct feature the abnormal reconstruction of the subchondral bone. OA and OP have been characterized as age-related diseases and have been associated with telomere shortening and altered telomerase activity (TA). This review discusses the role of telomeres and telomerase in OA and OP pathologies and focuses on the usability of telomere length (TL) and the rate of telomere shortening as potential disease biomarkers. A number of studies have demonstrated that telomere shortening may contribute to OA and OP as an epigenetic factor. Therefore, it has been claimed that the measurement of TL of chondrocytes and/or peripheral blood cells may be an appropriate marker for the evaluation of the progression of these diseases. However, there is a need to be perform further studies with larger cohorts, with the aim of obtaining objective results and a better understanding of the association between TL, inflammation and aging, in order to provide further insight into the pathophysiology of degenerative joint diseases.
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http://dx.doi.org/10.3892/etm.2019.8370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027092PMC
March 2020

What predicts mortality in the elderly patient presenting as a trauma call? A report from a Major Trauma Centre.

Surgeon 2020 Jun 28;18(3):142-149. Epub 2019 Aug 28.

Trauma and Orthopaedic Department, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom. Electronic address:

Purpose: Within the UK there is a continued expansion of the population over the age of 65, this currently accounts for 17.8% of the British population. We review the impact that centralization of Major Trauma has had, as well as analysing for significant predictors of poor outcome.

Method: All patients presenting to Leeds Major Trauma Centre as a 'Major Trauma' who were equal to or over the age of 65 were included in this study. Prospectively collected data from the Trauma Audit Research Network (TARN) was collated to include the above data set from the 1st April 2012 - 1st April 2016. The 1st April 2012 represents the commencement of the Major Trauma Network within Yorkshire. To allow more quantative assessment of patients' co-morbidities, they were coded as per Charlson Co-morbidity Index for analysis.

Results: 1167 patients presented within the above timeframe. Mean age was 79.5 (range 65-103.5). Mean ISS was 14.8 of the entire cohort. Mortality was 12.9% of the entire cohort. The leading mechanisms of injury were from low energy falls <2m-59.89%, Fall >2m-23.05% and Road Traffic Collision - 16.45%.

Conclusion: Mortality rates since the commencement of the Major Trauma Network within this age group have reduced. This is likely secondary to centralization of major trauma. Variables found to be statistically significant with increased mortality were increasing age, head injury, presence of Chronic Lung Disease, presence of metastases, decreased GCS and increased ISS.
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http://dx.doi.org/10.1016/j.surge.2019.07.008DOI Listing
June 2020

Application of the 'diamond concept' with fast bone marrow aspirate concentration for the treatment of medial malleolus non-union.

Injury 2018 12;49(12):2326-2330

Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2018.11.013DOI Listing
December 2018

Osteosynthesis of interprosthetic fractures: Evidence and recommendations.

Injury 2018 12;49(12):2097-2099

Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2018.11.011DOI Listing
December 2018

The Ilioinguinal Approach: State of the Art.

JBJS Essent Surg Tech 2018 Jun 27;8(2):e19. Epub 2018 Jun 27.

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom.

Introduction: The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery.

Indications & Contraindications:

Step 1 Preoperative Planning: Review the patient's general condition and imaging studies and plan the sequence of reduction and fixation.

Step 2 Preparation And Patient Positioning: Position the patient supine on the fracture table, induce anesthesia, prepare the surgical field, administer intravenous antibiotics, and apply traction.

Step 3 Ilioinguinal Approach: (Video 2).

Step 4 Fracture Reduction And Fixation: (Video 7).

Step 5 Wound Closure And Postoperative Aftercare: (Video 8).

Results: The ilioinguinal approach remains 1 of the standard approaches for the management of acetabular fractures.

Pitfalls & Challenges:
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http://dx.doi.org/10.2106/JBJS.ST.16.00101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143306PMC
June 2018

The Kocher-Langenbeck Approach: State of the Art.

JBJS Essent Surg Tech 2018 Jun 13;8(2):e18. Epub 2018 Jun 13.

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom.

Introduction: The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach.

Indications & Contraindications:

Step 1 Preoperative Planning: Review the patient's general condition and imaging studies, plan the sequence of reduction and fixation, and make sure that all of the necessary equipment is available.

Step 2 Preparation And Patient Positioning: Induce anesthesia, administer intravenous antibiotics as per local hospital protocol, apply antiembolism stockings, and insert a Foley catheter to the bladder.

Step 3 Kocher-langenbeck Approach: Make an incision that is 15 to 20 cm long and has 2 parts (proximal and distal), which are centered over the greater trochanter.

Step 4 Fracture Reduction And Fixation: The reconstruction of posteriorly based fractures depends on the specific fracture type, and the goal is to provide stable column fixation and anatomical reconstruction of the acetabular articular surface, with column fixation performed before the reconstruction of the posterior wall.

Step 5 Wound Closure And Postoperative Care: Meticulous hemostasis, application of drains, and watertight closure are the final steps of the operation.

Results: The Kocher-Langenbeck approach is the workhorse for the surgical management of acetabular fractures and provides sufficient access to the majority of posterior based acetabular fractures.

Pitfalls & Challenges:
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http://dx.doi.org/10.2106/JBJS.ST.16.00102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143312PMC
June 2018

Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review.

Surgeon 2019 Oct 27;17(5):257-269. Epub 2018 Aug 27.

Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, United Kingdom; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom.

Background: and purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting.

Methods: We searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result.

Results: Seventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94-99%). Deep infection rate was 6% (95% CI: 3-9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3-9.3%). Delayed union rate 3% (95% CI: 1-5.6%) while, malunion rate was 8.4% (95% CI: 5.7-11.6%). The need for bone grafting ranged from 0 to 9%.

Conclusions: IMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.
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http://dx.doi.org/10.1016/j.surge.2018.08.003DOI Listing
October 2019

Fracture Healing Adjuncts-The World's Perspective on What Works.

J Orthop Trauma 2018 Mar;32 Suppl 1:S43-S47

Orthopedic Surgery, BayCare Medical Group, St. Joseph's Hospital-North, Lutz, FL.

Treatment of bone defects remains a challenging clinical problem. Despite our better understanding of bone repair mechanisms and advances made in microsurgical techniques and regenerative medicine, the reintervention rates and morbidity remain high. Surgical techniques such as allograft implantation, free vascularized fibular graft, distraction osteogenesis, loaded titanium cages, and the induced membrane technique continue to evolve, but the outcome can be affected by a number of parameters including the age of the patient, comorbidities, systemic disorders, the location of the defect, and the surgeon's preference and experience. In the herein article, a brief summary of the most currently used techniques for the management of bone defects is presented.
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http://dx.doi.org/10.1097/BOT.0000000000001127DOI Listing
March 2018

Pipkin Type-III fractures of the femoral head: Fix it or replace it?

Injury 2017 Nov;48(11):2375-2378

Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2017.10.002DOI Listing
November 2017

Biological Facet of Segmental Bone Loss Reconstruction.

J Orthop Trauma 2017 Oct;31 Suppl 5:S27-S31

*Academic Department of Trauma and Orthopaedic Surgery, University of Leeds, Leeds, United Kingdom; and †NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom.

The management of long bone defects continues to be associated with significant challenges for optimum and timely bone repair. When bone grafting is needed, essential parameters to be addressed include adequate volume, optimum density, and structural capacity as well as potent biological properties. Although the autologous iliac crest bone graft remains the gold standard, its reduced availability and donor site morbidity have made the clinicians to seek for other alternative options. Reamer irrigator aspirator graft with materials used as graft expanders along with inductive molecules and cellular augmentation constitute the current trend for optimum bone regeneration. This article presents the contemporary thinking of the biological facet of segmental bone loss reconstruction.
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http://dx.doi.org/10.1097/BOT.0000000000000977DOI Listing
October 2017

Optimization of technique for insertion of implants at the supra-acetabular corridor in pelvis and acetabular surgery.

Eur J Orthop Surg Traumatol 2018 Jan 28;28(1):29-35. Epub 2017 Jun 28.

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK.

The technique for application of implants at the sciatic buttress has been well described in the pelvic and acetabular fracture reconstruction literature. We described a new use of the inlet-obturator oblique view for the identification of the anterior inferior iliac spine, which is the entry point of implants, and we provide a detailed fluoroscopic and radiographic description of this view. A small series of 15 patients who underwent an application of an anterior inferior pelvic external (supra-acetabular) fixator via this technique is presented. We consider the use of the obturator oblique for the identification of the entry point unnecessary, and we advocate for the use of only the inlet-obturator oblique and iliac oblique views when implants are applied to the sciatic buttress.
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http://dx.doi.org/10.1007/s00590-017-2007-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5754460PMC
January 2018

The floating knee: a review on ipsilateral femoral and tibial fractures.

EFORT Open Rev 2016 Nov 13;1(11):375-382. Epub 2017 Mar 13.

Leeds General Infirmary, Leeds, UK.

In 1975, Blake and McBryde established the concept of 'floating knee' to describe ipsilateral fractures of the femur and tibia. This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions.After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation.Definitive internal fixation of both bones yields the best results in almost all series.Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular.Plates are the 'standard of care' in cases with articular fractures.A combination of implants are required by 40% of floating knees.Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042.
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http://dx.doi.org/10.1302/2058-5241.1.000042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367526PMC
November 2016

The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety, efficacy and clinical outcomes.

Injury 2017 Jun 24;48(6):1139-1146. Epub 2017 Mar 24.

Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA West Yorkshire, Leeds, UK. Electronic address:

Objectives: To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients.

Design: A single center retrospective chart review.

Setting: A level-1 trauma center.

Patients And Methods: We reviewed all the polytrauma patients (ISS>16) between 2007 and 2012 that had a PEF applied more than 30days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al.

Results: 59 patients with mean age of 38.4 (16 - 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30-104) days. The average follow-up was 403days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p=0.034) but no correlation to the functional outcome was evident.

Conclusion: PEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome.

Level Of Evidence: Therapeutic Level III.
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http://dx.doi.org/10.1016/j.injury.2017.03.033DOI Listing
June 2017

Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes.

Injury 2016 Dec;47 Suppl 6:S53-S61

Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, UK.

This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18-80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean length of the bone defect area was 4.2 cm (range 2-12 cm). All patients were managed with the two stage technique receiving composited grafting (Autologous bone graft (Iliac crest/RIA), graft expander as required, osteoprogenitor cells, growth factor) during the second stage. There was one failure (humeral infected non-union) in a previous background of bone radiation that necessitated reconstruction with a free fibula vascularized graft. One patient had a fall and sustained implant failure (humeral defect) 3 months after reconstruction and following re-plating progressed to union 4 months later. Two patients required re-grafting due to failure of healing in one of the defect sides. One patient presented with a discharging sinus 2 years after successful healing of a tibial defect that was treated successfully with soft tissue and bone debridement without necessitating further interventions. One patient despite union (distal 1/3 tibia) underwent a below knee amputation due to a dysfunctional ankle/foot (previous foot compartment syndrome-regional pain syndrome). Of those patients, with lower limb injuries, 4 patients had leg length discrepancies of 1 cm, 1.5 cm, 2 cm (two patients) respectively. The mean time to radiological union was 5.4 months (range 2-12 months). The average time of healing of 1 cm bone defect was 1.24 months. Patients with upper limb reconstruction recovered earlier than those with lower limb injuries. At the latest follow up all patients were able to mobilize full weight bearing without residual pain. The induced membrane technique appears to be an alternative good option for the management of large bone defects secondary to acute bone loss or infected non-unions. The incidence of re-interventions was low in this challenging cohort of patients. The technique should be considered in the surgeon's armamentarium as it is effective and is associated with a low rate of complications.
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http://dx.doi.org/10.1016/S0020-1383(16)30840-3DOI Listing
December 2016

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing.

Injury 2016 Dec;47 Suppl 7:S49-S52

Academic department of Trauma and Orthopaedics, Leeds Teaching Hospitals, School of Medicine, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK. Electronic address:

Introduction: This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures.

Patients And Methods: We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions.

Results: 181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141).

Conclusion: Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.
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http://dx.doi.org/10.1016/S0020-1383(16)30855-5DOI Listing
December 2016

Use of Inlet-Obturator Oblique View (Leeds View) for Placement of Posterior Wall Screws in Acetabular Fracture Surgery.

J Orthop Trauma 2017 Apr;31(4):e133-e136

*Academic Department of Trauma and Orthopaedic Surgery, University of Leeds, Leeds, United Kingdom; and †NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, West Yorkshire, Leeds, United Kingdom.

Posterior wall (PW) fractures are the most common fractures requiring surgical fixation in acetabular surgery. Extra-articular screw placement must be confirmed intraoperatively. Herein we describe the use of the inlet and obturator oblique view (the Leeds view) for screw placement in elementary PW and in associated both-column with PW fractures. We highlight our steps to ensure accurate placement in a small series of patients.
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http://dx.doi.org/10.1097/BOT.0000000000000724DOI Listing
April 2017

Anteromedial dome impaction in acetabular fractures: Issues and controversies.

Injury 2016 Aug;47(8):1605-7

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2016.07.020DOI Listing
August 2016

Letter to the Editor: "A combined posterior reversed L-shaped and anterolateral approach for two column tibial plateau fractures in Caucasians: A technical note".

Injury 2016 Apr 12;47(4):983. Epub 2016 Feb 12.

Academic Department of Trauma & Orthopaedic Surgery, Leeds General Infirmary, Leeds LS1 3EX, UK; Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.

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http://dx.doi.org/10.1016/j.injury.2016.02.002DOI Listing
April 2016

What is new in distal femur periprosthetic fracture fixation?

Injury 2015 Dec;46(12):2293-6

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK. Electronic address:

Distal femoral periprosthetic fractures are on the rise. Increased mortality of these injuries is also evident from recent data. Their incidence and risk factors have been extensively reported in the past but new data are being available that merit attention. The increased incidence and the even higher projected incidence should direct the focus of future strategies to the education of surgeons, relevant capacity of hospital and reconfiguration of health care resources. New and potentially modifiable risk factors should be taken into consideration to the informed consent process and new studies should be developed to clarify the causative relationship of the new risk factors such as the peptic ulcer disease and the COPD. The main internal fixation techniques remain the lateral locking plating and the retrograde intramedullary nailing. New techniques in plating are the supplementary medial plate in selected cases and the far cortical locking. Nailing is considered a valid option especially in fractures located well above the anterior flange of the femoral component of the arthroplasty. Results and outcomes from good quality studies are still sparse regarding the comparison between plating and nailing. Interprosthetic fractures constitute an entity that is lately gaining considerable attention. The best method of management of these injuries is still evolving with considerable amount of work being done in the clinical and biomechanical level.
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http://dx.doi.org/10.1016/j.injury.2015.11.009DOI Listing
December 2015

Inflammation, Bone Healing, and Anti-Inflammatory Drugs: An Update.

J Orthop Trauma 2015 Dec;29 Suppl 12:S6-9

*Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds, United Kingdom; †Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, United Kingdom; ‡University of Colorado/Denver Health Medical Center, Denver, CO; §London Health Sciences Center, Victoria Hospital, London, ON, Canada; and ‖UCSF Department of Orthopaedic Surgery, UC Berkeley Department of Bioengineering & Material Science, Berkeley, CA.

Fracture healing is a unique multifaceted process requiring the presence of cells, molecular mediators, and angiogenic factors. The state of inflammation dominates the initial phase, but the ideal magnitude and duration of the process for an optimal outcome remains obscure. Biological response modifiers, such as platelet-rich plasma (PRP) preparations, have been used to reconstitute the desirable early inflammatory state, but the results obtained remain inconclusive. Ongoing research to characterize and quantify the inflammatory response after bone fracture is essential in order to better understand the molecular insights of this localized reaction and to expand our armamentarium in the management of patients with an impaired fracture healing response. Non-steroidal anti-inflammatory drugs frequently administered for analgesia after trauma procedures continue to be a cause of concern for a successful bone repair response.
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http://dx.doi.org/10.1097/BOT.0000000000000465DOI Listing
December 2015

What is new in acetabular fracture fixation?

Injury 2015 Nov;46(11):2089-92

Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds General Infirmary, Clarendon Wing, Floor A, Great George Street, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK. Electronic address:

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http://dx.doi.org/10.1016/j.injury.2015.10.012DOI Listing
November 2015
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