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INTRODUCTION: Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. METHODS: A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included. RESULTS: Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I2=42%, p=0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I2=95%, p=0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19, p<0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I2=94%, p=0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I2=0%, p=0.28). CONCLUSIONS: Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.

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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 1st May 2007 and 31st 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.

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AIM: Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals. PATIENTS AND METHODS: All hospitals in England with an Emergency Department were asked about the protocols which they use for assessing the cervical spine. All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded (response rate 91.5%). RESULTS: Written guidelines were used in 138 hospitals (85%). CT scanning was the first-line investigation in 122 (75%). A normal CT scan was sufficient to clear the cervical spine in 73 (45%). However, 40 (25%) would continue precautions until the patient regained full consciousness. MRI was performed in all confused or comatose patients with a possible cervical spinal injury in 15 (9%). There were variations in the grade and speciality of the clinician who had responsibility for deciding when to discontinue precautions. A total of 31 (19%) reported at least one missed cervical spinal injury following discontinuation of spinal precautions within the last five years. Only 93 (57%) had a formal mechanism for reviewing missed injuries. TAKE HOME MESSAGE: There are significant variations in protocols and practices for the clearance of the cervical spine in multiply injured patients in acute hospitals in England. The establishment of trauma networks should be taken as an opportunity to further standardise trauma care. Cite this article: Bone Joint J 2016;98-B:825-8.

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INTRODUCTION: As part of a wider drive to reduce Clostridium difficile rates (CDAD), our trust switched from cefuroxime to gentamicin and flucloxacillin prophylaxis for joint replacement surgery. Anecdotal evidence suggested that we were seeing an increased incidence of acute kidney injury (AKI) following elective total hip replacement (THR) and total knee replacement (TKR) since this change. The aim of this study was to compare rates of AKI and post-operative infection between the two antibiotic regimes. METHODS: We carried out a single-centre retrospective cohort study comparing 200 patients (100 THR and 100 TKR) who received cefuroxime with another age and procedure-matched group who received gentamicin and flucloxacillin (gentamicin 3 mg/kg and 5 g flucloxacillin in total). We compared rates of AKI, haemofiltration, CDAD, surgical site infection (SSI) and return to theatre for infection (RTT). RESULTS: Gentamicin was associated with a significant increase in AKI (1 vs. 8%, p < 0.01). More patients needed haemofiltration (0 vs. 1.5%) although this was not significant. Interestingly, when the groups were subdivided into THR and TKR, significantly more TKR patients receiving gentamicin developed AKI (0 vs. 11, p < 0.01). This difference was not significant following THR (2 vs. 5, p = 0.44). This may be related to tourniquet use in TKR. SSI and RTT were comparable. No patient developed CDAD. CONCLUSIONS: Gentamicin with flucloxacillin is comparable with cefuroxime in rates of SSI and RTT but is associated with a significant increase in AKI. AKI is associated with additional morbidity and mortality. This association should be considered when choosing a suitable prophylactic regime.

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La presente publicacion, cubre en forma practica los aspectos mas importantes de los sistemas de vigilancia de la calidad del aire y de la lucha contra la contaminacion. Contiene resenas de todo el problema de la reduccion y lucha contra la contaminacion atmosferica, pautas y criterios sobre ciertos contaminantes del aire urbano, sistemas automaticos de vigilancia de la calidad del aire. El proposito es orientar acerca de los metodos y medios para combatir la contaminacion atmosferica mediante la aplicacion de tecnicas y disposiciones legales.

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