Comparison of Outcomes of Long Versus Short Cephalomedullary Nails for the Fixation of Intertrochanteric Femur Fractures: A Systematic Review and Meta-analysis of 14,547 Patients

Purpose

Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF.

Methodology

PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1.

Results

Fourteen thousand five hundred forty-seven patients were included in this review.

Primary Outcomes

Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30 days and within 1 year.

Secondary Outcomes

Statistically significant shorter duration of surgery (MD-17.83 (95% CI - 22.03, - 13.63, p < 0.05), less intra-operative blood loss (MD - 62.65, 95% CI - 97.13 to - 28.17, p =  < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen.

Conclusion

With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter version of nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00915-5.

Wound alpha defensin levels are significantly higher in patients with fracture related infection: A pilot, prospective cohort study

BACKGROUND

In absence of frank purulence, wound cultures represent 'gold-standard' for diagnosis of fracture related infection (FRI). However, these are time-intensive, and may be falsely negative, necessitating the need for accurate and rapid biomarker-based diagnosis. We conducted this study to determine the accuracy of 3 wound-based biomarkers for the diagnosis of FRI.

METHODS

This was a prospective cohort study on adult patients who underwent an operative procedure for an upper or lower limb fracture. Wound fluid levels of alpha-defensin (AD), neutrophil elastase (NE) and IL-6 were evaluated on post-operative day 2, and patients were followed up for one month. Patients were categorized as cases (FRI) or controls (no FRI), on the basis of the consensus definition of FRI. Univariate analysis, along with receiver operating characteristic (ROC) analysis was performed.

RESULTS

48 patients were included. AD levels showed a 2.6-fold elevation in cases (n = 26, Median = 23.74 µg/ml) as compared to controls (n = 22, Median = 8.78 µg/ml). The area under the curve for this variable was 0.71 (95% Confidence Intervals = 0.56 - 0.86). The levels of NE and IL-6 were not significantly different between cases and controls.

CONCLUSION

Wound AD levels are significantly elevated in patients with FRI. However, these results need to be validated in a larger cohort of patients before it can be used as a biomarker of FRI.

Impact of the COVID-19 Lockdown and Confinement Measures on the Musculoskeletal Health of the Urban Geriatric Population

Background

Owing to the coronavirus disease 2019 (COVID-19) pandemic, a nationwide lockdown was imposed in India, with strict confinement measures imposed on the elderly. Because mobility and regular physical activity are considered to be the key determinants of musculoskeletal health, this study aimed to investigate the effect of lockdown and confinement measures on the musculoskeletal health and activities of daily living of the urban geriatric population.

Methodology

A cross-sectional survey was conducted among the elderly aged ≥60 years. The survey instrument consisted of a questionnaire, a modified Nordic Musculoskeletal Questionnaire (mNMQ), and the Barthel activities of daily living (ADL) index. The net mNMQ score and Barthel ADL index were compared before and during the lockdown. Univariate and multivariate analyses were performed to determine which factors could result in the worsening of the net mNMQ score. In addition, floor and ceiling effects of the net mNMQ score were determined.

Results

In this study, a total of 105 out of 150 eligible participants were enrolled. A significant decline in physical activity status was noted during the lockdown. Overall, 54.3% of the respondents reported that their medical services were impacted during the lockdown. The net mNMQ score showed a significant worsening during the lockdown (P < 0.0001). A statistically significant increase in the modified NMQ score was noted for the lower limb (P < 0.0001) and spine (P = 0.002), but not for the upper limb (P = 0.052). Elderly whose medical services were impacted during lockdown had significantly worse net mNMQ scores than those whose services were not impacted (odds ratio = 6.16; 95% confidence interval = 2.51-15.08; P = 0.0001). Age, gender, ambulatory status, increase in body weight, and indulgence in exercise before and during lockdown had no effect on the change in the net mNMQ score. A significant ceiling effect was noted in the mNMQ score; however, no floor effect was noted.

Conclusions

Lockdown and confinement measures resulted in a significant decline in physical activity as well as the overall musculoskeletal health of the urban geriatric population in the present study. Hence, policymakers should ensure uninterrupted medical care to the elderly during extended periods of confinement and develop optimal home-based physical activity programs to counter the problems associated with sedentarism.

The Increased Burden of SARS-CoV-2 Infection in Orthopaedic Trauma Patients: Comparison of Demographics of Both the Waves of the Pandemic-An Indian Tertiary Center Experience

BACKGROUND

The second wave of SARS-CoV-2 pandemic has posed new challenges in the management of Orthopedic trauma patients due to the overburdened healthcare facilities and we aim to present the differences in demographics between the first wave and the initial part of the second wave.

METHODOLOGY

This study was a retrospective cross-sectional study of our trauma registry from June 19, 2020 to October 13, 2020 (1st study period) and from April 1, 2021 to the first week of May 2021 (2nd study period). We looked into differences in the following three parameters: (1) infection rate among Orthopaedic patients in the first and second study period of SARS-CoV-2 pandemic, (2) infection rate among the Health Care Workers and (3) hospital-acquired SARS-CoV-2 infections in admitted Orthopaedic trauma patients.

RESULTS

35 out of 852 patients (4.1%) were positive for SARS-CoV-2 infection in 1st study period as compared to 48 out of 262 patients (18.3%) in the 2nd study period (p < 0.001). 23 HCW's involved in management of Orthopaedic trauma patients tested positive in the second study period compared to none in the first study period. 17 patients had Hospital-acquired SARS-CoV-2 infection in 2nd study period compared to 7 in 1st study period. There were more asymptomatic patients for SARS-CoV-2 infection in the 2nd study period.

CONCLUSION

Significant increase in the number of SARS-CoV-2 infection in Orthopaedic trauma patients, and the increased number of HCW's affected with SARS-CoV-2 infection have been the challenges in 2nd study period.

Fibular Strut Arthrodesis for Salvage of Campanacci Grade III Giant Cell Tumor of the Hallucal Proximal Phalanx: A Case Report

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

Does the use of intraoperative CT scan improve outcomes in Orthopaedic surgery? A systematic review and meta-analysis of 871 cases

BACKGROUND

Intraoperative imaging is frequently made use of in Orthopaedic surgery. Historically, conventional 2-dimensional fluoroscopy has been extensively used for this purpose. However, 2D imaging falls short when it is required to visualise complex anatomical regions such as pelvis, spine, foot and ankle etc. Intraoperative 3D imaging was introduced to counter these limitations, and is increasingly being employed in various sub-specialities of Orthopaedic Surgery.

OBJECTIVES

This review aims to outline the clinical and radiological outcomes of surgeries done under the guidance of intraoperative 3D imaging and compare them to those done under conventional 2D fluoroscopy.

METHODS

Three electronic databases (PubMed, Embase and Scopus) were searched for relevant studies that directly compared intraoperative 3D imaging with conventional fluoroscopy. Case series on intraoperative 3D imaging were also included for qualitative synthesis. The outcomes evaluated included accuracy of implant placement, mean surgical duration and rate of revision surgery due to faulty implants.

RESULTS

A total of 31 studies from sub-specialities of spine surgery, pelvi-acetabular surgery, foot and ankle surgery and trauma surgery, having data on a total of 658 patients were analysed. The study groups which had access to intraoperative 3D imaging was found to have significantly increased accuracy of implant positioning (Odds Ratio 0.35 [0.20, 0.62], p = 0.0002) without statistically significant difference in mean surgical time (p = 0.57). Analysis of the studies that included clinical follow up showed that the use of intraoperative 3D imaging led to a significant decrease in the need for revision surgeries due to faulty implant placement.

CONCLUSION

There is sufficient evidence that the application of intraoperative 3D imaging leads to precise implant positioning and improves the radiological outcome. Further research in the form of prospective studies with long term follow up is required to determine whether this superior radiological outcome translates to better clinical results in the long run.

Patterns and Trends of Foot and Ankle Injuries in Olympic Athletes: A Systematic Review and Meta-analysis

INTRODUCTION

Foot and ankle injuries in elite athletes can result in decreased performance, absence from sport and prolonged morbidity. There is paucity of data on foot and ankle injuries in Olympics athletes.

METHODS

We conducted a systematic review of the PubMed and EMBASE databases. Studies in English language that reported the incidence and/or prevalence of foot and ankle injuries in during Olympics games (summer, winter and youth Olympics) were included. Studies in languages other than English, those that looked at injuries other than foot and ankle injuries, studies looking at injuries in non-Olympics events and those looking at Olympics trials were excluded. We determined the injury rates and burden of foot and ankle injuries. We also looked at the patterns and trends of foot and ankle injuries.

RESULTS

A total of 399 foot and ankle injuries from 25 publications were included in the review. Foot and ankle injury rates ranged from 0.09 to 0.42 injuries per athlete-years for summer Olympics and 0.02-0.35 injuries per athlete-years for winter Olympics. Quantitative analysis revealed that foot and ankle injuries contributed to 16.9% of all injuries (95% CI 8.1-31.9%) for summer Olympics and 5.1% of all injuries (95% CI 1.9-12.6%) for winter Olympics; however, a high statistical heterogeneity was noted. The three most common injuries were tendon injuries, ligament injuries and stress fractures. The rates and burden of foot and ankle injuries showed a declining trend.

CONCLUSIONS

Foot and ankle injuries are an important cause of morbidity amongst Olympics athletes. The declining trend amongst these injuries notwithstanding, there is a need for a global electronic database for reporting of injuries in Olympics athletes.

“Push back” technique: A simple method to remove broken drill bit from the proximal femur

Broken drill bits can be difficult to remove from the proximal femur and may necessitate additional surgical exploration or special instrumentation. We present a simple technique to remove a broken drill bit that does not require any special instrumentation and can be accomplished through the existing incision. This technique is useful for those cases where the length of the broken drill bit is greater than the diameter of the bone.

A new technique for closed reduction of traumatic posterior dislocations of the hip: the 'PGI technique'

Many techniques have been described for closed reduction of posterior hip dislocations, but most require forceful and sustained traction, assistants to stabilise the pelvis and awkward positioning of the surgeon and/or the patient. We describe a new technique of closed reduction that does not need traction-countertraction or special positioning and can be safely and effectively performed by one surgeon.Fifteen patients, mean age 36.4 years, were subjected to reduction. There were five type I, four type II and six type III dislocations; ipsilateral injuries included one knee dislocation with patellar fracture, and two cases of tibia fracture. Closed reduction was achieved in 14 (93.3%) hips, with single attempt successful in 13 cases, while one needed two attempts. One hip could not be reduced due to incarceration of a posterior wall fragment and was managed by open reduction and internal fixation.Our new technique has proved to be a reliable, safe and effective alternative for closed reduction of posterior hip dislocations. It can be carried out by one surgeon, does not need traction and can be especially beneficial in polytrauma patients and also in those patients who have pelvic fractures and ipsilateral lower limb injuries.

Primary non Hodgkin's lymphoma of talus in a child-a rare presentation

We report a rare case of primary non-Hodgkin's lymphoma of bone which presented with an osteolytic lesion of the head of the right talus which to the best of our knowledge is the first case to be reported in the paediatric age group. Early and accurate identification is necessary as it has a good prognosis.

The posterior to anterior controlled technique of percutaneous Achilles tenotomy in the correction of idiopathic clubfoot: a technical report

Percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction. Although originally described by Ponseti as an office procedure that was performed under local anaesthesia, serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation have been reported. We describe a new tenotomy technique, the posterior to anterior controlled technique, that may decrease the possibility of neurovascular damage, does not require exposure of the Achilles tendon and can be performed as an office procedure under local anaesthesia.

Single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit

PURPOSE

To evaluate the outcome of single screwrod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit.

METHODS

16 men and 5 women aged 22 to 55 (mean, 34) years underwent single screw-rod anterior instrumentation for thoracolumbar burst fractures with incomplete neurological deficit. The vertebrae involved were T10 (n=2), T11 (n=2), T12 (n=7), L1 (n=8), and L2 (n=2). No patient had disruption of the posterior ligament complex. Postoperatively, a thoracolumbar sacral orthosis was used until solid fusion. Outcome measures included neurological recovery, degree of kyphosis, complications, and pain and functional status of the patients.

RESULTS

The mean follow-up duration was 36 (range, 13-50) months. All patients recovered neurologically by at least one grade. Of the 21 patients, 6 improved from grade B to grade C (n=4) or grade D (n=2), 13 from grade C to grade D, and 2 from grade D to grade E. The mean degree of kyphosis improved from 23º ± 5º to 7º ± 3º. Seven patients had complications including ipsilateral basal atelectasis (n=3), urinary tract infection (n=1), haematuria (n=1), postoperative ileus (n=1), and superficial wound infection (n=1). None had iatrogenic visceral or vascular injury, pseudoarthrosis or hardware-related complications. Only one patient had severe back pain persistently.

CONCLUSION

Single screw-rod anterior instrumentation supplemented with an orthosis can be an alternative for double screw-rod anterior instrumentation for thoracolumbar burst fractures in patients with smaller vertebral bodies.

Giant cell tumor of talus: a case report

Giant cell tumor of talus is a rare entity. In contrast to GCT of long bones, most cases occur in a younger age group and tend to be multicentric. The authors report a case of GCT in a 19 year old boy which had led to extensive destruction of the talus. In view of the extensive involvement, total talectomy along with tibio – calcaneal arthrodesis was performed. At 6 months of followup, the patient had a painless and well arthrodesed ankle. There was no evidence of recurrence at 18 months of followup.