Can intermittent pneumatic compression (IPC) reduce time to surgery for malleolar fractures?

BACKGROUND

Surgery of malleolar fractures are often delayed due to oedema of the ankle. The use of intermittent pneumatic compression (IPC) is thought to reduce oedema of the fracture site and thereby time to surgery in patients with malleolar fractures.

PURPOSE

To investigate the influence of IPC on the time from admission to surgery in adult patients with internal fixated primary malleolar fractures.

METHODS

February 1st 2013 IPC was introduced as a standard treatment for all patients admitted with a malleolar fracture. Data was retrieved from the hospital database 2 years prior and after the introduction date. The patients were found using ICD-10 diagnoses codes (DS825-8) in combination with NOMESCO procedure codes (KNHJ40-3, KNHJ60-3, KNHJ70-3, KNHJ80-3). One reviewer examined all the journals and classified the x-ray images by the AO classification. The primary outcome measure was time from diagnosis to surgery.

RESULTS

74 patients in the IPC cohort and 113 in the non-IPC cohort were included in the study. Time from admission to surgery was 21.9 (10.8-45.0) hours in the control group and 22.1 (8.9-41.2) hours in the IPC group. The difference is not statistically significant (p=0.420). A subgroup analysis divided the patients operated before and after 24h from admission. The median (IQR) time to surgery for patients operated before 24h was 10.9 (6.4-16.9) hours for the control group and 9.9 (5.8-20.1) hours in the IPC group (p=0.989). The median (IQR) time to surgery for patients operated after 24h was 21.5 (4.1-57.0) hours for the control group and 18.4 (7.4-32.3) hours in the IPC group (p=0.353).

INTERPRETATION

There was no benefit from IPC on time to surgery in patients with acute primary malleolar fracture in a cohort with a mean surgical delay less than 24h.

Complications and functional outcome after fixation of distal tibia fractures with locking plate - A multicentre study

INTRODUCTION

The aim of this study was to evaluate the proportion of complications and the functional outcome following ORIF with low-profile locking plates in patients with distal tibia fractures.

METHOD

Retrospective data was retrieved using county databases, operation books, health record and X-ray images for 6 hospitals (1 level 1, 5 level 2) in the Region of Southern Denmark. Between January 2007 and April 2011 70 consecutive patients with 71 distal tibia fractures were treated with low-profile locking plate were included. The proportion of post-operative complications, classified as minor and major complications, was retrieved from electronic health records and patient interviews. Long-term functional outcome assessed by EuroQol EQ-5D-5L questionnaire, AOFAS Ankle-Hindfoot scale, and return to pre-injury job function through patient interview and examination.

RESULTS

There were 32 43A, 5 43B and 34 43C-fractures, 12 open and 10 high-energy fractures. Forty-nine cases (69%) experienced complications during the follow-up time, of which 34 were minor complications and 15 were major complications. Median EQ-5D-5L index value was 0.76, median EQ VAS-score was 80, and median AOFAS score was 73. Thirty-three percent of working patients had not returned to work as a result of the fracture.

CONCLUSIONS

Our study suggest that treatment of distal tibia fractures with low-profile locking plates might have a higher proportion of complications and worse functional outcome than previously reported.

LEVEL OF EVIDENCE

Therapeutic level IV Case Serie.

Low bone mineral density is not related to failure in femoral neck fracture patients treated with internal fixation

BACKGROUND AND PURPOSE

Internal fixation (IF) in femoral neck fractures has high reoperation rates and some predictors of failure are known, such as age, quality of reduction, and implant positioning. Finding new predictors of failure is an ongoing process, and in this study we evaluated the importance of low bone mineral density (BMD).

PATIENTS AND METHODS

140 consecutive patients (105 females, median age 80) treated with IF had a dual-energy X-ray absorptiometry (DXA) scan of the hip performed median 80 days after treatment. The patients' radiographs were evaluated for fracture displacement, implant positioning, and quality of reduction. From a questionnaire completed during admission, 2 variables for comorbidity and walking disability were chosen. Primary outcome was low hip BMD (amount of mineral matter per square centimeter of hip bone) compared to hip failure (resection, arthroplasty, or new hip fracture). A stratified Cox regression model on fracture displacement was applied and adjusted for age, sex, quality of reduction, implant positioning, comorbidity, and walking disability.

RESULTS

49 patients had a T-score below -2.5 (standard deviation from the young normal reference mean) and 70 patients had a failure. The failure rate after 2 years was 22% (95% CI: 12-39) for the undisplaced fractures and 66% (CI: 56-76) for the displaced fractures. Cox regression showed no association between low hip BMD and failure. For the covariates, only implant positioning showed an association with failure.

INTERPRETATION

We found no statistically significant association between low hip BMD and fixation failure in femoral neck fracture patients treated with IF.

Lower reoperation rate for cemented hemiarthroplasty than for uncemented hemiarthroplasty and internal fixation following femoral neck fracture: 12- to 19-year follow-up of patients aged 75 years or more

BACKGROUND AND PURPOSE

Elderly patients with displaced femoral neck fractures are commonly treated with a hemiarthroplasty (HA), but little is known about the long-term failure of this treatment. We compared reoperation rates for patients aged at least 75 years with displaced femoral neck fractures treated with either internal fixation (IF), cemented HA, or uncemented HA (with or without hydroxyapatite coating), after 12-19 years of follow-up.

METHODS

4 hospitals with clearly defined guidelines for the treatment of 75+ year-old patients with a displaced femoral neck fracture were included. Cohort 1 (1991-1993) with 180 patients had undergone IF; cohort 2 (1991-1995) with 203 patients had received an uncemented bipolar Ultima HA stem (Austin-Moore); cohort 3 (1991-1995) with 209 patients had received a cemented Charnley-Hastings HA; and cohort 4 (1991-1998) with 158 patients had received an uncemented hydroxyapatite-coated Furlong HA. Data were retrieved from patient files, from the region-based patient administrative system, and from the National Registry of Patients at the end of 2010. We performed survival analysis with adjustment for comorbidity, age, and sex.

RESULTS

Cemented HA had a reoperation rate (RR) of 5% and was used as reference in the Cox regression analysis, which showed significantly higher hazard ratios (HRs) for IF (HR = 3.8, 95% CI: 1.9-7.5; RR = 18%), uncemented HA (HR = 2.2, CI: 1.1-4.5; RR = 11%) and uncemented hydroxyapatite-coated HA (HR = 3.6, CI: 1.8-7.4; RR = 16%).

INTERPRETATION

Cemented HA has a superior long-term hip survival rate compared to IF and uncemented HA (with and without hydroxyapatite coating) in patients aged 75 years or more with displaced femoral neck fractures.