Comparison of plate and intramedullary nail fixation of extra-articular tibial fractures: A retrospective study exploring hidden blood loss

Impact of surgical approaches on stem position and hidden blood loss in total hip arthroplasty: minimally invasive vs. posterolateral

BACKGROUND

The surgical approach impacts the outcomes and recovery after total hip arthroplasty (THA), and approaches may affect the stem positioning. Contrary to the general concept of minimally invasive surgery, the direct anterior approach (DAA) results in more intraoperative blood loss. Therefore, the objective of this study was to compare stem positioning and hidden blood loss (HBL) among three surgical approaches: the minimally invasive DAA, Orthopadische Chirurgie Munchen (OCM), and the traditional posterolateral approach (PLA).

METHODS

A total of 201 patients undergoing their first non-cemented THA using the DAA, OCM, and PLA were included in the study. General demographic data, stem alignment, and blood loss were evaluated. Specific comparison measurements included femoral neck anteversion, femoral stem anteversion, alignment of the stem in coronal and sagittal planes, proximal and distal medullary ratios, and femoral offset. Blood loss was measured by calculating Intraoperative Blood Loss ( IBL), visible blood loss (VBL), and hidden blood loss (HBL).

RESULTS

There were no significant differences in age, gender, body mass index, preoperative diagnosis, or femoral Dorr classification among the three groups. The mean surgical time was longer for the DAA and OCM compared to the PLA (P < 0.01). IBL was highest in the DAA group and lowest in the PLA (P < 0.05). Postoperative stem anteversion were significantly different among the groups, with the DAA showing the greatest anteversion difference (P < 0.05). There was no difference in the stem coronal alignment. However, there were more valgus and varus implants in the sagittal plane for the DAA and OCM. The femoral offset reduction was less optimal in the DAA and OCM groups (P < 0.05). The proximal and distal medullary ratios were lower in the DAA and OCM (P < 0.05). HBL was significantly lower in the DAA and OCM compared to the PLA (P < 0.05).

CONCLUSION

Minimally invasive approaches such as DAA and OCM offer advantages in muscle and soft tissue preservation, leading to reduced HBL compared to the conventional PLA. However, these approaches present challenges in femoral stem positioning and longer surgical times.

Effect of matrix material property on the composite tibia fracture plate: a biomechanical study

For the purpose of fixing tibia fractures, composite bone plates are suggested. Metal plates cause stress shielding, lessen the compression force at the fracture site, and have an impact on the healing process because they are significantly more rigid than bone. To prevent excessive shear strain and consequent instability at the fracture site, it is imperative to reduce stiffness in the axial direction without lowering stiffness in the transverse direction. Only a carefully crafted fiber reinforced composite with anisotropic properties will suffice to accomplish this. The purpose of the current study is to examine the impact of axial and shear movements at the fracture site on the fixing of metal and composite bone plates. After modeling the tibia with a 1 mm fracture gap, titanium plates, carbon/epoxy, carbon/PEEK, and carbon/UHMWPE composite bone plates were used to fix it. There are 6 holes on each of the 103 mm long plates. To determine the stresses and axial movement in the fracture site, anatomical 3D Finite Element (FE) models of the tibia with composite bone plates are built. The simulations that were run for various composite plate layouts and types give suggestions for selecting the best composite bone plate. Although the matrix material causes some variations in behaviors, most of the plates perform as well as or even better than metal plates. Thus, the appropriate composite combinations are recommended for a given fracture structure.

Dynamic Compression Plating Versus Antegrade Intramedullary Nailing for the Treatment of OTA/AO 12-A Fractures: A Retrospective Cohort Study

BACKGROUND

Fractures of the humerus diaphysis are common and often result from motor vehicle accidents (MVAs). Treatment methods range from nonoperative approaches to various operative techniques, including antegrade intramedullary nailing (AIMN) and dynamic compression plate (DCP) fixation. This study aimed to compare the cost effectiveness and outcomes of plating and nailing for humerus diaphyseal fractures.

METHODS

 A retrospective cohort study involving 59 cases of humerus diaphyseal OTA/AO 12-A fractures was conducted at King Saud Medical City (KSMC), a level I trauma center located in the center region in Riyadh, Saudi Arabia. Patients treated with AIMN, anterolateral plating, or posterior plating were included. Data on demographics, clinical parameters, radiographic healing, and costs were collected and analyzed.

RESULTS

The average surgical duration was shorter in the AIMN group compared to the anterolateral and posterior plating groups but with no statistical significance (P > 0.05). The average length of stay (LOS) was shorter, and the change in hemoglobin levels was lower in the AIMN group when compared to other groups but without a statistically significant difference (P > 0.05). The average cost of AIMN was significantly higher than that of anterolateral and posterior plating groups (P < 0.0001).

CONCLUSION

 While both nailing and plating procedures are options for treating OTA/AO 12-A fractures, AIMN carries a higher overall procedural cost. The practice of drain placement in our study population is likely the cause of the increased LOS in the plating groups. Relative additional analgesic requirements were associated with AIMN. Surgeons should consider meticulous hemostasis to avoid drain placement, which can decrease LOS, thus possibly decreasing unnecessary treatment costs of humerus shaft fractures.

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

BACKGROUND

The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the 'gold standard' of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal.

OBJECTIVES

The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post-operatively.

METHODS

Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8-year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow-up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra-operative transfusion or transfusion during the first 48 h post-operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post-operatively.

RESULTS

Incidence of blood transfusion was 6.0% pre-operatively, compared to 62.7% post-operatively. A total of 230 patients (52.3%) required either intra-operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post-operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30-day (p = 0.033) and one-year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post-operative hours was a pre-operative Hb <100 g/L (OR 6.64); a nail/canal ratio <70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre-operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30-day mortality (OR 12.07).

CONCLUSION

Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48-h post-operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and mortality risk.

LEVEL OF EVIDENCE

III.

BIOMECHANICAL STUDY OF MINIMALLY INVASIVE TECHNIQUES IN SURGICAL TREATMENT OF THE TIBIA PROXIMAL EPIMETAPHYSIS FRACTURES

OBJECTIVE

The aim: Improving efficiency of the tibia proximal epimetaphysis fractures treatment by introducing minimally invasive techniques using the up-to-date metallic constructions.

PATIENTS AND METHODS

Materials and methods: The study is based on the results of examination and treatment of 119 patients, using arthroscopic technique. The results were evaluated regarding the P. Rasmussen scheme, post-traumatic arthrosis -Kellgren - Lawrence, life quality - «SF-36 Health Status Survey».

RESULTS

Results: The offered treatment method provided for the following: good outcomes in BI- 94.1%, satisfactory ones - 5.9%; respectively in BII - 91.7%, 8.3%; ВIII - 92.9%, 7.1%; СI- 87.5%,12.5%; СII - 91.7%, 8.3%; СIII -88.9%, 7.4%, unsatisfactory outcomes - 3.7.

CONCLUSION

Conclusions: The tibia proximal epimetaphysis fractures make up from 8.9% to 11% of all lower leg fractures and up to 87% of the knee joint fractures. Such fractures are accompanied with the knee joint soft tissue injuries in up to 56% of cases. The meniscus injury is diagnosed in 50-94% of the patients; collateral ligament injury: 20% - 83%; anterior cruciate ligament injury : 20% - 69%, femoral muscle ligament injury- up to 47%, joint capsule ruptures - up to 75%, fibular nerve injury - 3% of cases. The treatment fails in 24.2-50% of cases. Operative treatment of such injuries using arthroscopic method provides for mini-invasive intervention character, visualizing and splint reposition control; the opposite compression screw provides for strong fixation.

The hidden blood loss and its factors in patients undergoing minimally invasive knee arthroscopy

Background

With respect to knee arthroscopy, assessing the amount of hidden blood loss is of great importance to avoid potential complications such as fever, anemia, difficulty in wound healing and wound infection. The current study aims to investigate the hidden blood loss and its factors in patients who underwent minimally invasive knee arthroscopy.

Methods

Consecutive patients with knee joint injury, who underwent arthroscopic minimally invasive treatment, were enrolled from January 2019 to November 2020 and were retrospectively studied. Demographic information on these patients, such as medical history and biochemical parameters, was collected. The hidden blood loss was calculated. Multivariate linear regression analysis was used to confirm independent factors associated with hidden blood loss.

Results

Finally, a total of 100 patients aged 44.78 ± 13.67 (range 17–66) years were reviewed, and it was found that a substantial amount of [387.02 ± 252.56 (range 18.89–1130.06) ml] hidden blood loss occurred after minimally invasive knee arthroscopy. Univariate analysis showed that this hidden blood loss was negatively correlated with age, gender, postoperative hemoglobin, and postoperative hematocrit (all P < 0.05), while it was positively correlated with body mass index (BMI), length of hospital stay, preoperative red blood cells, preoperative hemoglobin, preoperative hematocrit, blood volume, and the presence of medical conditions (all P < 0.05). Further multivariate linear regression indicated that preoperative hematocrit, blood volume, and postoperative hematocrit were independent factors associated with actual blood loss, and preoperative hematocrit, blood volume, postoperative hematocrit, and gender were independent factors associated with hidden blood loss, respectively (all P < 0.05).

Conclusion

Preoperative hematocrit, preoperative blood volume, postoperative hematocrit, and gender are the influencing factors of hidden blood loss in patients undergoing minimally invasive treatment under knee arthroscopy. More attention should be paid to hidden blood loss and its factors during the perioperative period.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Osteosynthesis or non-operative treatment of the fibula for distal lower-leg fractures with tibial nailing: a systematic review and meta-analysis

Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Investigation of perioperative blood loss of femoral shaft fractures treated with intramedullary nail or locking compression plate

INTRODUCTION

Femoral shaft fractures (FSFs) are associated with significant blood loss, resulting in anemia and hemorrhagic shock. However, there has been limited data for the blood loss of FSFs during the whole perioperative period. Our primary aim is to quantify the blood loss associated with FSFs treated with intramedullary nail or locking compression plate fixation, as well as to identify the relative affecting factors for perioperative hidden blood loss (HBL).

PATIENTS AND METHODS

131 consecutive patients with FSFs were enrolled in the retrospective study between January 2009 and January 2020, including 90 cases for intramedullary nail (Nail group) and 41 cases for locking compression plate fixation (Plate group). Demographics and perioperative data were collected and analyzed. Total blood loss (TBL), visible blood loss (VBL), HBL, and percentage of HBL (PHBL) were calculated based on hematocrit (Hct) changes.

RESULTS

There was a large drop of hemoglobin (Hb) during the perioperative time. Of all 131 patients, the average HBL was 1445.5 ± 443.2 mL, accounting for 78.7% of TBL (1815.1 ± 446.3 mL). TBL and HBL in Nail group were 1886.1 ± 438.6 mL and 1546.0 ± 424.7 mL; while TBL and HBL in Plate group were 1659.5 ± 427.9 mL and 1225.1 ± 405.7 mL. The differences between the two groups were statistically significant (p = 0.007, p < 0.001, respectively). Besides, statistical significance (p< 0.05, p< 0.05, respectively) was also reported in HBL between Type-A and Type-C, and between Type-B and Type-C (1395.8 ± 444.8 mL vs. 1651.6 ± 495.7 mL; and 1411.2 ± 383.4 mL vs. 1651.6 ± 495.7 mL, respectively).

CONCLUSIONS

Patients of FSFs had significant TBL and HBL, the amount of which was much larger than that observed intra-operatively. Moreover, two readily available preoperative factors for nail fixation and Type-C were associated with a higher likelihood of more HBL. Therefore, it was argued that regular perioperative monitoring and timely blood transfusion were crucially important for patients to avoid possible risks of anemia and facilitate recovery.

May minimally invasive plate osteosynthesis be an alternative to intramedullary nailing in selected spiral oblique and spiral wedge tibial shaft fractures?

Objectives

This study aims to compare intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) treatment methods in Arbeitsgemeinschaft für Osteosynthesefragen (AO) 42A1 & 42B1 selected tibial shaft fractures.

Patients and methods

Fifty-one patients (31 males, 20 females; mean age 43.5±14.2 years; range, 18 to 81 years) operated for AO 42A1 or AO 42B1 tibial shaft fractures between January 2006 and January 2012 were retrospectively evaluated. Twenty-three of these patients were treated with MIPO and 28 with IMN. Patients were compared in terms of union time, return to work, infection, malunion, hospital stay, and sixth month and two-year Lower Extremity Functional Scale (LEFS) values.

Results

There was no difference between the MIPO and IMN groups in terms of demographic data, etiology, and fracture patterns. The mean follow-up time was 37.8±8.8 months in MIPO group and 35.9±8.7 months in IMN group. Union time (p=0.575), return to work (p=0.155), infection (p=0.643), malunion (p=0.471), and hospital stay (p=0.538) were all similar between groups. Although the LEFS value was higher in IMN group in sixth month (p=0.026), the two-year LEFS value was similar between groups (p=0.085).

Conclusion

Results of the study showed that both treatment methods are similar regarding clinical and functional outcomes. According to these results, MIPO can be recommended as an alternative to IMN in tibial shaft fractures formed as spiral oblique and spiral wedge.

Analysis of hidden blood loss and its influential factors in myomectomy

OBJECTIVE

This study was performed to quantify hidden blood loss (HBL) and explore its influential factors in myomectomy.

METHODS

Two hundred nine patients who underwent myomectomy by laparotomy or laparoscopy from 1 January 2017 to 31 December 2018 were analyzed. Each patient's estimated blood volume and total blood loss (TBL) were calculated by the Nadler formula and Gross formula, respectively. The HBL was calculated by subtracting the visible blood loss (VBL) from the TBL. A multivariate linear stepwise analysis was applied to identify the influential factors of HBL in myomectomy.

RESULTS

The mean perioperative VBL and estimated TBL during myomectomy were 137.81 ±104.43 and 492.24 ± 225.00 mL, respectively. The mean HBL was 354.39 ± 177.69 mL, which accounted for 71.52% ± 15.75% of the TBL and was two to three times higher than the VBL. The duration of surgery, number of removed leiomyomas, and location of removed leiomyomas were independent risk factors for HBL in myomectomy.

CONCLUSIONS

HBL accounted for a significant percentage of TBL in myomectomy. A full understanding of the HBL in perioperative blood management may improve patients' postoperative rehabilitation.

Hidden blood loss after hip hemiarthroplasty using the superPATH approach: A retrospective study

OBJECTIVE

The purpose of this study was to compare perioperative hidden blood loss after hip hemiarthroplasty via the SuperPATH approach and the conventional posterior approach (the Moore approach).

PATIENTS AND METHODS

From January 2015 to January 2017, 130 patients (80.7 ± 6.0 years) with displaced femoral neck fracture (Garden type III or IV) undergoing hip hemiarthroplasty were included in this study. As a non-randomisation study, Fifty-two patients (SuperPATH group) were operated using the SuperPATH approach, and 78 patients (Moore group) were operated with the conventional posterior approach (Moore approach). The demographic and relevant clinical information of the patients were collected. According to the combination formulas of Nadler, Gross and Sehat, the hidden blood loss (HBL) of each patient was calculated. Student's t-test for independent samples was used to compare the normally distributed variables and the Mann-Whitney U test was used to compare variables not following a normal distribution.

RESULTS

The visible blood loss (VBL) in the SuperPATH group was 123.7 ± 47.5 ml, the hidden blood loss (HBL) was 1084.1 ± 816.8 ml and the HBL% was 82.7 ± 16.5%. In the Moore group, the VBL was 303.6 ± 139.6 ml, the HBL was 700.2 ± 563.8 ml and the HBL% was 61.5 ± 23.8%. The patients in the SuperPATH group had more HBL and HBL% (P < 0.05). However, no significant difference was observed of total blood loss (TBL) between the two groups (P = 0.125).

CONCLUSIONS

HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of TBL. Compared with the conventional approach, the SuperPATH approach had a greater amount of HBL. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety.