Exposing the incidence of ileus in pelvic and acetabular fractures: a retrospective case analysis

BACKGROUND

Paralytic ileus is a temporary inhibition of gastrointestinal mobility in the absence of mechanical obstruction. Ileus has previously been observed in up to 40% of patients undergoing bowel surgery, leading to increased morbidity and length of stay. Pelvic and acetabular fractures are often caused by high energy trauma and are associated with a risk of visceral injury.  Prior to this study, there were no reported figures for the incidence of ileus in patients presenting with pelvic and/or acetabular fractures.

METHODS

All patients over the age of 16 presenting to a major trauma centre throughout 2019 were included. Data collected included patient demographics, injury pattern, fracture management and presence of ileus. As in previous studies, patients were identified as having ileus if they failed to tolerate an oral diet and open their bowels for more than three days (GI-2). Analysis assessed risk factors for ileus as well as its effect on length of stay.

RESULTS

An incidence of ileus of 40.35% was observed in the 57 included patients. Across all patients, ileus was three times more common in patients with a diagnosis of diabetes mellitus (p= 0.56) and 2.5 times more common in the presence of an open pelvic/ acetabular fracture (p= 0.73). Length of stay was significantly longer in patients under 65 years identified as having ileus (p= 0.046). Gender, age, opiate use, fracture management and surgical approach were not identified as risk factors for ileus.

CONCLUSION/ FINDINGS

This is the first study to report the incidence of and risk factors for ileus following admission with pelvic and/or acetabular fractures. Due to the morbidity and cost associated with this condition, further research is required to assess the effect of interventions to reduce its incidence in this patient subgroup.

The acute management of ankle fractures (Augment) study: A prospective trainee led national collaborative audit of the Boast 12 guidelines

BACKGROUND

Ankle fractures are one of the most common fractures in adults aged 20-65 years. The British Orthopaedic Association (BOA) and British Orthopaedic Foot and Ankle Society (BOFAS) jointly produced Standards for Trauma (BOAST) BOAST 12, with the aim of reducing morbidity by standardising care of these injuries. The primary aim of the AUGMENT study was to determine the extent and clinical effect of variation from BOAST 12.

METHODS

AUGMENT was a multi-centre prospective trainee led audit of consecutive patients presenting with an ankle fracture within a four-week period. Data were collected on patient demographics, comorbidities, management and 12-week outcome. The BOAST 12 standards were divided into four subgroups; documentation, imaging, management and follow-up. Percentage compliance with each subgroup was analysed. A multivariate logistic regression analysis was used to determine impact of overall compliance on likelihood of discharge in follow-up period.

FINDINGS

971 patients were included across 52 sites. The overall rate of BOAST 12 compliance was 41.7%. Variations in practice were observed in clinical documentation, especially of neurovascular status, (40.7%) and VTE assessment (61.5%). Patient management compliance with all 16 of the BOAST 12 standards was associated with a higher rate of discharge during the 12-week follow-up period (p = 0.005).

CONCLUSION

AUGMENT has demonstrated that the management of ankle fractures is variable across the UK. Over half of patients had aspects of their care that were not BOAST 12 compliant. When compliance was observed, it was associated with earlier discharge from orthopaedic care.

The impact of COVID-19 on morbidity and mortality in neck of femur fracture patients: a prospective case-control cohort study

AIMS

Within the UK, around 70,000 patients suffer neck of femur (NOF) fractures annually. Patients presenting with this injury are often frail, leading to increased morbidity and a 30-day mortality rate of 6.1%. COVID-19 infection has a broad spectrum of clinical presentations with the elderly, and those with pre-existing comorbidities are at a higher risk of severe respiratory compromise and death. Further increased risk has been observed in the postoperative period. The aim of this study was to assess the impact of COVID-19 infection on the complication and mortality rates of NOF fracture patients.

METHODS

All NOF fracture patients presenting between March 2020 and May 2020 were included. Patients were divided into two subgroup: those with or without clinical and/or laboratory diagnosis of COVID-19. Data were collected on patient demographics, pattern of injury, complications, length of stay, and mortality.

RESULTS

Overall, 132 patients were included. Of these, 34.8% (n = 46) were diagnosed with COVID-19. Bacterial pneumonia was observed at a significantly higher rate in those patients with COVID-19 (56.5% vs 15.1%; p =< 0.000). Non respiratory complications such as acute kidney injury (30.4% vs 9.3%; p =0.002) and urinary tract infection (10.9% vs 3.5%; p =0.126) were also more common in those patients with COVID-19. Length of stay was increased by a median of 21.5 days in patients diagnosed with COVID-19 (p < 0.000). 30-day mortality was significantly higher in patients with COVID-19 (37.0%) when compared to those without (10.5%; p <0.000).

CONCLUSION

This study has shown that patients with a neck of femur fracture have a high rate of mortality and complications such as bacterial pneumonia and acute kidney injury when diagnosed with COVID-19 within the perioperative period. We have demonstrated the high risk of in hospital transmission of COVID-19 and the association between the infection and an increased length of stay for the patients affected.Cite this article: Bone Joint Open 2020;1-11:669-675.

Functional Outcomes Following Operative and Nonoperative Management of Weber C Ankle Fractures: A Systematic Review

Weber C ankle fractures are unstable ankle fractures occurring above the syndesmosis. These fractures are often managed operatively, although a small population of patients are still selected for nonoperative management. This study primarily aimed to summarize the current evidence on functional outcomes for Weber C patients managed operatively and nonoperatively. Evidence on secondary outcomes such as complications and radiographic outcomes were also reviewed. This systematic search was conducted according to PRISMA guidelines. A literature search was conducted using the EMBASE, Medline, and Central databases. A total of 26 studies were included in the final analysis. All papers studied the management of Weber C fractures using open reduction and internal fixation (ORIF). Three main functional outcome scores were identified: American Orthopedic Foot and Ankle Society score, Olerud-Molander Ankle Score, and Foot and Ankle Outcome Score. Only 1 study compared operative and conservative management, which showed similar outcomes for either option (median Olerud-Molander Ankle Score 95 [range 20 to 95] vs 100 [70 to 100], respectively). Complications associated with operative management included infection, wound dehiscence, implant failure, and malunion or nonunion. The mean rate of syndesmosis malreduction was 18.2%. This study showed that operative management, regardless of the method of ORIF used, as well as nonoperative management resulted in good functional outcomes, indicating that patient selection for either method is important. However, there is limited evidence on the complications and radiographic outcomes associated with nonoperative management. We recommend further studies to compare all ORIF methods with conservative management and examine the complications associated with nonoperative management.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

RATeS (Re-Admissions in Trauma and Orthopaedic Surgery): a prospective regional service evaluation of complications and readmissions

INTRODUCTION

All the surgeries carry risks, which may lead to readmission at a later date. At present, there is limited Trauma and Orthopaedic (T&O) specific data in the literature. As a result, a prospective regional service evaluation aimed to discover the current complication and readmission rates across all T&O procedures and identify any factors associated with these outcomes.

METHODS

Data were collected at six sites across Yorkshire and Humber for all T&O procedures during October 2016. Patient demographics and procedure-specific data were collected. Post-operative complications and length of stay were recorded. All the patients were then followed up for 30 days post-discharge to determine if they experienced complications which resulted in readmission and further surgical intervention.

RESULTS

1411 patients having a total of 64 operations were recorded with 1391 completing follow-up (98.5%). Overall in-patient complication rate was 8.4% with the readmission rate being 4.4%. An ASA grade of three or more was found to be associated with readmission. Procedure-related factors such as the use of VTE prophylaxis and prophylactic antibiotics, as well as the elective nature of certain operations were negatively associated with readmission. The largest subgroup of patients was those undergoing total hip (THR) or knee replacements (TKR). For these 234 patients, the readmission rate for TKR and THR being 3.77% and 3.13%, respectively.

CONCLUSIONS

This large, multi-centre project describes readmission rates following trauma and orthopaedic surgery. In the presented study, the elective nature of the procedure was associated with a reduced risk of readmission.

Objective assessment of sleep and alertness in medical house staff and the impact of protected time for sleep

We studied 26 physicians in postgraduate medical training ("house staff") to objectively quantify their sleep, alertness, and psychomotor performance while working on call. This study provided precise data on the extent of sleep deprivation during a typical call night, the workload factors predictive of sleep loss, and the extent to which protected time for sleep within the call night can ameliorate sleep loss and consequent daytime sleepiness. We used ambulatory EEG recording equipment and a standardized computer-based performance test to monitor sleep and alertness over the course of a 36-hour call day. Comparisons were made between interns provided with 4 hours of protected time for sleep by a covering resident ("night-float") and interns without such coverage. As anticipated, we found evidence that hospital interns were severely sleep-deprived, to an extent even greater than prior behavioral observations have suggested. Interns in both conditions spent an average of less than 5 hours (295.4 minutes) in bed attempting to sleep and obtained an average of 3.67 hours (220.1 minutes) of sleep (range 37.4-358.4 minutes). Provision of the night-float for 4 hours did not significantly change total sleep time (TST) (212.8 minutes covered vs. 224.9 minutes uncovered), but sleep efficiency was significantly improved (86.5% vs. 70.3%; p = 0.001). Covered interns also obtained significantly more slow-wave sleep than the uncovered interns (65.4 minutes vs. 51.1 minutes; p = 0.05). However, measures of alertness and performance were not significantly different between the two groups and were only weakly related to TST. These data suggest that significant chronic sleep deprivation is relatively unaffected by sleep obtained in the hospital and that provision of protected time for sleep does not significantly improve TST.

The effects of pentoxifylline on the relative perfusion of tumours growing in three sites in the mouse

The haemorheological agent pentoxifylline (PTX) has been shown to improve the relative perfusion and oxygenation of subcutaneous tumours in the mouse. In order to establish whether this effect is dependent on the site of tumour growth, we have looked at changes in the distribution of the cardiac output (COD) to the murine NT carcinoma grown either intradermally (i.d.), intramuscularly (i.m.), on the wall of the caecum, or in all three sites, following i.p. administration of 50 mg kg-1 PTX. In animals bearing a single tumour, PTX treatment significantly increases the COD to tumours located in the caecum, but has no significant effect on the COD to those located in the i.d. or i.m. sites. If all three tumours are present in a single animal, the COD to all three tumours is significantly enhanced by PTX. This appears to reflect the presence of the caecum tumour and does not appear to relate to changes in tumour size or to the haematocrit (HCT) of the blood. We propose that this site dependency implies that a significant increase in blood viscosity only occurs in animals with tumours located in specific sites. Therefore, the potential radiosensitising capability of PTX is highly dependent on tumour location.

Experience with Vi typhoid capsular polysaccharide vaccine in the U.K

Adult volunteers were immunised with a single dose of typhoid Vi capsular polysaccharide vaccine. After immunisation, 96% of the 103 subjects seroconverted and 94% had antibody levels above the protective threshold. Systemic reactions were uncommon, local reactions were mild and transient.

A profile of Australian women practicing breast self-examination

Breast self-examination (BSE) and medical breast examination practices were studied in a group of 1,103 women without diagnosed breast cancer, randomly sampled to conform in age and social status with breast cancer cases from the population of Brisbane, Australia between 1981 and 1985. Relationships between these practices and sociodemographic factors, breast cancer risk indicators, health related behaviors and source of knowledge about BSE were analyzed. Overall, 63% of women reported performing BSE. BSE was practiced frequently (monthly or more). BSE frequency was only weakly associated with breast cancer risk indicators. It was more strongly linked with age, the 20-44 year group being more likely to examine their breasts occasionally and the women 65 years and over being less likely to examine their breasts. Married women were the most likely to practice BSE frequently and widowed or single women most likely never to practice. Women who underwent cervical smear testing were more likely to perform BSE than those who did not have smear tests. Women who learned BSE from their doctors as opposed to other sources practiced BSE more frequently and were more likely to practice BSE exactly as taught.

An evaluation of diphtheria--tetanus (adult) vaccine in unselected human volunteers

One hundred unselected adult volunteers received an adult diphtheria (less than 2 Lf)-tetanus (greater than or equal to 40 IU) adsorbed vaccine without prior Schick testing. No volunteer had a moderate or severe reaction although 39% complained of a transient sore arm. Only 10% reported local erythema. Of the study group, 37/43 (86%) patients who were initially seronegative for diphtheria attained levels normally considered as seropositive. The results confirm the safety and efficacy of adult diphtheria-tetanus vaccine and allow its recommendation for use in 'at risk' individuals without the need for prior Schick testing.

Influenza vaccine: the effects of the 1986/1987 viral strains

One hundred and twenty healthy volunteers were recruited for a study to evaluate the reactogenicity and serological response of differing doses of the 1986/87 World Health Organization-recommended influenza viral strains. Each vaccine was prepared by Institut Merieux and contained A/Mississippi/1/85, A/Chile/1/83 and B/Ann Arbor/1/86. One vaccine was formulated as a 10/10/10 micrograms HA and the other as a 15/10/15 micrograms HA. No significant advantage could be found with the 15/10/15 micrograms HA combination and it was recommended, therefore, that a 10/10/10 micrograms HA formulation was to be preferred. This vaccine demonstrated a minimal cross-sensitivity to the A/Singapore/6/86 influenza strain. In view of the prevalence of the A/Singapore strain, a second study was subsequently undertaken with a monovalent A/Singapore/6/86-like vaccine in a further 62 volunteers. This demonstrated an overall sero-conversion rate of 90%. Local side-effects with both vaccines were lower than in a similar study in 1984 and this may reflect a reduction in endotoxin levels achieved by a minor modification in the manufacturing technique. These studies confirmed the efficacy of a trivalent A/Mississippi, A/Chile, B/Ann Arbor influenza vaccine and the efficacy of, and necessity for, an additional A/Singapore vaccine.

Rubella vaccination: a study in adult male volunteers

One hundred adult male volunteers were randomized to receive either Merieux or Wellcome RA27/3 rubella vaccine. Prior to vaccination, 10% of the subjects were seronegative and all of these seroconverted. No significant boosting effect was found in those with a high pre-vaccine titre but some boost was shown in those with a low level. Side-effects reported were mild and self-limiting. No clinically or statistically significant difference could be found between the two vaccines. It is suggested that in view of the finding of 10% seronegative adult males it would be worthwhile considering routine screening of all medical staff who have contact with women in the early months of pregnancy.

A comparative bioavailability study of Molipaxin capsules and a trazodone liquid formulation in normal volunteers

The pharmacokinetic parameters of Molipaxin capsules and a trazodone liquid formulation have been compared in healthy volunteers. The mean area under the plasma concentration/time curve was 10.07 micrograms h ml-1 and 10.44 micrograms h ml-1, for Molipaxin capsules and trazodone liquid, respectively. The difference was not statistically significant. There was considerable individual variation between the observed maximum plasma concentration of Molipaxin capsules and trazodone liquid but the mean values of 1.61 micrograms/ml and 1.66 micrograms/ml, respectively, were very similar. The time to observed maximum plasma concentrations varied from 15 min to 4 h, but there was no statistical difference between the two formulations. The terminal phase half-life was 7.16 h for Molipaxin capsules and 6.73 h for trazodone liquid. The difference was not statistically significant. Molipaxin capsules and trazodone liquid have similar kinetic profiles and they are considered to have comparable bioavailability. Tolerance to the two formulations was similar.

Buprenorphine in postoperative pain: results in 7500 patients

Buprenorphine, a partial opiate-receptor agonist with potent analgesic properties, was given to 7548 patients in the immediate postoperative period. Ninety per cent of patients had good or adequate pain relief for at least 4 hours; there were few adverse effects and the incidence of drug-associated respiratory depression was estimated at less than 1%. There were no other side-effects of clinical note.

The monitored release of buprenorphine: results in the young

Temgesic Injection (buprenorphine), a potent analgesic agent, was given to 240 patients under 18 years of age during a year of monitored release. All but four had the product for the management of moderate or severe pain in the immediate post-operative period. Analgesia was reported as adequate or good in 90% of these young patients when it was assessed 2 and 4 hours after infection. There were no reports of side-effects commonly associated with strong analgesics and particularly antagonist-analgesics such as confusion, hallucination, blurred vision, dry mouth and lightheadedness. There were no serious respiratory or cardiovascular effects. The incidences of other events did not differ from those recorded in the much larger adult population of almost 8,000 patients. Buprenorphine is an effective analgesic suitable for use in the young post-operative patient.

Methodology of monitored release of a new preparation: buprenorphine

The analgesic agent Temgesic (buprenorphine) was made available under monitored release regulations for one year, which yielded data from 1736 doctors on 9123 patients. An analysis of 17 120 administrations of the drug confirmed the results of the pre-licensing clinical studies encompassing data from nine British hospitals on 483 patients. No important new adverse effects attributable to the product were observed, and apart from giving reassurance, the usefulness of monitored release is questioned in the light of the relatively small amount of additional information arising from it.

Pain relief in the post-operative period: a comparative trial of morphine and a new analgesic buprenorphine

In a comparative trial, buprenorphine 0-3 mg or morphine 10 mg was administered intramuscularly to patients post-operatively. The new drug buprenorphine produced more pain relief than morphine and appeared to have a longer duration of action. The side-effects produced by the two drugs were similar, as were the effect on respiratory and cardiovascular measurements.