Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures

INTRODUCTION

Hip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications.

METHODS

This retrospective study included 803 IM nails performed between 2008-2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery.

RESULTS

The overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years.

DISCUSSION

The rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

The Evaluation of Serum Metal Ion Levels and Metallosis in Graduated Patients With Magnetically Controlled Growing Rods

BACKGROUND

Magnetically controlled growing rods (MCGR) aim to control curve progression while limiting surgical burden in children with early-onset scoliosis. Systemic and local distribution of metal debris has been documented in children with spinal implants. The aim of the study was to assess serum metal ion levels and local metal debris-related changes at the conclusion of MCGR treatment.

METHODS

Between February 2019 and September 2022, all patients who had a conversion to definitive fusion at the completion of MCGR treatment in our institution were invited to participate in this study. Consenting patients had serum metal ion levels drawn (titanium, cobalt, and chromium) and histologic analyses of peri-implant tissue samples.

RESULTS

We enrolled 24 children who underwent definitive fusion post-MCGR treatment for early-onset scoliosis. The average age at definitive fusion was 13.3 years (range: 11 to 17 y). The average length of MCGR treatment was 4.8 years (range: 1.5 to 6.8 y). At the end of the MCGR treatment, 23 (96%) patients had elevated serum metal ion levels. Mean serum titanium levels were 165.4 nmol/L (range: 30 to 390 nmol/L), mean serum cobalt levels were 4.6 nmol/L (range: 1.2 to 14 nmol/L), and mean serum chromium levels were 14 nmol/L (range: 2.4 to 30 nmol/L). Peri-implant soft tissue histologic analysis demonstrated local metal debris and foreign body reactions in all patients.

CONCLUSIONS

At the completion of MCGR treatment, the majority of patients demonstrate elevated serum metal ion levels and local metal debris-related peri-implant soft tissue changes. Although there is no current literature to suggest these findings are harmful, further research as to the clinical significance is required.

LEVEL OF EVIDENCE

Level IV.

259 AN AUDIT OF DNACPR FORM USAGE IN A LEVEL 4 HOSPITAL FOLLOWING RE-DESIGN AND IMPLICATIONS FOR ITS FUTURE USE

Background

In 2020 during the Covid-19 pandemic our hospital introduced a new green DNACPR form with 2 significant changes. It now specifies if the patient is or is not for resuscitation (as a yes/no choice) and a Treatment Escalation Plan (TEP) has moved to the front of the page from the back. A subsequent audit found that 19% of inpatients had forms completed, of which 68% stated DNACPR and 29% for CPR. 76% of forms had a TEP (versus 56% on the old forms). We repeated the hospital wide audit in 2022 to assess if the improvement in TEP documentation was sustained, and if it was used on all patients or primarily to document DNACPR decisions.

Methods

The hospital-wide audit was performed on the 25.05.2022. Charts were reviewed on medical and surgical wards. ICU patients were excluded. The following data were recorded: Resuscitation status, form completion, presence of a TEP, if the date of admission and form completion were recorded, if the name of doctor and nature of discussion with patient and family were documented, and if the TEP was consistent with the most recent clinical notes. The data was compared to the 2020 audit and against the Hospital’s DNAR & TEP policy.

Results

634 inpatients were identified. 15.7% (100) had a form completed of which 92% stated DNAR. One of these did not have a TEP. The doctor’s name and grade were clearly documented on all forms.

Conclusion

99% of patients who were not for CPR had a TEP indicating sustained improvement since the introduction of the new form. Given 83.3% of patients did not have any documented resuscitation status the approach of documenting yes or no for resuscitation is not being utilised. A return to a dedicated form that indicates someone should not undergo attempts at resuscitation may offer more clarity.

154 SAFEGUARDING ADULTS AT RISK OF ABUSE—IDENTIFYING KNOWLEDGE GAPS AMONGST HOSPITAL STAFF TO GUIDE POLICY IMPLEMENTATION AND TRAINING

Background

Safeguarding is the protection of health, wellbeing and life free from abuse. Abuse is a a violation of a person’s human and civil rights; forms include psychological, financial, physical, sexual, neglect and self-neglect. Health Service Executive (HSE) drafted the 2019 ‘Adult Safeguarding Policy’ for adults at risk of abuse to replace the 2014 version. In preparation for implementation a tertiary hospital founded a Safeguarding Committee in 2021. A core objective was establishing staff understanding, experience of safeguarding and education needs to guide future training.

Methods

10-question survey of 223 staff; included doctors, nurses, allied health professionals, medical social workers, healthcare assistants, porters, psychologists.

Results

91% response rate.

184 (91%) staff were familiar with the term ‘safeguarding’; only 44% were aware of the HSE 2019 policy. 129 (64%) had experience with a case of suspected abuse. Most common forms were financial, psychological and self-neglect (n = 60, 47, 39 respectively). Sexual abuse was least common (n = 10).

47% felt ‘somewhat’ confident recognising possible abuse compared to 42% who felt ‘extremely’ or ‘very’ confident.

61% were ‘somewhat’ or ‘not so’ confident about the next steps for suspected abuse; only 11% were ‘extremely’ confident.

49% felt ‘extremely’ or ‘very’ confident in reporting a suspected abuse case; 50% felt ‘somewhat’ or ‘not so’ confident.

Most common reasons for lack of confidence were lack of training, unclear reporting process and lack of experience with cases of abuse. Medical social workers were most confident; doctors were the least.

170 (84%) wanted more safeguarding training—the most popular options were online or in-person training.

Conclusion

Gaps in knowledge and confidence were identified amongst staff for cases of suspected abuse. This will guide future training in the hospital in line with the HSE Adult Safeguarding policy.

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.

Dedicated general practitioner education sessions can improve diagnostic capabilities and may have a positive effect on referral patterns for common skin lesions

INTRODUCTION

General practitioners (GPs) require the necessary skills to identify potentially malignant skin lesions and refer patients in an appropriate and timely manner. We examined the impact of a single consultant delivered education session to GP trainees on their diagnosis of common skin lesions.

METHODS

A prospective analysis of baseline knowledge was assessed using a photographic questionnaire. A dedicated education session was delivered by a consultant plastic surgeon. Their knowledge was re-assessed after 3 months.

RESULTS

There were 23 participants. Baseline ability to correctly diagnose skin lesions improved significantly at 3 months following dedicated teaching (baseline mean 30.2%, 3-month mean 65.9%, p = 0.001). All trainees recommended that dedicated skin education should be incorporated into GP training curricula.

CONCLUSION

Dedicated education sessions on skin lesions can improve the diagnostic accuracy of GP trainees, and we suggest that they are incorporated into the GP training curriculum.

Proximal component modularity in THA--at what cost? An implant retrieval study

BACKGROUND

While modular femoral heads have been used in THA for decades, a recent innovation is a second neck-stem taper junction. Clinical advantages include intraoperative adjustment of leg length, femoral anteversion, and easier revision, all providing flexibility to the surgeon; however, there have been reports of catastrophic fracture, cold welding, and corrosion and fretting of the modular junction.

QUESTIONS/PURPOSES

We asked whether (1) the neck-stem junction showed the same degradation mechanisms, if any, as the head-neck junction, (2) the junction contributed to THA revision, (3) the alloy affected the degree of degradation, and (4) the trunion machine finish affected the degradation mechanisms.

METHODS

We compared 57 retrievals from seven total hip modular designs, three cobalt-chromium-molybdenum and four titanium based: Bionik(®) (four), GMRS(®) (four), Margron(®) (22), Apex(®) (five), M-series(®) (five), ZMR(®) (two), and S-ROM(®) (15). Macroscopic inspection, microscopy, and micro-CT were conducted to determine the effects of materials and design.

RESULTS

The cobalt-chromium-molybdenum components showed crevice corrosion and fretting of the neck-stem taper, whereas the titanium components had less corrosion; however, there were several cases of cold welding where disassembly could not be achieved in theater.

CONCLUSIONS

Even with modern taper designs and corrosion-resistant materials, corrosion, fretting, and particulate debris were observed to a greater extent in the second neck-stem junction. Titanium-based modular arthroplasty may lessen the degree of degradation, but cold welding of the components may occur.

CLINICAL RELEVANCE

Degradation of the second junction contributed to 8 cases of metallosis and two cases of aseptic lymphocyte-laminated vascular-associated lesions contributing to revision.

Essentials of shoulder MR arthrography: a practical guide for the general radiologist

Lesions of the glenoid labrum and ligamentous structures commonly occur secondary to shoulder trauma and are a frequent cause of shoulder joint instability. Numerous eponyms, acronyms and subclassifications are used to describe the often confusing array of bony and labro-ligamentous abnormalities of the shoulder. This aim of this review is to illustrate the relevant features of these lesions and to provide a systematic and practical approach to imaging of the shoulder using MR arthrography.

Von Hippel-Lindau disease: a radiological essay

Von Hippel-Lindau disease is a progressive autosomal dominant disorder with multi-organ involvement. A variety of benign and malignant disease processes lie within the spectrum of disease processes associated with this condition. Early detection and treatment of complications is paramount in the management of these patients. The purpose of this pictorial review is to depict the various radiological manifestations that are commonly seen in this disease.

The imaging spectrum of Baker's (Popliteal) cysts

Baker's (Popliteal) cysts are frequently encountered on cross-sectional imaging of the knee. These consist of enlarged gastrocnemius semimembranosus bursa which typically communicate with the knee. They may be imaged with a variety of techniques including arthopgraphy, CT, ultrasound and MRI, with the latter two being more commonly used. Examples of bursa imaged with all of the above techniques are demonstrated in the essay, as well as variance of normal appearance and pathological entities including ruptured bursa, abnormally positioned bursa, osteochondromatosis, septic complications of the bursa and pigmented villonodular synovitis.

The "dependent viscera" sign in CT diagnosis of blunt traumatic diaphragmatic rupture

OBJECTIVE

The objective of our study was to describe the "dependent viscera" sign and determine its usefulness at CT in the diagnosis of diaphragmatic rupture after blunt abdominal trauma.

MATERIALS AND METHODS

The study sample consisted of 28 consecutive patients (19 men, nine women) between 17 and 74 years old (mean age, 31 years) who had undergone abdominal CT and subsequent emergency laparotomy after a blunt trauma. Ten patients had a diaphragmatic rupture (six, right-sided; four, left-sided) at laparotomy. An experienced radiologist unaware of the surgical findings retrospectively reviewed the CT scans, and then a second radiologist reviewed the scans to provide interobserver agreement. Note was made of discontinuity of the diaphragm, intrathoracic herniation of abdominal contents, and waistlike constriction of bowel (the collar sign). Also noted was whether the upper one third of the liver abutted the posterior right ribs or whether the bowel or stomach lay in contact with the posterior left ribs. Either of these findings was termed the "dependent viscera" sign. The radiologists' detection rate of diaphragmatic rupture on the CT scans via observance of the dependent viscera sign was determined. Interobserver agreement was assessed using Cohen's kappa statistic.

RESULTS

The dependent viscera sign was observed on the CT scans of 100% of the patients with a left-sided diaphragmatic rupture and of 83% of the patients with right-sided diaphragmatic rupture. Both observers missed one case of right-sided diaphragmatic rupture. The radiologists' overall rate of detecting diaphragmatic rupture was 90% using the dependent viscera sign. We found excellent interobserver agreement (kappa = 1) for detection of the dependent viscera sign and for the diagnosis of diaphragmatic tear on CT scans.

CONCLUSION

The dependent viscera sign increases the detection at CT of acute diaphragmatic rupture after blunt trauma.

MR imaging of bone oedema: mechanisms and interpretation

Widespread use of MRI now allows the routine identification of previously unevaluated traumatic bone marrow oedema and haemorrhage. Similar marrow oedema is identified in patients with tumours, hyperaemia and medullary congestion. Patterns and extent of traumatic bone marrow oedema and haemorrhage are dictated by mechanism. Diffusion techniques may allow precise evaluation of severity of injury. Illustrative examples and discussion are presented. Eustace, S. (2001). Clinical Radiology56, 4-12.

MR imaging of bone tumors of the cervical spine

MR Imaging has altered radically the detection, characterization, and the staging of bone tumors. This article reviews MR imaging techniques and appearances of benign and malignant bone tumors that are encountered in the cervical spine.

Catecholamines increase monocyte TNF receptors and inhibit TNF through beta 2-adrenoreceptor activation

Postinjury deficits in monocyte tumor necrosis factor receptors (moTNFR) activity may alter beneficial functions during an inflammatory response. Several counter-regulatory hormones elicited during inflammation may modulate tumor necrosis factor (TNF) activity, but little is known about their influence on moTNFR. Also, catecholamines inhibit TNF production, but the adrenoreceptor mechanism of this effect has not been fully clarified. To determine the effect of catecholamines and corticosteroids on moTNFR, whole blood was coincubated for up to 8 (moTNFR) or 24 h (cytokines) in the presence of lipopolysaccharide (100 ng/ml) and 1) epinephrine (Epi, 10(-6) M), dexamethasone (Dex, 10(-6) M) or both (EpiDex, 10(-6) M) to assess the expression of total moTNFR, moTNFR-I, and moTNFR-II. 2) Epi and norepinephrine (EpiNE, 10(-6) M) and the alpha 1 + 2-, beta 1 + 2-, beta 1-, or beta 2-adrenergic antagonists were used to assess the role of such adrenoreceptors on total moTNFR and TNF production, and N6,2'-O-dibutyryl adenosine 3',5'-cyclic monophosphate (DBcAMP) alone or in combination with the phosphodiesterase inhibitor Ro-20-1724/000, to study the cAMP-dependent pathway on total moTNFR. We found that Epi upregulated total moTNFR and moTNFR-II. Dex did not significantly influence total moTNFR or moTNFR-II. Also, EpiNE increased total moTNFR and inhibited TNF by a beta 2-dependent mechanism. DBcAMP (10(-5) M) modestly enhanced total moTNFR. This suggests a common mechanism for acutely enhancing moTNFR and attenuation of soluble TNF appearance during conditions of severe stress.

Continuous quality improvement can improve glycemic control for HMO patients with diabetes

OBJECTIVE

To evaluate the impact of a continuous quality improvement (CQI) intervention on glycemic control of patients with diabetes mellitus attending a primary care clinic.

METHODS

A CQI process designed by the Minnesota Department of Health to improve diabetes care was implemented at a volunteer clinic, with another similar clinic not using the CQI process assessed for comparison. Adults with diabetes were identified at both clinics using diagnostic and pharmacy databases. Glycosylated hemoglobin (HbA1c) values (reference range, 4.3%-6.1%) and out-patient utilization and charges were compared for all patients with diabetes at each clinic for the 12 months before and 18 months after initiation of the CQI intervention.

RESULTS

The mean HbA1c value at the intervention clinic fell from 8.9% at baseline to 8.4% at 12 months and to 7.9% at 18 months. The mean HbA1c value at the comparison clinic was 8.9% at baseline, 8.9% at 12 months, and 8.8% at 18 months (difference between clinics, t = 4.13, P < .001). Differences after the intervention in the proportion of patients at the comparison clinic (n = 121) vs the intervention clinic (n = 122) with HbA1c values of 8% or less (40% vs 51%), between 8% and 10% (33% vs 37%), and 10% or greater (27% vs 12%) were unlikely due to chance (chi 2 = 9.7, 2 df, P = .008). The intervention was not associated with increased utilization of outpatient visits or outpatient charges.

CONCLUSIONS

Involvement of nurses, physicians, and managers in a CQI process can improve patients' glycemic control in some health maintenance organization primary care settings, without increasing utilization or charges. Health maintenance organizations should consider CQI as one possible method to improve diabetes outcomes.

Role and effect of TNF-alpha in experimental visceral leishmaniasis

TNF-alpha has been implicated in cytokine-induced macrophage activation and tissue granuloma formation, two activities linked to control of intracellular visceral infection caused by Leishmania donovani. To determine the role of TNF-alpha in L. donovani-infected BALB/c mice, we measured TNF-alpha levels and treated mice with either anti-TNF-alpha antiserum or TNF-alpha. TNF-alpha activity in infected livers was increased by 2.7-fold 2 wk after challenge and by 5.5-fold at wk 8. In parallel, although control mice acquired resistance by wk 4 and resolved infection by wk 8, liver parasite burdens steadily increased in anti-TNF-alpha-treated animals. Hepatic granuloma formation, however, was not impaired by anti-TNF-alpha. Endogenous TNF-alpha levels provoked by L. donovani appeared sufficient and optimal because exogenous TNF-alpha administration had no beneficial effect on established infection and continuous high-dose treatment impaired antileishmanial activity. Thus, although not required for granuloma formation, endogenous TNF-alpha appears to be critical to both initial acquisition of resistance to L. donovani and resolution of experimental visceral infection.

Role and effect of TNF-alpha in experimental visceral leishmaniasis

TNF-alpha has been implicated in cytokine-induced macrophage activation and tissue granuloma formation, two activities linked to control of intracellular visceral infection caused by Leishmania donovani. To determine the role of TNF-alpha in L. donovani-infected BALB/c mice, we measured TNF-alpha levels and treated mice with either anti-TNF-alpha antiserum or TNF-alpha. TNF-alpha activity in infected livers was increased by 2.7-fold 2 wk after challenge and by 5.5-fold at wk 8. In parallel, although control mice acquired resistance by wk 4 and resolved infection by wk 8, liver parasite burdens steadily increased in anti-TNF-alpha-treated animals. Hepatic granuloma formation, however, was not impaired by anti-TNF-alpha. Endogenous TNF-alpha levels provoked by L. donovani appeared sufficient and optimal because exogenous TNF-alpha administration had no beneficial effect on established infection and continuous high-dose treatment impaired antileishmanial activity. Thus, although not required for granuloma formation, endogenous TNF-alpha appears to be critical to both initial acquisition of resistance to L. donovani and resolution of experimental visceral infection.

Identification of a novel tumor necrosis factor alpha/cachectin from the livers of burned and infected rats

Tumor necrosis factor alpha (TNF-alpha)/cachectin is a monocyte/macrophage-derived cytokine implicated as a proximal mediator of many of the catastrophic host responses to infection or endotoxin. However, circulating levels of TNF-alpha/cachectin have only been episodically detected in hospitalized patients with life-threatening bacterial infections. In the present report, increased quantities of immune-reactive TNF-alpha/cachectin were recovered from the livers of rats 3 days following a lethal burn and infection. Two species of TNF-alpha/cachectin were detected, one of approximately 29 kd and the other 17 kd, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. In murine peritoneal macrophages and rat Kupffer cells stimulated in vitro with endotoxin, a 29-kd cell-associated and 17-kd secreted form were also detected. We conclude that the increased appearance in vivo of a 29-kd form of TNF-alpha/cachectin from the livers of lethally burned and infected rats represents a novel cell-associated form of the protein.

The changing pattern of coronary heart disease in Australia

In this paper we describe a method for constructing long series of comparable mortality statistics from published figures that are subject to periodic changes in coding practice. The case discussed in some detail is that of Australian coronary heart disease mortality 1931-1985, the coding of which has been liable to alteration on four occasions due to revisions to the procedures of the International Classification of Diseases. Reference is made to comparable work on US figures and it is shown that the Australian data require relatively smaller adjustments.