A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options

Background

Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management.

Methods

A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates.

Results

Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)).

Discussion

Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Use of the Pixel Value Ratio Following Intramedullary Limb Lengthening: Uncomplicated Full Weight-bearing at Lower Threshold Values

Aims

The pixel value ratio (PVR) can be used to assess regenerate consolidation after lengthening and guide advice for full weight-bearing (FWB). This study aimed to analyse the PVR in adults having femoral lengthening, the time to FWB and compare findings with the reported values in the literature.

Materials and methods

A retrospective database review identified 100 eligible patients who underwent lengthening using the PRECICE nail (68 antegrade and 32 retrograde). The PVR was calculated in each cortex on plain radiographs at every visit. The ratio between the regenerate and an average from the adjacent normal bone was calculated and plotted against the clinical decision to allow FWB.

Results

Eighty-seven patients (58 men and 29 women) were assessed; eleven had bilateral lengthening and two patients underwent lengthening twice. The median age was 30.5 years. The underlying cause of shortening was post-traumatic in 46%, with the remaining due to a wide variety of causes, including congenital 16%, syndromic 12% and other causes. The median lengthening achieved was 45 mm, at a median of 57.5 days. The PVR increased with each visit (p <0.0001). FWB was allowed at a median of 42 days after the last day of lengthening, with PVR values of 0.83, 0.84, 0.93 and 0.84 for the anterior, posterior, medial and lateral cortex noted, respectively (average 0.85). There were no implant failures, shortening or regenerate fractures. No differences were detected between antegrade and retrograde nails or with lengthening greater or less than 45 mm. One surgeon allowed earlier FWB at median 31 days with no nail failures.

Conclusion

PVR is a valuable tool that quantifies regenerate maturity and provides objectivity in deciding when to allow FWB after intramedullary lengthening with the PRECICE nail. FWB was permitted at an earlier time point, corresponding with lower PVR values than have been reported in the literature and with no mechanical failure or regenerate deformation.

How to cite this article

Elsheikh AA, Wright J, Stoddart MT, et al. Use of the Pixel Value Ratio Following Intramedullary Limb Lengthening: Uncomplicated Full Weight-bearing at Lower Threshold Values. Strategies Trauma Limb Reconstr 2022;17(1):14–18.

Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis

OBJECTIVES

To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, and OpenGrey.

STUDY SELECTION

Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.

DATA EXTRACTION

Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis.

DATA SYNTHESIS

A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)].

RESULTS

In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage.

CONCLUSIONS

Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

Congenital amegakaryocytic thrombocytopenia (CAMT) presenting as severe pancytopenia in the first month of life

Congenital amegakaryocytic thrombocytopenia (CAMT) is characterised by neonatal thrombocytopenia, with reduced or absent bone marrow megakaryocytes, leading eventually to pancytopenia. The mean age for progression to bone marrow failure is four years, with the earliest reported being six months. We describe a CAMT patient with compound heterozygous mutations of the causative MPL gene (one being a previously unreported splice site mutation in intron 11) who developed pancytopenia within the first month of life. This report emphasises the importance of considering CAMT in the differential diagnosis of congenital aplastic anaemia or idiopathic aplastic anaemia in babies.