1
|
Affiliation(s)
- S-T Jerry Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, and Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - A Hamish R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, and Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
2
|
Nicholson JA, Tsang STJ, MacGillivray TJ, Perks F, Simpson AHRW. What is the role of ultrasound in fracture management?: Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019; 8:304-312. [PMID: 31463038 PMCID: PMC6691369 DOI: 10.1302/2046-3758.87.bjr-2018-0215.r2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management. Methods A review of relevant literature was undertaken, including articles indexed in PubMed with keywords "ultrasound" or "sonography" combined with "diagnosis", "fracture healing", "impaired fracture healing", "nonunion", "microbiology", and "fracture-related infection". Results The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation. Conclusion Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing.Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304-312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2.
Collapse
Affiliation(s)
- J A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - S T J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - T J MacGillivray
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - F Perks
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
3
|
Abstract
External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.
Collapse
Affiliation(s)
- A H R W Simpson
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom.
| | - L Robiati
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - M M K Jalal
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - S T J Tsang
- Department of Trauma and Orthopaedics, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| |
Collapse
|
4
|
Abstract
Objectives Periprosthetic joint infection following joint arthroplasty surgery is one of the most feared complications. The key to successful revision surgery for periprosthetic joint infections, regardless of treatment strategy, is a thorough deep debridement. In an attempt to limit antimicrobial and disinfectant use, there has been increasing interest in the use of acetic acid as an adjunct to debridement in the management of periprosthetic joint infections. However, its effectiveness in the eradication of established biofilms following clinically relevant treatment times has not been established. Using an in vitro biofilm model, this study aimed to establish the minimum biofilm eradication concentration (MBEC) of acetic acid following a clinically relevant treatment time. Materials and Methods Using a methicillin-sensitive Staphylococcus aureus (MSSA) reference strain and the dissolvable bead assay, biofilms were challenged by 0% to 20% acetic acid (pH 4.7) for ten minutes, 20 minutes, 180 minutes, and 24 hours. Results The MBEC of acetic acid was found to be: 15%, 11%, 3.2%, and 0.8% following a ten-minute, 20-minute, 180-minute, and 24-hour treatment, respectively. Conclusion This study found that the MBEC of acetic acid following a 10- or 20-minute treatment time exceeded its safety threshold, making these concentrations unsuitable as a topical debridement adjunct. However, a clinically acceptable concentration (5%) was still found to eliminate 96.1% of biofilm-associated MSSA following a 20-minute treatment time. Cite this article: S. T. J. Tsang, P. J. Gwynne, M. P. Gallagher, A. H. R. W. Simpson. The biofilm eradication activity of acetic acid in the management of periprosthetic joint infection. Bone Joint Res 2018;7:517–523. DOI: 10.1302/2046-3758.78.BJR-2018-0045.R1
Collapse
Affiliation(s)
- S T J Tsang
- Department of Orthopaedic Surgery and School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | - M P Gallagher
- School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | - A H R W Simpson
- Department of Orthopaedics, Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
5
|
Tsang STJ, McHugh MP, Guerendiain D, Gwynne P, Boyd J, Laurenson IF, Templeton KE, Lewis S, Simpson AHRW, Walsh TS. Evaluation of Staphylococcus aureus eradication therapy in orthopaedic surgery. J Med Microbiol 2018; 67:893-901. [PMID: 29671723 DOI: 10.1099/jmm.0.000731] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Despite WHO recommendations, there is currently no national screening and eradication policy for the detection of methicillin-sensitive Staphylococcus aureus (MSSA) in the UK prior to elective orthopaedic surgery. This study aimed to evaluate the effectiveness of current standard methicillin-resistant S. aureus (MRSA) eradication therapies in the context of S. aureus (both MRSA and MSSA) decolonization in an elective orthopaedic population. METHODOLOGY A total of 100 patients awaiting joint replacement surgery who were positive for S. aureus on PCR nasal screening underwent the current standard MRSA pre-operative decolonization regimen for 5 days. Prior to commencement of the eradication therapy, swabs of the anterior nares, throat and perineum were taken for culture. Further culture swabs were taken at 48-96 h following treatment, at hospital admission for surgery and at hospital discharge. Following the completion of treatment, patients were asked to provide feedback on their experience using Likert rating scales. The primary outcome of this study was S. aureus clearance 48-96 h following eradication treatment.Results/Key Findings. Clearance of S. aureus 48-96 h following treatment was 94 % anterior nares, 66 % throat and 88 % groin. Mean completion with nasal mupirocin was 98 %. There was no statistically significant recolonization effect between the end of the eradication treatment period and the day of surgery (P>0.05) at a median time of 10 days. CONCLUSION Current MRSA decolonisation regimens are well tolerated and effective for MSSA decolonization for the anterior nares and groin. The decolonization effect is preserved for at least 10 days following treatment.
Collapse
Affiliation(s)
- S T J Tsang
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France, Crescent Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - M P McHugh
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D Guerendiain
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P Gwynne
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - J Boyd
- Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent , Old Dalkeith Road, Edinburgh EH16 4SB, Scotland
| | - I F Laurenson
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - K E Templeton
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - S Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France, Crescent Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - T S Walsh
- Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent , Old Dalkeith Road, Edinburgh EH16 4SB, Scotland
| |
Collapse
|
6
|
Tsang STJ, McHugh MP, Guerendiain D, Gwynne PJ, Boyd J, Simpson AHRW, Walsh TS, Laurenson IF, Templeton KE. Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques: One third of carriers missed. Bone Joint Res 2018; 7:79-84. [PMID: 29330346 PMCID: PMC5805824 DOI: 10.1302/2046-3758.71.bjr-2017-0175.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Nasal carriers of Staphylococcus (S.) aureus (MRSA and MSSA) have an increased risk for healthcare-associated infections. There are currently limited national screening policies for the detection of S. aureus despite the World Health Organization's recommendations. This study aimed to evaluate the diagnostic performance of molecular and culture techniques in S. aureus screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on S. aureus detection in orthopaedic patients. METHODS Paired nasal swabs for polymerase chain reaction (PCR) assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint arthroplasty surgery. RESULTS The prevalence of MSSA nasal colonization was found to be between 22.4% to 35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p = 0.005), failing to identify its presence in approximately one-third of patients undergoing joint arthroplasty surgery. CONCLUSION Modelling these results to national surveillance data, it was estimated that approximately 5000 to 8000 S. aureus surgical site infections could be prevented, and approximately $140 million to $950 million (approximately £110 million to £760 million) saved in treatment costs annually in the United States and United Kingdom combined, by using alternative diagnostic methods to direct culture in preoperative S. aureus screening and eradication programmes.Cite this article: S. T. J. Tsang, M. P. McHugh, D. Guerendiain, P. J. Gwynne, J. Boyd, A. H. R. W. Simpson, T. S. Walsh, I. F. Laurenson, K. E. Templeton. Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques: One third of carriers missed. Bone Joint Res 2018;7:79-84. DOI: 10.1302/2046-3758.71.BJR-2017-0175.R1.
Collapse
Affiliation(s)
- S T J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK and School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - M P McHugh
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D Guerendiain
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - J Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh (Usher Institute), Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX
| | - A H R W Simpson
- Department of Orthopaedic Surgery, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - T S Walsh
- Critical care and Pain Medicine, Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - I F Laurenson
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - K E Templeton
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| |
Collapse
|
7
|
Dall GF, Tsang STJ, Gwynne PJ, Wilkinson AJ, Simpson AHRW, Breusch SJB, Gallagher MP. The dissolvable bead: A novel in vitro biofilm model for evaluating antimicrobial resistance. J Microbiol Methods 2017; 142:46-51. [PMID: 28870772 DOI: 10.1016/j.mimet.2017.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 12/22/2022]
Abstract
In vitro biofilm assays are a vital first step in the assessment of therapeutic effectiveness. Current biofilm models have been found to be limited by throughput, reproducibility, and cost. We present a novel in vitro biofilm model, utilising a sodium alginate substratum for surface biofilm colony formation, which can be readily dissolved for accurate evaluation of viable organisms. The dissolving bead biofilm assay was evaluated using a range of clinically relevant strains. The reproducibility and responsiveness of the assay to an antimicrobial challenge was assessed using standardised methods. Cryo-scanning electron microscopy was used to image biofilm colonies. Biofilms were grown for 20h prior to testing. The model provides a reproducible and responsive assay to clinically-relevant antimicrobial challenges, as defined by established guidelines. Moreover cryo-scanning electron microscopy demonstrates that biofilm formation is localised exclusively to the alginate bead surface. Our results suggest that this simple model provides a robust and adaptable assay for the investigation of bacterial biofilms.
Collapse
Affiliation(s)
- G F Dall
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, United Kingdom; Department of Orthopaedic surgery, University of Edinburgh, Chancellor's building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, United Kingdom
| | - S T J Tsang
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, United Kingdom; Department of Orthopaedic surgery, University of Edinburgh, Chancellor's building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, United Kingdom; Department of Orthopaedic surgery, Royal Infirmary of Edinburgh, 51 Little France, Old Dalkeith Road, Edinburgh EH16 4SA, United Kingdom.
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, United Kingdom
| | - A J Wilkinson
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, United Kingdom
| | - A H R W Simpson
- Department of Orthopaedic surgery, University of Edinburgh, Chancellor's building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, United Kingdom; Department of Orthopaedic surgery, Royal Infirmary of Edinburgh, 51 Little France, Old Dalkeith Road, Edinburgh EH16 4SA, United Kingdom
| | - S J B Breusch
- Department of Orthopaedic surgery, Royal Infirmary of Edinburgh, 51 Little France, Old Dalkeith Road, Edinburgh EH16 4SA, United Kingdom
| | - M P Gallagher
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, United Kingdom
| |
Collapse
|
8
|
Tsang STJ, McMorran D, Robinson L, Herman J, Robb JE, Gaston MS. A cohort study of tibialis anterior tendon shortening in combination with calf muscle lengthening in spastic equinus in cerebral palsy. Gait Posture 2016; 50:23-27. [PMID: 27559938 DOI: 10.1016/j.gaitpost.2016.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/21/2016] [Accepted: 08/12/2016] [Indexed: 02/02/2023]
Abstract
The aim of this study was to evaluate the outcome of combined tibialis anterior tendon shortening (TATS) and calf muscle-tendon lengthening (CMTL) in spastic equinus. Prospectively collected data was analysed in 26 patients with hemiplegic (n=13) and diplegic (n=13) cerebral palsy (CP) (GMFCS level I or II, 14 males, 12 females, age range 10-35 years; mean 16.8 years). All patients had pre-operative 3D gait analysis and a further analysis at a mean of 17.1 months (±5.6months) after surgery. None was lost to follow-up. Twenty-eight combined TATS and CMTL were undertaken and 19 patients had additional synchronous multilevel surgery. At follow-up 79% of patients had improved foot positioning at initial contact, whilst 68% reported improved fitting or reduced requirement of orthotic support. Statistically significant improvements were seen in the Movement Analysis Profile for ankle dorsi-/plantarflexion (4.15°, p=0.032), maximum ankle dorsiflexion during swing phase (11.68°, p<0.001), and Edinburgh Visual Gait Score (EVGS) (4.85, p=0.014). Diplegic patients had a greater improvement in the EVGS than hemiplegics (6.27 -vs- 2.21, p=0.024). The originators of combined TATS and CMTL showed that it improved foot positioning during gait. The present study has independently confirmed favourable outcomes in a similar patient population and added additional outcome measures, the EVGS, foot positioning at initial contact, and maximum ankle dorsiflexion during swing phase. Study limitations include short term follow-up in a heterogeneous population and that 19 patients had additional surgery. TATS combined with CMTL is a recommended option for spastic equinus in ambulatory patients with CP.
Collapse
Affiliation(s)
- S T J Tsang
- Department of Orthopaedics, Royal Hospital for Sick Children Edinburgh, 9 Sciennes Place, Edinburgh EH9 1LF, United Kingdom.
| | - D McMorran
- University of Edinburgh, College of Medicine and Veterinary Medicine, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, United Kingdom
| | - L Robinson
- University of Edinburgh, College of Medicine and Veterinary Medicine, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, United Kingdom
| | - J Herman
- The Anderson Gait Laboratory, SMART Centre, Astley Ainslie Hospital, 133 Grange Loan, Edinburgh EH9 2, United Kingdom
| | - J E Robb
- The Anderson Gait Laboratory, SMART Centre, Astley Ainslie Hospital, 133 Grange Loan, Edinburgh EH9 2, United Kingdom
| | - M S Gaston
- Department of Orthopaedics, Royal Hospital for Sick Children Edinburgh, 9 Sciennes Place, Edinburgh EH9 1LF, United Kingdom; The Anderson Gait Laboratory, SMART Centre, Astley Ainslie Hospital, 133 Grange Loan, Edinburgh EH9 2, United Kingdom
| |
Collapse
|
9
|
Tsang STJ, Mills LA, Baren J, Frantzias J, Keating JF, Simpson AHRW. Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure. Injury 2015; 46:2404-9. [PMID: 26489394 DOI: 10.1016/j.injury.2015.09.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 02/02/2023]
Abstract
The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.
Collapse
Affiliation(s)
- S T J Tsang
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, UK.
| | - L A Mills
- Department of Trauma and Orthopaedics, Royal Aberdeen Children's Hospital, UK
| | - J Baren
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, UK
| | - J Frantzias
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, UK
| | - J F Keating
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, UK
| | - A H R W Simpson
- Department of Trauma and Orthopaedic surgery, University of Edinburgh, UK
| |
Collapse
|
10
|
Abstract
INTRODUCTION Hip fractures remain the most common orthopaedic injury requiring hospital admission. Failed surgery for any cause carries a higher morbidity, mortality, and healthcare-related cost. The aims of this study were to determine risk factors for surgical complications of hip fracture surgery, when they occurred and their effect on mortality. PATIENTS AND METHODS From a prospectively collected consecutive database of 795 hip fractures admitted between July 2007 and June 2008, all surgical and non-surgical complications were identified as well as re-operation for any cause and mortality in the 4 years since surgery. RESULTS Fifty-five (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age, smoking and cannulated screw fixation. Cannulated screw fixation was associated with a 30.9% rate of re-operation. Post-operative medical complication occurred in 21.8%. It was associated with a 78.5% mortality at 4 years with a median time to mortality of 58 days (95% CI 0-120 days). CONCLUSIONS Mechanical failure was the most common reason for cannulated screw re-operation. Hip hemiarthroplasty most commonly failed by infection. Inter-trochanteric and sub-trochanteric fracture fixation had very low failure rates. Post-operative medical complications, but not surgical complications, were associated with a higher mortality rate.
Collapse
Affiliation(s)
- S T J Tsang
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK.
| | - S A Aitken
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - S K Golay
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - R K Silverwood
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - L C Biant
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| |
Collapse
|