The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: a multi-centre cohort study

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5 degrees of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (<5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001).

Grading the evidence: levels of evidence and grades of recommendation

Evidence-based medicine is using the best available evidence in order to make accurate and knowledgeable treatment decisions. It is not the automatic gainsay of "low quality" evidence and acceptance of randomized controlled trials (RCT's). To be able to make a sound recommendation for a therapy based on the best available evidence, it is necessary to follow steps in acquiring literature, appraising it for study design and quality, and to assess its results, as well as look at the net benefits and net harms.

Acute colonic pseudo-obstruction after elective total joint arthroplasty

A retrospective review of 31 patients who developed acute colonic pseudo-obstruction (ACPO) after total joint arthroplasty was undertaken to determine predisposing factors related to, and outcomes following, therapeutic intervention. Comparison with all patients who underwent total joint arthroplasty revealed an overall 1.2% incidence of ACPO. There was a higher incidence of ACPO in patients undergoing sequential bilateral total knee arthroplasty (3.4%) compared with unilateral total knee arthroplasty (0.3%) and a higher incidence in patients undergoing revision total hip arthroplasty (5.6%) compared with primary total hip arthroplasty (1.4%). Additional risk factors for developing ACPO included slow postoperative mobilization and male gender. No association was found with respect to body mass index, age, comorbidity, anesthetic type, international normalized ratio level, or postoperative analgesia. There were no deaths, and 2 patients required operative intervention. The remaining cases of ACPO resolved with nonsurgical treatment. In all cases, there was a prolonged length of hospitalization (mean, 13.2 days) compared with all other arthroplasties performed at our institution (mean, 7.5 days).

Extracorporeal shockwave therapy: A systematic review of its use in fracture management

Extracorporeal shockwave therapy is increasingly used as an adjuvant therapy in the management of nonunions, delayed unions and more recently fresh fractures. This is in an effort to increase union rates or obtain unions when fractures have proven recalcitrant to healing. In this report we have systematically reviewed the English language literature to attempt to determine the potential clinical efficacy of extracorporeal shockwave therapy in fracture management. Of 32 potentially eligible studies identified, 10 were included that assessed the extracorporeal shockwave therapy use for healing nonunions or delayed unions, and one trial was included that assessed its use for acute high-energy fractures. From the included, studies' overall union rates were in favor of extracorporeal shockwave therapy (72% union rate overall for nonunions or delayed unions, and a 46% relative risk reduction in nonunions when it is used for acute high-energy fractures). However, the methodologic quality of included studies was weak and any clinical inferences made from these data should be interpreted with caution. Further research in this area in the form of a large-scale randomized trial is necessary to better answer the question of the effectiveness of extracorporeal shockwave therapy on union rates for both nonunions and acute fractures.

Wound irrigation does not affect health-related quality of life after open fractures: results of a randomized controlled trial

AIMS

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

PATIENTS AND METHODS

Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores.

RESULTS

We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001).

CONCLUSION

Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88-94.

Communicating study results to our patients: which way is best?

Before we are able to communicate evidence and evidence results to patients we must first be familiar with the common ways by which results may be presented to our patients. We describe five approaches (relative risk, risk reduction, odds ratio, absolute risk difference and number needed to treat) of transforming the results of an orthopaedic study for communication with patients.