Retrograde intramedullary nailing or locked plating for stabilisation of distal femoral fractures? A comparative study of 193 patients

PURPOSE

The aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the rate of complications was different between the two groups.

METHODS

Between January 2009 and December 2018 adult patients with distal femoral fractures managed in our unit with either LP or IMN for extra and intra-articular fractures were eligible to participate. Demographic details, fracture type, procedures performed, time to union, complications and functional scores (Oxford Knee Score) were recorded and analysed. The mean follow up was 4 years (12-120 months).

RESULTS

Out of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were treated with LP. Mean age was 64.2 (18-99) and 70.1 (18-100) for the IMN and LP groups respectively. Overall, the two groups had similar demographics and there was no significant difference in the type of fractures sustained (p > 0.05). The Oxford Knee Score was highest for patients fixed with LP, mean 37.3 (6-48, SD 7.3) versus 28.4 (3-48, SD 14.4), (p =  < 0.02) compared to the IMN group. In terms of complications, the rate of non-union was higher in the LP group 8.6% versus 4% in those patients treated with an IMN, p value < 0.01.

CONCLUSION

While the rate of non-union was higher in the LP group and the functional results were superior in the plating group.

874 Impact of Covid-19 Measures on Surgical Site Infection Rate in Orthopaedic Patients

Aim

Rate of surgical site infections (SSI) in orthopaedic surgery is low but can have disastrous consequences. The aim of this study was to assess the impact of Covid-19 measures on the rate of SSI and subsequent readmissions in orthopaedic patients.

Method

Retrospective, observational study comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods: 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI.

Results

The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p &lt;0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836).

Conclusion

Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

The treatment of intramedullary osteomyelitis of the femur and tibia using the Reamer–Irrigator–Aspirator system and antibiotic cement rods

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

Genetic predisposition to non-union: evidence today

Atrophic non-union represents a complex clinical condition and research is ongoing in an effort to elucidate its pathophysiology and to offer new and more efficient treatment modalities. Differences seen in fracture healing responses and final outcome may be attributed among other factors to biological variations between patients resulting in a "disturbed" signalling pathway and an "inert or deficient local biology with reduced potentials for bone regeneration". The genetic contribution with or without the interaction of other exogenous factors in cases of impaired fracture healing, is yet to be elucidated. However, preliminary animal and human studies demonstrate the molecular basis of fracture non-unions and correlate genetic variants of the molecules regulating fracture healing and their expression patterns with impaired bone healing and fracture non-union. Further research is needed to clarify the genetic component and its role and interaction with other risk factors that may result in increased susceptibility of a patient to develop this complication.

A 2-year experience, management and outcome of 200 clavicle fractures

INTRODUCTION

Clavicle fractures can cause pain and functional impairment if not managed appropriately. This article evaluates the prevalence of clavicular fractures, estimates the number of cases requiring operative treatment, evaluates whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative groups.

PATIENTS AND METHODS

Between November 2005 and November 2007, patients with clavicular fractures were eligible for participation. Patients below 18 years of age and those with pathological fractures were excluded. Demographic details, mechanism of injury, operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal and functional outcome using the University of California, Los Angeles (UCLA) shoulder-rating score were documented and analysed.

RESULTS

Out of 16,280 fractures that presented to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. As many as 20 patients were lost due to natural attrition. A total of 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients were operated upon, over half of them for symptomatic non-union. All clavicles united postoperatively. Eighty-one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative patient groups in mid-shaft fractures. There was no statistical difference between the operative and non-operative groups in lateral-end fractures. A total of 42.9% required removal of metal implant due to soft tissue irritation with complete resolution of symptoms.

CONCLUSION

The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hardware-related irritation.

Seasonality of violent suicides in the Athens greater area

The aim of the study was to ascertain suicide seasonality in the Greek population and to associate this seasonal variation with age, sex, and suicide method. Studying seasonality can be of help in establishing a public health policy, related with suicide prevention. This is an epidemiologic study based on forensic evidence. We studied the deaths caused by self-injury (trauma), namely deaths by violent suicide (not self-poisoning). Statistically significant suicide seasonality was established with a peak in May. This seasonal variation is attributed mainly to males. As for the method, suicide by hanging peaks in June and by shooting in April. It was also observed that seasonality for individuals above the age of 45 peaks in early May.

Autopsy findings from 111 deaths in the 1999 Athens earthquake as a basis for auditing the emergency response

Background

The aim of the study was to assess the emergency response to an earthquake.

Methods

This retrospective study, based on formal autopsy findings from 111 earthquake-related deaths, evaluated demographic data, circumstances of death, rescue time, mechanisms of injury, causes of death, Abbreviated Injury Scale (AIS 90) and Injury Severity Score (ISS) values, vital functions, co-morbidity and preventable deaths.

Results

The median extrication time for 99 of 102 victims buried or trapped in collapsed buildings was 2·1 (range 0·1–7·8) days. Deaths were cause by blunt injuries, asphyxia and myocardial infarction. Injuries impaired the airway, breathing, circulation, and brain or spinal functions in 10·5, 61·9, 46·6 and 57·1 per cent of the victims respectively. The 105 injured victims were classified into three main categories. The first comprised 36 victims (34·3 per cent) with injuries not compatible with life (ISS 75), the second included 38 victims (36·2 per cent) who suffered life-threatening injuries (ISS 9–74) but had no evidence of asphyxia, and the third category contained 31 victims (29·5 per cent) with findings of asphyxia and an ISS of 1–18. The reviewers concluded that 13 trauma-related deaths and 31 deaths from asphyxia were potentially preventable.

Conclusion

A method based on detailed evaluation of deaths provided information with which to audit the emergency response to an earthquake.