Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

ObjectivesHistorically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients.MethodsA prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2–4 weeks, and 3, 6 and 12 months after fracture.Results102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2–4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0–8) vs. 5 (0–10), p = 0.19) and ADL scores (85 (25–100) vs. 78.6 (5–100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%.ConclusionsThe vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.     

Isokinetic quadriceps symmetry helps in the decision to return to running after anterior cruciate ligament reconstruction

BackgroundAfter anterior cruciate ligament reconstruction (ACLR), the decision to allow a return to running is empirical, and the post-operative delay is the most-used criterion. The Quadriceps isokinetic-strength Limb Symmetry Index (Quadriceps LSI), with a cutoff of 60%, could be a useful criterion.ObjectiveTo determine the association between a Quadriceps LSI ≥ 60% and return to running after ACLR.MethodsOver a 10-year period, we retrospectively included 470 patients who underwent ACLR. Four months after ACLR, participants performed an isokinetic test; quadriceps concentric peak torque was used to calculate the Quadriceps LSI at 60?/s. With a Quadriceps LSI ≥ 60%, a return to running was suggested. At 6 months after ACLR, participants were clinically evaluated for a return to sport and post-operative middle-term complications. A multivariable predictive model was built to assess the efficiency diagnosis of this cutoff in order to consider cofounding factors. Quadriceps LSI cutoff ≥ 60% was assessed with sensitivity, specificity and the area under the receiver operating characteristic curve (AUC).ResultsAccording to our decision-making process with the 60% Quadriceps LSI cutoff at 60?/s, 285 patients were authorized to return to running at 4 months after ACLR and 185 were not, but 21% (n = 59) and 24% (n = 45), respectively, were not compliant with the recommendation. No iterative autograft rupture or meniscus pathology occurred at 6 months of follow-up. On multivariable logistic regression analysis, a return to running by using the 60% Quadriceps LSI cutoff was associated with undergoing the hamstring strand procedure (odds ratio 2.60, 95% confidence interval [CI] 1.75–3.84; P < 0.0001) and the absence of knee complications (1.18, 1.07–1.29; P = 0.001) at 4 months. The sensitivity and specificity of the 60% Quadriceps LSI cutoff were 83% and 70%, respectively. The AUC was 0.840 (95% CI 0.803–0.877).ConclusionsUsing the 60% cutoff of the isokinetic Quadriceps LSI at 4 months after ACLR could help in the decision to allow a return to running.     

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation.ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.Level of EvidenceII.     

The role of hip arthroplasty in management of the hip fracture patient

Hip fractures are becoming increasingly common in a growing elderly population, and are associated with significant morbidity and mortality. Displaced intracapsular femoral neck fractures are usually treated with either total hip arthroplasty (THA) or hemiarthroplasty, although the indication for each operation remains an area for debate. THA has been associated with longer operative time, increased risk of dislocation and a slight increase in general complications compared with hemiarthroplasty. However, it has also been associated with a modest improvement in functional outcomes and quality of life. Guidelines have been created within the UK to aid the decision-making process based upon current available literature. The principal focus of these has been to identify patients suitable for THA, and include patients who are cognitively intact, mobile outside their home with the use of no more than one stick, and who are medically fit enough for the procedure. However, implant selection must also be taken into consideration in order to achieve the best outcomes for patients. Options for implants include use of dual mobility cups and choice of femoral head size in THA, bipolar versus unipolar hemiarthroplasty, and cemented versus uncemented implants. Further research is required into this area to make additional recommendations.     

136例老年高能量股骨转子间骨折的临床治疗分析

目的明确高能量股骨转子间骨折对老年患者的影响。方法高能量创伤老年患者319例,排除伴有外伤性脑损伤及伴有神经症状的脊柱损伤患者。分为骨折组及对照组:骨折组136例,有股骨转子间骨折,平均年龄(70.84±8.06)岁。对照组183例,无股骨转子间骨折,平均年龄(69.09±7.64)岁。记录患者的住院死亡率,6个月及1年死亡率,并发症,ICU时间,住院时间,出院情况,伴随骨折,手术干预情况。采用x~2检验、Fisher's精确概率法、t检验、KaplanMeier评估法以及Cox回归分析对数据进行分析。结果两组间住院死亡率、6个月死亡率、1年死亡率比较,差异无统计学意义(P0.05)。高能量股骨骨折的老年患者并发症增加(P0.05),多伴有长骨骨折(P0.05)和非长骨骨折(P0.05),更多需要外科手术治疗(P0.05),住院时间较长(P0.05),两组患者平均ICU天数相似。结论高能量股骨转子间骨折增加了老年患者的并发症发生率,但并没有增加死亡率。对这一群体,伴随损伤可能发挥着更为重要的作用。     

Sit-to-walk and sit-to-stand-and-walk task dynamics are maintained during rising at an elevated seat-height independent of lead-limb in healthy individuals

IntroductionSit-to-walk (STW) is a common transitional motor task not usually included in rehabilitation. Typically, sit-to-stand (STS), pause, then gait initiation (GI) before walking is used, which we term sit-to-stand-and-walk (STSW). Separation between centre-of-pressure (COP) and whole-body centre-of-mass (BCOM) during GI is associated with dynamic postural stability. Rising from seats higher than knee-height (KH) is more achievable for patients, but whether this and/or lead-limb significantly affects task dynamics is unclear. This study tested whether rising from seat-heights and lead-limb affects STW and STSW task dynamics in young healthy individuals.MethodsTen (5F) young (29 ± 7.7 years) participants performed STW and STSW from a standardised position. Five trials of each task were completed at 100 and 120%KH leading with dominant and non-dominant legs. Four force-plates and optical motion capture delineated key movement events and phases with effect of seat-height and lead-limb determined by 2-way ANOVA within tasks.ResultsAt 120%KH, lower peak vertical ground-reaction-forces (vGRFs) and vertical BCOM velocities were observed during rising irrespective of lead-limb. No other parameters differed between seat-heights or lead-limbs. During GI in STSW there was more lateral, and less posterior, COP excursion than expected.ConclusionReduction in vGRFs and velocity during rising at 120%KH is consistent with reduced effort in young healthy individuals and is likely therefore to be an appropriate seat-height for patients. Lead-limb had no effect upon STSW or STW parameters suggesting that normative data independent of lead-limb can be utilised to monitor motor rehabilitation should differences be observed in patients. STSW should be considered an independent movement transition.     

Micro computed tomography features of laryngeal fractures in a case of fatal manual strangulation

Cases of subtle fatal neck compression are often complicated by the lack of specificity of the post-mortem signs of asphyxia and by the lack of clear signs of neck compression.Herein we present a forensic case of a 45-year-old schizophrenic patient found on the floor of the bedroom of a psychiatric ward in cardiopulmonary arrest and who died after two days in a vegetative state. The deposition of the roommate of the deceased, who claimed responsibility for the killing of the victim by neck compression, was considered unreliable by the prosecutor.Autopsy, toxicological analyses, and multi-slice computed tomography (MSCT), micro computed tomography (micro-CT) and histology of the larynx complex were performed. Particularly, micro-CT analysis of the thyroid cartilage revealed the bilateral presence of ossified triticeous cartilages and the complete fragmentation of the right superior horn of the thyroid, but it additionally demonstrated a fracture on the contralateral superior horns, which was not clearly diagnosable at MSCT. On the basis of the evidence of intracartilaginous laryngeal hemorrhages and bilateral microfracture at the base of the superior horns of the larynx, the death was classified as a case of asphyxia due to manual strangulation.Micro-CT was confirmed as a useful tool in cases of subtle fatal neck compression, for the detection of minute laryngeal cartilage fractures, especially in complex cases with equivocal findings on MSCT.     

对比观察跨伤椎固定与经伤椎固定在治疗胸腰段脊柱骨折的临床疗效

目的对比观察跨伤椎固定与经伤椎固定在治疗胸腰段脊柱骨折的临床疗效。方法将患者平均分为实验组和对照组,对照组行跨伤椎固定,实验组行经伤椎固定。结果经过治疗后实验组JOA为(23.4±1.8)分,VAS为(2.6±0.8)分,与对照组相比,P0.05,差异不具有统计学意义。实验组手术后与手术前伤椎前后缘之差,以及半年后测量值与术后前后缘之差对比,P0.05,差异具有统计学意义。结论与跨伤椎固定相比,采用经伤椎固定的方法治疗胸腰段脊柱骨折具有更好的临床效果。