Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

桡骨远端B型骨折

目的：探讨桡骨远端B型骨折腕关节镜直视下复位后予Herbert螺钉固定治疗的临床疗效。方法：2013年6月至2015年7月,采用腕关节镜直视下手法复位及撬拨复位Herbert螺钉固定同时修复关节内软组织损伤的方法治疗桡骨远端患者28例,男15例,女13例;年龄17～69岁,平均45.3岁;病程为伤后4～7d。受伤后患者具有典型桡骨远端骨折体征,X线片及CT明确诊断,并确定不合并其余部位骨折及神经血管损伤,不合并严重内科疾病,无手术禁忌证。按AO/OTA分型：B1型8例,B2型7例,B3型13例。随访观察骨折愈合情况及腕关节功能恢复情况,并评定疗效。结果：全部患者无手术并发症发生,28例桡骨远端B型骨折术后均获随访,平均随访时间（12.1±1.4）个月,骨折全部愈合,测量掌倾角（15.2±3.4）°,尺偏角（20.4±6.4）°。根据Cooney腕关节评分量表评估疗效,优21例,良5例,可2例。术中关节镜检合并舟月韧带撕裂3例,合并月三角韧带撕裂1例,合并TFCC损伤16例。结论：腕关节镜辅助下复位Herbert螺钉固定治疗桡骨远端B型骨折可使关节面平整度最大程度恢复,应用Herbert螺钉固定创伤小,术后恢复时间短,减少骨折后创伤性关节炎的发病,同时可对骨折合并关节内韧带及软骨损伤一并修复恢复关节稳定性,降低腕关节慢性疼痛的发生率。     

Evaluation of patients with pathological fractures treated by standard trauma principles but neglecting the underlying malign bone disease

IntroductionThere are several studies in the literature about pathological fractures but almost no information about patients whose pathological fracture caused by a malignant lesion misdiagnosed and treated as a simple fracture. The aim of this study was to investigate patient and fracture characteristics, and outcomes in cases where fractures occurred in the presence of a malign pathology but were treated as simple fractures.Patients and MethodsCases of malign bone lesions between 2000 and 2020 were retrospectively reviewed. Patients with a final diagnosis of malign bone lesion but whose pathological fractures were treated ignoring the underlying malign bone disease were included. Demographic, clinical and outcome data were collected from patient's medical records and analyzed.ResultsSix patients met the inclusion criteria. Three of the patients were female and the cohort mean age was 56.8 ± 21.8 years at the time of admission. Patient diagnoses were: renal cell carcinoma metastasis (n = 1); colon cancer metastasis (n = 1); chondrosarcoma (n = 2); osteosarcoma (n = 1); and undifferentiated pleomorphic sarcoma of bone (n = 1). In all cases surgical management differed from those that should have been applied if the pathological fracture had been identified. Furthermore, surgical management after definitive histological diagnosis were more aggressive compared to if the malignancy had been identified at first admission. All patients died after a mean follow-up of 16.67 ± 11.7 months and the complication rate was 100%.ConclusionWhen a pathological fracture is misdiagnosed and managed as a simple bone fracture, outcomes are extremely poor. In these situations, remedial surgery is more extensive, with increased complication rates and there is poor life expectancy.     

Risk factors for loss to follow up of pelvis and acetabular fractures

IntroductionPelvic and acetabular fracture incidence is increasing worldwide for more than four decades. There is currently no evidence examining risk factors for loss to follow up in patients with these injuries.MethodsPatients presenting with pelvic and/or acetabular fractures at our institution between 2015 and 2020 were included. Demographic, injury, treatment, and follow up information was included. Excluded patients were those who sustained a pathologic fracture, has a course of treatment prior to transfer to our centre, or expired prior to discharge.Results446 patients, 263 with a pelvic ring injury, 172 with an acetabular fracture, and 11 with combined injuries were identified. 271 (61%) of patients in our cohort followed up in Orthopaedic clinic (p = 0.016). With an odds ratio of 2.134, gunshot wound mechanism of injury was the largest risk factor for loss to follow up (p = 0.031) followed by male sex (OR= 1.859) and surgery with general trauma surgery (OR=1.841). The most protective risk factors for follow up with Orthopaedic surgery were operatively treated pelvic and acetabular fractures (OR=0.239) and Orthopaedic Surgery as the discharging service (OR=0.372).DiscussionNumerous risk factors exist for loss to follow up including male sex, ballistic mechanism, and discharging service. Investigation into interventions to improve follow up in these patients are warranted.     

Emergency readmissions following geriatric ground-level falls: How does frailty factor in?

BackgroundGround-level falls (GLFs) in older adults are increasing as life expectancy increases, and more patients are being discharged to skilled nursing facilities (SNFs) for continuity of care. However, GLF patients are not a homogenous cohort, and the role of frailty remains to be assessed. Thus, the aim of this study is to examine the impact of frailty on the in-hospital and 30-day outcomes of GLF patients.Materials and MethodsThis is a cohort analysis from the Nationwide Readmissions Database 2017. Geriatric (age ≥65 years) trauma patients presenting following GLFs were identified and grouped based on their frailty status. The associations between frailty and 30-day mortality and emergency readmission were examined by multivariate regression analyses adjusting for patient demographics and injury characteristics.ResultsA total of 100,850 geriatric GLF patients were identified (frail: 41% vs. non-frail: 59%). Frail GLF patients were younger (81[74–87] vs. 83[76–89] years; p<0.001) and less severely injured–Injury Severity Score [ISS] (4[1–9] vs. 5[2–9]; p<0.001). Frail patients had a higher index mortality (2.9% vs. 1.9%; p<0.001) and higher 30-day readmissions (14.0% vs. 9.8%; p<0.001). Readmission mortality was also higher in the frail group (15.2% vs. 10.9%; p<0.001), with 75.2% of those patients readmitted from an SNF. On multivariate analysis, frailty was associated with 30-day mortality (OR 1.75; p<0.001) and 30-day readmission (OR 1.49; p<0.001).ConclusionFrail geriatric patients are at 75% higher odds of mortality and 49% higher odds of readmission following GLFs. Of those readmitted on an emergency basis, more than one in seven patients died, 75% of whom were readmitted from an SNF. This underscores the need for optimization plans that extend to the post-discharge period to reduce readmissions and subsequent high-impact consequences.     

大鼠成骨细胞增殖及护骨素蛋白含量与甲状旁腺激素的调节效应

目的:体外观察甲状旁腺激素对大鼠成骨细胞增殖和护骨素分泌的调节作用。方法:实验于2005-06/2006-05在四川大学华西医院生物治疗国家重点实验室干细胞与组织工程研究室完成。采用酶消化法和骨组织块法联合分离培养新生SD大鼠颅骨成骨细胞,间歇加药方法将不同浓度0,10-6,10-7,10-8,10-9mol/L甲状旁腺激素作用于大鼠成骨细胞(0mol/L作为空白对照组),经碱性磷酸酶染色及钙结节茜素红染色证实培养的成骨细胞后,采用四甲基偶氮唑盐比色法检测细胞增殖能力,蛋白免疫印迹测定护骨素的分泌量。结果:①成骨细胞的形态变化:倒置相差显微镜下可见培养的成骨细胞呈短梭形、三角形和多边形。碱性磷酸酶染色光镜下可见成骨细胞胞浆中分布特征性蓝紫色细颗粒;成骨细胞的钙结节在镜下可见部分细胞聚集一起呈"集落状"生长。②成骨细胞增殖率:10-6～10-9mol/L浓度甲状旁腺激素对成骨细胞增殖均显示刺激作用,与空白对照组相比,差异显著(P<0.05),增殖率以10-8mol/L甲状旁腺激素组最高。③成骨细胞护骨素的表达:甲状旁腺激素下调成骨细胞中护骨素的分泌,与空白对照组相比,10-6mol/L甲状旁腺激素组抑制作用最明显(P<0.01),无显著剂量依赖性。结论:甲状旁腺激素对体外培养成骨细胞的增殖具有明显促进作用,通过下调成骨细胞中护骨素的分泌,促进破骨细胞生成、活化,促进骨吸收。     

Mid-term results using a cementless hip prosthesis in young Chinese patients: a five- to seven-year follow-up study

A retrospective study was undertaken to evaluate the clinical and radiographic outcomes of 74 cementless total hip arthroplasties (THA) in 69 young Chinese patients. The Asian size and MMA AML stems with smoothly tapered tip were used, and the patients were followed up for at least five years. The mean Harris hip score was 45.4 preoperatively and 95.3 at the last follow-up. The incidence of thigh pain was 5.4%, and was related to the short stature of the patient (<160 cm) (P = 0.030). Six patients (6 hips, 8.1%) had acetabular osteolysis in zone 2; reoperation was performed in one patient because of osteolysis and wear of the polyethylene liner. The survival rate of the metal acetabular and femoral components was 100% (95% confidence interval, 0.95–1.0). Primary THA with this AML prosthesis had an acceptable mid-term result in young Chinese patients.     

软骨素酶ABC促进大鼠脊髓损伤后轴突再生和功能恢复的初步研究

目的探讨软骨素酶ABC（ChABC）对大鼠脊髓横断损伤（SCI）后轴突再生和功能恢复的影响。方法SD大鼠随机分为实验组（SCI＋ChABC）,对照组（SCI＋NS）及正常组。采用T2-8脊髓完全横断模型,术后2周和10周脊髓标本分别行OBT、GFAP、NSE及NF免疫组化染色,术后1、2、3、4、5、6、8、10周进行行为学评分。结果行为学评分,术后3周实验组评分高于对照组（P〈0．05）,同时实验组疤痕中OBT和GFAP染色低于对照组（P〈0．05）,GFAP和NF染色高于对照组（P〈0．05）。结论ChABC能有效降低损伤部位硫酸软骨素蛋白多糖（CSPGs）的活性,从而促进SCI大鼠感觉、运动功能的恢复和轴突的再生。     

The utilization of decellularized tendon slices to provide an inductive microenvironment for the proliferation and tenogenic differentiation of stem cells

The extracellular matrix (ECM) microenvironment for the stem cell niches, including but not limited to the biochemical composition, matrix topography, and stiffness, is crucial to stem cell proliferation and differentiation. The purpose of this study was to explore the capacity of the decellularized tendon slices (DTSs) to induce stem cell proliferation and tenogenic differentiation. Rat adult stem cells, including tendon-derived stem cells (TDSCs) and bone marrow-derived stem cells (BMSCs), were identified to have universal stem cell characteristics. The DTSs were found to retain the native tendon ECM microenvironment cues, including the inherent surface topography, well-preserved tendon ECM biochemical composition and similar stiffness to native tendon. When the TDSCs and BMSCs were cultured on the DTSs respectively, the LIVE/DEAD assay, alamarBlue^® assay, scanning electron microscopy examination and qRT-PCR analysis demonstrated that the DTSs have the capacity to support these stem cells homogeneous distribution, alignment, significant proliferation and tenogenic differentiation. Taken together, the findings of this study indicate that the DTSs can provide a naturally inductive microenvironment for the proliferation and tenogenic differentiation of TDSCs and BMSCs, supporting the use of decellularized tendon ECM as a promising and valuable approach for tendon repair/reconstruction.