Does obesity influence the outcome after the operative treatment of ankle fractures?

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI > or = 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.     

Factors affecting transfusion requirement after hip fracture: Can we reduce the need for blood?

Background

Hip fractures are common injuries that result in blood loss and frequently require the transfusion of blood products. We sought to identify risk factors leading to increased blood transfusion in patients presenting with hip fractures, especially those factors that are modifiable.

Methods

We retrospectively reviewed the cases of all patients who had fixation of their hip fractures between October 2005 and February 2010. The need for transfusion was correlated with potential risk factors, including age, sex, preoperative hemoglobin, fracture type, fixation method and more.

Results

A total of 835 patients had fixation of their hip fractures during the study period; 631 met the inclusion criteria and 249 of them (39.5%) were transfused. We found an association between need for blood transfusion and female sex (p = 0.018), lower preoperative hemoglobin (p < 0.001), fracture type (p < 0.001) and fixation method (p < 0.001). Compared with femoral neck fractures, there was a 2.37 times greater risk of blood transfusion in patients with intertrochanteric fractures (p < 0.001) and a 4.03 times greater risk in those with subtrochanteric fractures (p < 0.001). Dynamic hip screw (DHS) fixation decreased the risk of transfusion by about half compared with intramedullary nail or hemiarthroplasty. We found no association with age, delay to operation (p = 0.17) or duration of surgery (p = 0.30).

Conclusion

The only modifiable risk factor identified was fixation method. When considering blood transfusion requirements in isolation, we suggest a potential benefit in using a DHS for intertrochanteric and femoral neck fractures amenable to DHS fixation.     

Does the term scaphocapitate syndrome need to be revised? A report of 6 cases

This is a retrospective study of six patients with displaced fractures of the neck of the capitate. In four of the six patients the diagnosis was delayed by at least 1 week. After open reduction and internal fixation the results were assessed as excellent (three cases), fair (two cases) or poor (one case). In all cases there was a concomitant injury to the radial side of the wrist: in four cases this was a fracture of the waist of the scaphoid. In five of the six cases there was also an injury to the ulnar side of the wrist. As a scaphoid fracture does not always occur with the fracture of the neck of the capitate, we consider the term "scaphocapitate syndrome" inappropriate for this injury.     

Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature

BackgroundAnkle trauma in children and adolescents is the most common orthopedic injury encountered in pediatric trauma. It has long been recognized that a lateral ankle injury in this population is often a Salter and Harris type I fracture of the distal fibula (SH1). The purpose of this study is to confirm the existence of a lateral ankle sprain and to report the incidence of each pathology of the lateral ankle compartment: SH1 fracture, ATFL injury, and osteochondral avulsions.MethodsA systematic review of the literature is done using the database provided by PubMed and Embase. All articles reporting the incidence of imaging modality-confirmed lateral ankle injury (SH1, ATFL injury, osteochondral avulsion) in children and adolescents were included. Exclusion criteria were the following: case reports or articles with less than ten subjects, unspecified imaging modality and articles unrelated to lateral ankle lesions. Thus, 237 titles and abstracts were selected, 25 were analyzed thoroughly, and 11 articles were included for final analysis.ResultsSH1 fractures were found in 0–57.5% of the cases in all series and 0–3% in the most recent series. A diagnosis of an ATFL injury was found in 3.2–80% and an osteochondral avulsion of the distal fibula in 6–28.1%. The most recent series report 76–80% and 62% for ATFL injury and osteochondral avulsion respectively.ConclusionsThere is a non-negligible incidence of ATFL sprains and fibular tip avulsions in patients with a suspected SH1 fracture of the distal fibula. According to recent evidence and MRI examinations, the most common injuries of the pediatric ankle are ATFL sprain and osteochondral avulsions. This should be taken into consideration in daily practice when ordering radiological examination and deciding on treatment modalities     

Does adding a lesser-curvature gastrogastric plication suture reduce the need for revision after laparoscopic adjustable gastric band placement?

Background  

The need for revision after laparoscopic adjustable gastric band (LAGB) surgery has been reduced over the past 10 years with the introduction of the pars flaccida technique, delicate band tightening, and concurrent hiatal hernia repairs. However, band revision still occurs for as many as 5% of patients. Placement of a lesser-curvature gastrogastric suture distal to the band is one newer technique suggested to lower band slippage. To evaluate the worth of this technique, the authors have investigated two groups of patients in their practice: one group with the plication stitch and one group without it.     

Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients

The aim of the study was to determine if the level of an intracapsular femoral fracture influences the risk of non-union or avascular necrosis occurring after internal fixation. An observer blinded to the outcome of the treatment (fracture union, non-union or avascular necrosis) reviewed the radiographs of 411 patients with an intracapsular fracture, which had been treated by internal fixation. The level of the fracture was determined by two methods, a direct distance measurement and a ratio method. In addition, the diameter of the femoral head was measured. Results indicated that none of the methods for determining the fracture level had any relationship to the risk of non-union or avascular necrosis occurring. Undisplaced fractures were found to be more proximally located than displaced fractures. We conclude that the level of an intracapsular fracture should not be used as a method of deciding if the femoral head should be preserved or replaced. The level of an intracapsular fracture may determine if the fracture displaces at the time of injury.     

Is the location of a positive surgical margin after radical prostatectomy important for prognosis?

This Practice Point commentary discusses the findings and limitations of the study by Eastham and co-workers, which concludes that the location of a positive surgical margin after radical prostatectomy is important for prognosis. The study found that posterolateral margins markedly increased the risk of biochemical failure while apical margins did not. Posterolateral margin status was found to be even more important for predicting biochemical failure than was lymph node positivity or seminal vesicle invasion. For several reasons, however, these results might not be generalizable to other groups of patients or to clinically relevant end points, such as cancer-specific survival. Consequently, these data should be regarded as preliminary and should not inform therapeutic decisions. Instead, knowledge of the most-common sites of margin positivity might direct surgeons to examine any shortcomings in their surgical technique. We contend that positive margins can be prevented at even the most difficult-to-access locations if appropriate steps are taken.     

Post-operative anaemia in femoral neck fracture patients: Does it need treatment? A single blinded prospective randomised controlled trial

A prospective randomised controlled trial was performed to establish the effect of oral iron supplementation on haemoglobin level at 4 weeks post-operative in elderly patients with fractured neck of femur undergoing surgical treatment. We single blindly randomised 68 patients into two groups. Thirty-four patients in the treatment group were compared with 32 in the control group. The treatment group received 200 mg of oral iron tablets 3 times a day for 4 weeks in the post-operative period compared to nothing for the control group. The groups were comparable in all other aspects. The iron treatment resulted in significantly increased haemoglobin value at 4 weeks; 0.76 g% higher than the control group (95% CI of +0.01 to +1.51) which is statistically significant (P < 0.05). There was no major complication. We recommend oral iron supplementation in elderly anaemic patients with hip fracture in the post-operative period.     

Construction of a FRAX? model for the assessment of fracture probability in Canada and implications for treatment

Summary

We describe the creation of a FRAX? model for the assessment of fracture probability in Canadian men and women, calibrated from national hip fracture and mortality data. This FRAX tool was used to examine possible thresholds for therapeutic intervention in Canada in two large complementary cohorts of women and men.

Objective

To evaluate a Canadian World Health Organization (WHO) fracture risk assessment (FRAX?) tool for computing 10-year probabilities of osteoporotic fracture.

Methods

Fracture probabilities were computed from national hip fracture data (2005) and death hazards (2004) for Canada. Probabilities took account of age, sex, clinical risk factors (CRFs), and femoral neck bone mineral density (BMD). Treatment implications were studied in two large cohorts of individuals age 50?years and older: the population-based Canadian Multicentre Osteoporosis Study (4,778 women and 1,919 men) and the clinically referred Manitoba BMD Cohort (36,730 women and 2,873 men).

Results

Fracture probabilities increased with age, decreasing femoral neck T-score, and number of CRFs. Among women, 10.1?C11.3% would be designated high risk based upon 10-year major osteoporotic fracture probability exceeding 20%. A much larger proportion would be designated high risk based upon 10-year hip fracture probability exceeding 3% (25.7?C28.0%) or osteoporotic BMD (27.1?C30.9%), and relatively few from prior hip or clinical spine fracture (1.6?C4.2%). One or more criteria for intervention were met by 29.2?C34.0% of women excluding hip fracture probability (35.3?C41.0% including hip fracture probability). Lower intervention rates were seen among CaMos (Canadian Multicentre Osteoporosis Study) men (6.8?C12.9%), but in clinically referred men from the Manitoba BMD Cohort, one or more criteria for high risk were seen for 26.4% excluding hip fracture probability (42.4% including hip fracture probability).

Conclusions

The FRAX tool can be used to identify intervention thresholds in Canada. The FRAX model supports a shift from a dual X-ray absorptiometry (DXA)-based intervention strategy, towards a strategy based on fracture probability for a major osteoporotic fracture.     

Magnet stimulation therapy: a simple solution for the treatment of stress and urge incontinence?

AIM: Magnet stimulation therapy has been offered as a new, conservative therapy for stress and urge incontinence in Germany since 2001. Focussed, pulsating magnetic fields are used to stimulate the musculature of the floor of the pelvis. This publication describes our initial experience with this method. PATIENTS AND METHODS: We treated 27 patients with magnetic stimulation. The individual patient sits clothed on a therapy-chair and is treated for 20 min twice a week for 2 weeks. RESULTS: The best results were recorded in female patients with grades I and II stress incontinence who could not actively flex their pelvic-floor musculature during physiotherapy. A marked reduction in the frequency of micturition was obtained in 67% of patients with urge incontinence symptoms and non-responsiveness to anticholinergic therapy. Patients with a non-organically tangible pelvic-pain-syndrome did not benefit from the therapy. CONCLUSIONS: Magnet stimulation therapy can act as a useful addition to conservative therapies for stress and urge incontinence. It is free of complications and does not involve the insertion of an electrode into the patient as is the case for vaginal and anal electrostimulation. However, this method does not appear to be useful for chronic, non-specific pain in the lower pelvis.     

Kingella kingae spondylodiscitis in young children: toward a new approach for bacteriological investigations? A preliminary report

As the result of improved bacteriological techniques, Kingella kingae is a slow-growing Gram-negative coccobacillus that is emerging as an important cause of spondylodiscitis in children younger than 3 years of age. The high pharyngeal carrier rates of this slow-growing Gram-negative coccobacillus combined with the low incidence of identified K. kingae infections is possibly explained by a low virulence of this bacterium. The use of specific real-time polymerase chain reaction (PCR) on blood samples and throat swabs opens new prospects in the bacteriological investigations of young children suspected to have spondylodiscitis, an approach that could prevent, in the future, unnecessary invasive interventions.     

Do we need to cool the lung graft after ex vivo lung perfusion? A preliminary study

Background

After normothermic ex vivo lung perfusion (EVLP), pulmonary grafts are usually flush-cooled and stored on ice until implantation although evidence for this practice lacks. We compared outcomes between 2 post-EVLP preservation strategies in a porcine left single-lung transplantation model.

Material and methods

After cold flush and 2-h EVLP, donor lungs were prepared and split. In [C], (n = 5) lungs cooled on device to 15°C were preserved in ice-water; in [W] (n = 5), lungs were disconnected from EVLP at 37°C and kept at room temperature. The left lung was transplanted in a recipient animal. Posttransplant, 6 h-monitoring included hourly assessment of pulmonary vascular resistance, pulmonary artery pressure, plateau airway pressure, compliance, and oxygenation before and after exclusion of the right lung. Lung biopsies and bronchoscopy with bronchoalveolar lavage (BAL) were performed at retrieval, at the end of EVLP (R lung), and 1 and 6 h after reperfusion (L lung).

Results

Lungs in [W] showed the highest compliance (P < 0.05) and the lowest plateau airway pressure (not statistically significant) throughout the whole reperfusion period. Oxygenation and pulmonary artery pressure were similar between groups. Pulmonary vascular resistance was stable in [C], but rose after reperfusion in [W]. Histologic signs of lung injury and BAL neutrophilia were more pronounced in [C] at 1 h (not statistically significant and P < 0.05, respectively). BAL cytokine levels and lung tissue expression of intercellular adhesion molecule 1 did not differ between groups.

Conclusions

Normothermic preparation after EVLP results in similar graft performances compared with lung cooling after EVLP.     

Is fusion superior to non-fusion for the treatment of thoracolumbar burst fracture? A systematic review and meta-analysis

Objective

The purpose of this meta-analysis was to compare the efficacy and safety between patients with thoracolumbar burst fracture who underwent posterior fixation alone (non-fusion) and supplemented with fusion.

Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report

Minimally Invasive Plate Osteosynthesis (MIPO) has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. An anatomical study was performed to evaluate the feasibility of MIPO for the humeral shaft fractures, and to study the relationship between the radial nerve and the plate with the forearm in full pronation and in supination. The study was performed on ten arms from five fresh cadavers. Two separate incisions, one proximal and one distal, were made in each arm with the forearm in full supination. A 9-hole narrow DCP was inserted into a tunnel using an anterior approach and fixed with 2 screws each on the proximal and distal humerus. The tunnel was then explored to identify the relationship between the radial nerve and the plate. No radial nerve compression or entrapment by the plate was found. The distance measured from the closest part of the plate to the radial nerve was 2.0-4.9 mm (average 3.2 mm). When the forearm was pronated, the radial nerve moved closer to the plate by a distance of 0-3 mm. The results of this study showed that it is possible to treat humeral shaft fractures by the MIPO method using an anterior approach. To reduce the risk of radial nerve injury, the forearm must be kept in full supination during plate insertion, and excessive force should be avoided during retraction of the lateral half of the brachialis muscle together with the radial nerve in the distal incision. The results of using this MIPO approach for humeral shaft fractures in 4 patients were also reviewed.     

Short-term outcomes with the Ajust? system: a new single incision sling for the treatment of stress urinary incontinence

Introduction and hypothesis  

To evaluate the efficacy and safety of the minimally invasive Ajust™ system in the treatment of stress urinary incontinence.     

Does treatment of cadaveric organ donors with desmopressin increase the likelihood of pancreas graft thrombosis? Results of a preliminary study

Desmopressin (DDAVP) is commonly used in cadaveric organ donors to treat diabetes insipidus. The thrombogenic potential of DDAVP is well known. Recent animal data have demonstrated that DDAVP impairs pancreas graft (PG) microcirculation and perfusion. The aim of this study was too evaluate the effect of DDAVP on the incidence of PG thrombosis in clinical pancreas transplantation. A retrospective review of simultaneous kidney-pancreas transplant (SKPT) entered in the Scientific Registry of Transplant Recipients (SRTR) between 10/5/87 and 9/27/02 was performed. Patients were included for analysis if there was definitive documentation as to whether DDAVP was (DDAVP-Y) or was not (DDAVP-N) administered to the donor. Both dose and duration of DDAVP treatment were not recorded by SRTR. A total of 2804 SKPTs were available for analysis. Mean follow-up was 1.75 years (range, 1 month to 8.4 years). A total of 1287 SKPT patients (46%) received a PG from a DDAVP-Y donor. Graft ischemia times, donor and recipient ages, recipient gender distribution, surgical techniques, and immunosuppressive regimens were similar in both groups. The overall incidence of PG thrombosis was 4.3%. The incidence of PG thrombosis in recipients of grafts from DDAVP-Y donors was 5.1% compared to 3.5% in recipients of grafts from DDAVP-N donors (P =.04). Fifty-eight percent of thrombosed PG came from DDAVP-Y donors compared to 42% from DDAVP-N donors (P =.04). We conclude that there appears to be a relationship between donor treatment with DDAVP and PG thrombosis. A prospective study is needed to verify these findings and to determine their clinical significance.