The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

Effect of fragmentary displacement and morphology in the treatment of comminuted femoral shaft fractures with an intramedullary nail

Objective

Our study aimed to determine whether the displacement and morphology of a fragment in femur fracture with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association/32-B/32-C (AO/OTA/32-B/32-C) classification affect the outcomes following closed reduction and internal fixation with an interlocking nail.

Design

This was a retrospective study.

Setting

The study was conducted at a Level III trauma centre.

Patients

A total of 50 consecutive patients presenting femoral shaft fracture with AO/OTA-type 32-B/32-C were included in the present study.

Interventions

Patients were divided into two groups according to the displacement of the fragments. In the large displacement group, patients were further subgrouped according to whether a reversed morphology of the fragment was present.

Outcomes measurement

The radiographic union score of femur (RUSF), the mean union time and the re-operation rate were assessed.

Results

The union rate of small- and large-gap groups at 12 months postoperatively was 75.9% and 21.1%, respectively (p = 0.000). The mean union time of those union cases in these two groups was 7.8 and 13.0 months, respectively (p = 0.000). The union rate of the non-reversed and reversed groups at 12 months postoperatively was 30% and 11.1%, respectively (p = 0.179). The mean RUSF at 12 months in the non-reversed and reversed groups was 8.8 and 8.3, respectively (p = 0.590). However, we found that patients presenting a reversed fragment had an increased risk of more than one re-operation (p = 0.030).

Conclusions

A fragmentary displacement of >1 cm in AO/OTA-type 32-B/32-C femoral shaft fracture after nailing affected bone healing. Among the large-gap group patients, an unreduced reverse fragment presented a negative prognostic factor for re-operation.

Level of evidence

Prognostic level III.     

Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures

Introduction

Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability.

Patients and methods

A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion.

Results

28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI > 30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P < 0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach.

Discussion

Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.     

Timing of diaphyseal femur fracture nailing: Is the difference night and day?

Introduction

Most hospitals are faced with reduced personnel, resources, and provider fatigue or shift changes when day turns to night. For these reasons, some have suggested that diaphyseal femur fractures should be fixed during the daytime. The purpose of this study is to determine whether the time of surgery affects the post-operative difference in femoral version (DFV) and femoral length (DFL) between the fixed and uninjured sides following intramedullary nailing (IMN).

Materials and methods

Over a 10-year period, 340 patients underwent IMN of a diaphyseal femur fracture (AO types 32-A to C) with a post-operative computed tomography scanogram for version measurement. Demographic and surgical data, including time operated was collected. “Daytime” was defined as 7:00 AM to 6:59 PM, while the remainder of the clock was “nighttime”. Additionally, the night hours were split into 3 consecutive 4-h categories for further analysis. Stepwise, multivariate regressions were used to evaluate any effect of time of surgery on post-operative DFV or DFL. Other variables included in these statistical models were age, sex, mechanism of injury, open vs. closed fracture, trauma vs. non-trauma surgeon, and AO and Winquist classifications.

Results

Overall, 22.4% (76/340) of all fractures were fixed at night. The mean post-operative DFV and DFL from the uninjured side in these patients was 8.9° and 4.1 mm, respectively, compared to 9.0° and 4.8 mm in those treated during the daytime. This difference was not statistically significant when accounting for other factors (p > 0.05). There was no statistically significant difference in patients with >10 mm limb length discrepancy or >15 degrees DFV (p = 1.0 for both).

Conclusion

The time of day at which diaphyseal femur fractures are treated does not have an impact on post-operative femoral version or length. While certain other injuries may be better handled during daytime hours, acceptable IMN of mid-shaft femur fractures may be achieved during all hours at a level 1 trauma centre.     

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

Background

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

Materials and methods

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n = 26) comprised patients who had their fibula fixed while Group II (n = 34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

Results

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

Conclusion

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.     

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged

Background

Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population.

Methods

Study design: retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27–60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores.

Results

All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome.

Conclusion

Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.     

Radiological outcome and intraoperative evaluation of a computer-navigation system for femoral nailing: A retrospective cohort study

Aim

Intraoperative determinations of femoral antetorsion and leg length during fixation of femoral shaft fractures present a challenge. In femoral shaft fracture fixations, a computer-navigation system has shown promise in determining antetorsion and leg length discrepancies. This retrospective cohort study aimed to determine whether the use of computer navigation during femoral nailing procedures reduced postoperative femoral malrotation and leg length discrepancy, as well as the number of revision cases. We also sought to determine whether radiation exposure time was reduced when computer navigation was used.

Materials and methods

Of 246 patients treated for femoral shaft fractures between 2004 and 2012, we selected those that received postoperative computed tomography for rotation and leg length control. We included 24 patients who received navigation-assisted treatments and 48 who received unassisted treatments, matched for age, sex, and fracture type. All patients were treated by femoral nailing.

Results

The groups showed significant differences in the mean (standard deviation (SD) delay before surgery (navigation-assisted vs. unassisted groups: 8.5 ± 3.2 vs. 5.2 ± 5.8 days; P < 0.05) and surgery times (163.7 ± 43.94 vs. 98.3 ± 28.13 min; P < 0.001). The groups were significantly different in the mean (SD) radiation exposure time (4.43 ± 1.35 vs. 3.73 ± 1.5 min; P = 0.042), and were not significantly different in the postoperative femoral antetorsion difference (8.83 ± 5.52° vs. 12.4 ± 9.2°; P = 0.056), or in the postoperative length discrepancy (0.92 ± 0.75 vs. 0.95 ± 0.94 cm; P = 0.453). Four (16.7%) navigation-assisted and 15 (31.25%) unassisted surgeries got revision for torsion and/or length corrections.

Conclusion

Our results showed that, compared to unassisted femoral surgery, the computer-navigation system did not improve postoperative results or reduce radiation exposure. In the future, improvements in handling and application could facilitate the workflow and may provide better postoperative results. Currently, computer navigation may provide advantages for complicated or sophisticated cases, such as complex three-dimensional deformity corrections.

Level of evidence

Level III.     

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

Objective

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

Design

Prospective Cohort.

Setting

Level I Trauma Centre.

Patients/Participants

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

Intervention

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

Main outcome measure(s)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >10°.

Results

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.0° with a mean difference of 16.2° (p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >10° from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.3° with a mean difference of 11.5° (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >10° from the uninjured limb.

Conclusions

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation. The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

Femoral malrotation after intramedullary nailing in obese versus non-obese patients

Objective

Intramedullary nailing (IMN) of obese patients with femoral fractures can be difficult due to soft tissue considerations and overall body habitus. Complications including malrotation can occur and have significant impact on postoperative function. The purpose of this study was to evaluate femoral rotation after intramedullary nailing of obese and non-obese patients to see if there was a difference in rotation, complications and any risk factors for malrotation.

Materials and methods

Between 2000 and 2009, 417 consecutive patients with femur fractures treated with IM nail at Level I trauma and tertiary referral center. Of these, 335 with postoperative computed tomography (CT) scanogram of the bilateral lower extremities were included in this study. Baseline demographic, perioperative and postoperative femoral version calculations were included in the dataset. Statistical analysis included chi-squared test for categorical data, t-test for continuous data, and univariate and multivariate regression analysis. Significance was set at p < 0.05.

Results

Of the 417 patients with femur fractures between 2000 and 2009, 335 met criteria for this study. There were 111 patients with a BMI <25, 129 with BMI 25–29.9, and 95 patients with a BMI >30. When BMI was categorised into 3 groups (<25, 25–29.9, or 30+), none of these groups were predictive of version in univariate or multivariate regressions. Among only obese patients (BMI 30+), BMI of 35+ was not a significant predictor of version when compared to BMI 30–34.9. There were no significant differences in femoral version based on entry point (antegrade vs. retrograde) in any BMI category. There were also no significant difference between groups of patients with a DFV of >15? (p = 0.212).

Conclusions

Based on this study, BMI did not have an effect on postoperative difference in femoral version. In fact, in our multivariate regression analysis, BMI of over 30 was actually predictive of significantly lower difference in femoral version. While other studies have documented the intraoperative difficulties encountered with obese patients with femur fractures, the outcome of femoral rotation is not affected by an increasing BMI.     

Delirium in older people after proximal femoral fracture repair: Role of a preoperative screening cognitive test

Objective

Preoperative cognitive impairment has been identified as a major risk factor for postoperative delirium in older people. The aim of this study was to evaluate whether a validated and rapid screening cognitive test — COgnitive Disorder EXamination (CODEX) — performed preoperatively before proximal femoral fracture repair, was associated with a risk of postoperative delirium.

Study design

We performed an observational prospective cohort study in orthopedic surgery department of a French hospital.

Patients

We included patients aged 70 years or older undergoing proximal femoral fracture repair and who were free of known dementia and delirium at the preoperative phase.

Methods

Before surgery, the anesthesiologist realized the CODEX based on three-word recall test, simplified clock drawing and if one of these tasks was abnormal, spatial orientation was assessed. Delirium was routinely sought on postoperative day 3 (D3) using the Confusion Assessment Method by the geriatrician.

Results

Among the 52 included patients, seven (13.5%) had delirium on D3. All seven patients were among the 25 patients with abnormal CODEX results. None of the 27 patients with normal CODEX results had postoperative delirium. Abnormal CODEX was significantly associated with the risk of postoperative delirium in univariate analysis and after adjustment for age (odds ratio [OR]: 13.33; 95% confidence interval, [95%CI]: 1.85 ± ∞; P < 0.003).

Conclusion

Abnormal preoperative rapid screening test CODEX is independently associated with postoperative delirium in older people undergoing hip fracture surgery and free of known dementia.     

Study of agreement of aortic,radial and femoral blood pressures during aortic endografting

Purpose

To estimate the agreement between radial or femoral, and ascending aortic invasive blood pressure values.

Patients and methods

Prospective study on 32 patients who underwent an aortic endografting under general anesthesia. After deploying the prosthesis under controlled hypotension, a catheter was introduced in the aorta to measure the staged systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, in particular at the level of ascending aorta and femoral artery.

Results

No differences were observed between SAP, DAP or MAP measured in the aorta versus femoral or radial arteries. A better agreement was observed between the aortic and femoral MAP (bias of 1 mmHg, limits of agreement between: –8.8 mmHg and +10.8 mmHg) than between the aortic and the radial MAP (bias of 1.7 mmHg, limits of agreement between: –14.1 mmHg and +17.5 mmHg). The comparison between radial and femoral MAP was not satisfying (bias of –4.7 mmHg and limits of agreement between –19.1 mmHg and +9.7 mmHg).

Conclusion

The femoral MAP is more accurate to predict value of the aortic MAP than the radial MAP in a hypotensive setting. The clinician should be aware of these discrepancies in conditions of hemodynamic impairment to optimize the treatment.     

Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur

Objectives

The purpose of our study was to analyse the incidence and factors predicting the ‘change in discharge destination’ in patients with fractured neck of femur who were treated surgically.

Materials and methods

Fifteen hundred and seventy-three consecutive patients admitted with a fractured neck of femur, residing in their own home prior to admission were studied. Patients who did not have an operation (n = 70) for their hip fracture were excluded from the study.Residential location in the UK is broadly categorised as:

(1)

living in their own home;

(2)

residential home;

(3)

nursing home;

(4)

hospitalised.

Results

A downward drift in “discharge destination” of 20% was noted after analysis. Univariate analysis revealed that age, gender, AMT score, place of fall, type of fracture, walking ability outdoor and indoor, ASA grade, medical co-morbidity requiring physician review and delay beyond 36 h to surgery had a significant effect.Multiple logistic regression analysis revealed that increasing age, male gender (OR = 1.67), accompaniment for outdoor mobilisation (OR = 1.96), increasing ASA grade, AMT score <6 (OR = 4.86), pre-operative medical condition requiring physician review (OR = 2.27), delay greater than 36 h for medical reasons (OR = 4.38) were predictors of the change in discharge destination.

Conclusion

The most important predictors of the change in the discharge destination were the medical condition, cognitive and physical function of the patient at admission. Male gender and increasing age were contributory. The only clinician dependent factor that seemed to affect this change of residential status was delay to surgery secondary to medical problems. Awareness of key predictors that affect the “discharge destination” can be useful for the multidisciplinary team and patients’ families to evaluate and plan for an early, satisfactory and appropriate referral to either community services or institutional care, which in turn could have a significant socioeconomic impact.     

Comparing Femoral Version After Intramedullary Nailing Performed by Trauma-Trained and Non-Trauma Trained Surgeons: Is There a Difference?

Introduction

As with some procedures, trauma fellowship training and greater surgeon experience may result in better outcomes following intramedullary nailing (IMN) of diaphyseal femur fractures. However, surgeons with such training and experience may not always be available to all patients. The purpose of this study is to determine whether trauma training affects the post-operative difference in femoral version (DFV) following IMN.

Materials and Methods

Between 2000 and 2009, 417 consecutive patients with diaphyseal femur fractures (AO/OTA 32A-C) were treated via IMN. Inclusion criteria for this study included complete baseline and demographic documentation as well as pre-operative films for fracture classification and post-operative CT scanogram (per institutional protocol) for version and length measurement of both the nailed and uninjured femurs. Exclusion criteria included bilateral injuries, multiple ipsilateral lower extremity fractures, previous injury, and previous deformity. Of the initial 417 subjects, 355 patients met our inclusion criteria. Other data included in our analysis were age, sex, injury mechanism, open vs. closed fracture, daytime vs. nighttime surgery, mechanism of injury, and AO and Winquist classifications. Post-operative femoral version of both lower extremities was measured on CT scanogram by an orthopaedic trauma fellowship trained surgeon. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for malrotation between the two cohorts.

Results

Overall, 80.3% (288/355) of all fractures were fixed by trauma-trained surgeons. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. This difference was not statistically significant when accounting for other factors in a multivariate model (p > 0.05). The same statistical trend was true when analyzing outcomes of only the more severe Winquist type III and IV fractures. Additionally, surgeon experience was not significantly predictive of post-operative version for either trauma or non-trauma surgeons (p > 0.05 for both).

Conclusions

Post-operative version or percentage of DFV >15° did not significantly differ following IMN of diaphyseal femur fractures between surgeons with and without trauma fellowship training. However, prospective data that removes the inherent bias that the more complex cases are left for the traumatologists are required before a definitive comparison is made.     

Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min

Introduction

We evaluated the relationship between survival and time from arrival to angiography for hemodynamically unstable patients with pelvic trauma.

Methods

A retrospective review of patients admitted to Fukui Prefectural Hospital with pelvic fractures during a 7.5-year period. Charts were reviewed for age, injury characteristics, injury severity score, systolic blood pressure and heart rate on arrival, base deficit, and the lactate concentration on arrival, transfusion requirement, fracture pattern, the time from hospital arrival to angiography, and the time spent in the angiography suite.

Results

Of a total of 140 patients, 68 patients underwent pelvic angiography and embolization. Of the patients, 24 patients were hemodynamically unstable. The average injury severity score was 41.7. Of the patients, 17 had major ligamentous disruption. The average time from hospital arrival to angiography suite was 76 min. Of the hemodynamically unstable 24 patients, there were 12 deaths (50%). Patients who were embolized within 60 min of arrival had a significantly lower mortality rate (16 vs. 64%; p = 0.04). There was no embolization-related complication and repeat angiography was not required in all patients.

Conclusion

Earlier pelvic embolization within 60 min may affect the survival of hemodynamically unstable patients with pelvic fracture.     

Functional late outgrowth endothelial progenitors isolated from peripheral blood of burned patients

Background

Bioengineered skin substitutes are increasingly considered as a useful option for the treatment of full thickness burn injury. Their viability following grafting can be enhanced by seeding the skin substitute with late outgrowth endothelial progenitor cells (EPCs). However, it is not known whether autologous EPCs can be obtained from burned patients shortly after injury.

Methods

Late outgrowth EPCs were isolated from peripheral blood sampled obtained from 10 burned patients (extent 19.6 ± 10.3% TBSA) within the first 24 h of hospital admission, and from 7 healthy subjects. Late outgrowth EPCs were phenotyped in vitro.

Results

In comparison with similar cells obtained from healthy subjects, growing colonies from burned patients yielded a higher percentage of EPC clones (46 versus 17%, p = 0.013). Furthermore, EPCs from burned patients secreted more vascular endothelial growth factor (VEGF) into the culture medium than did their counterparts from healthy subjects (85.8 ± 56.2 versus 17.6 ± 14 pg/mg protein, p = 0.018). When injected to athymic nude mice 6 h after unilateral ligation of the femoral artery, EPCs from both groups of subjects greatly accelerated the reperfusion of the ischaemic hindlimb and increased the number of vascular smooth muscle cells.

Conclusions

The present study supports that, in patients with burns of moderate extension, it is feasible to obtain functional autologous late outgrowth EPCs from peripheral blood. These results constitute a strong incentive to pursue approaches based on using autotransplantation of these cells to improve the therapy of full thickness burns.     

Treatment of ipsilateral concomitant fractures of proximal extra capsular and distal femur

Objectives

Ipsilateral concomitant fractures of proximal extracapsular and distal femur are rare injuries and pose a great challenge for orthopaedics. In this study, we reviewed and examined the approaches and outcomes of this complex injury.

Methods

From August 2002 to January 2010, seven patients (six males and one female) with a mean age of 39 years (range, 20-48 years) were involved in the study. They had suffered from ipsilateral concomitant fractures of proximal extracapsular and distal femur, with two cases of unstable intertrochanteric fractures, three cases of subtrochanteric fractures and two cases of extracapsular femoral neck fractures. The distal femoral fractures were categorised based on the Arbeitsgemeinschaft für Osteosynthes (AO) classification: 2, A3; 2, C1; 2, C2 and 1, C3, and the proximal femoral fractures were stabilised via nailing, whilst the distal ones via less-invasive stabilisation system-distal femur (LISS-DF) plating in all six patients. In the one with the ‘floating knee’ injury, the subtrochanteric fracture was stabilised by reversed LISS-DF, and the distal one, by retrograde nailing. The healing of each femoral fracture was evaluated radiologically and clinically with follow-up. The functional outcomes were assessed through the Friedman and Wyman system.

Results

The mean follow-up interval was 2 years (range, 1.5-3 years). Six femoral fractures healed uneventfully, whilst the one with the ‘floating knee’ injury developed a delayed union postoperatively due to metal failure in 6 months, and, eventually, a malunion with coxa vara deformity 1.5 years later. The clinical functions at the final follow-up were found to be good in five cases, and fair and poor in one case each.

Conclusion

The nailing of a proximal femoral fracture and an LISS-DF fixation of a distal one could be a reliable and effective approach to handle ipsilateral concomitant fractures of a proximal extracapsular and distal femur.     

The Effect of Tumor Location on Prognosis in Patients Treated with Radical Nephroureterectomy at Memorial Sloan-Kettering Cancer Center

Background

The prognostic impact of primary tumor location on outcomes for patients with upper-tract urothelial carcinoma (UTUC) is still contentious.

Objective

To test the association between tumor location and disease recurrence and cancer-specific survival (CSS) in patients treated with radical nephroureterectomy (RNU) for UTUC.

Design, setting, and participants

Prospectively collected data were retrospectively reviewed from 324 consecutive patients treated with RNU between 1995 and 2008 at a single tertiary referral center. Patients who had previous radical cystectomy, preoperative chemotherapy, previous contralateral UTUC, or metastatic disease at presentation were excluded. This left 253 patients for analysis. Tumor location was categorized as renal pelvis or ureter based on the location of the dominant tumor. Recurrences in the bladder only, in nonbladder sites, and in any site were analyzed.

Intervention

All patients were treated with RNU.

Measurements

Recurrence-free survival and CSS probabilities were estimated using Kaplan-Meier and Cox regression analyses.

Results and limitations

Median follow-up for survivors was 48 mo. The 5-yr recurrence-free probability (including bladder recurrence) and CSS estimates were 32% and 78%, respectively. On multivariable analysis, pathologic stage was the only predictor for disease recurrence (p = 0.01). Tumor location was not an independent predictor for recurrence (hazard ratio: 1.19; p = 0.3), and there was no difference in the probability of disease recurrence between ureteral and renal pelvic tumors (p = 0.18). On survival analysis, we also found no differences between ureteral and renal pelvic tumors on probability of CSS (p = 0.2). On multivariate analysis, pathologic stage (p < 0.0001) and nodal status (p = 0.01) were associated with worse CSS. This study is limited by its retrospective nature.

Conclusions

Our study did not show any differences in recurrence and CSS rates between patients with ureteral and renal pelvic tumors treated with RNU.     

Risk factors for contra-lateral hip fracture in elderly patients with previous hip fracture

Introduction

Contra-lateral hip fractures in elderly patients with a previous hip fracture increase the incidence of complications and socioeconomic burden. The purpose of this study was to identify the risk factors that contribute to the occurrence of contra-lateral hip fracture in elderly patients.

Materials and methods

Among 1093 patients treated for a hip fracture, 47 patients sustained a contra-lateral hip fracture. These patients were compared with 141 patients with a unilateral hip fracture (controls).

Results

The incidence of contra-lateral hip fracture was 4.3% among the 1093 patients treated for a hip fracture at our institute. A contra-lateral hip fracture occurred within 2 years of initial fracture in 66%, and subsequently, the annual incidence rate decreased. A similar fracture pattern was noted in 70% of patients who sustained an intertrochanteric fracture. In terms of preoperative factors, respiratory disease (OR 2.57, P = 0.032) and visual impairment (OR 2.51, P = 0.012) were higher in patients with a contra-lateral hip fracture than in controls, and for postoperative factors, the proportions of patients with postoperative delirium (OR 2.91, P = 0.022), late onset of rehabilitation (OR 1.05, P = 0.023), and poor ambulatory status at 3 months (OR 1.34, P = 0.002) were also significantly higher in patients than in controls.

Conclusions

Postoperative delirium and underlying visual impairment and respiratory disease could be risk factors of contra-lateral fracture in elderly patients. Early and active rehabilitation after surgery is important to prevent the occurrence of contra-lateral hip fracture in the elderly.