Updated Three-Column Concept in surgical treatment for tibial plateau fractures – A prospective cohort study of 287 patients

PurposeThis study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures.Patients and methodsFrom 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed.Results287 treated fractures were followed up for a mean period of 44.5 months (range: 22–96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10–28) and 14.8 weeks (range: 10–26) respectively. The average functional Knee Society Score was 93.0 (range: 80–95). The average range of motion of the affected knees was 1.5–121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated.ConclusionAn updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. Limited results demonstrate successful application of biologically friendly fixation constructs while avoiding fixation failure and associated complications of both simple and complex tibial plateau fractures.Level of evidenceLevel II, prospective cohort study.     

Treating patella fractures with a fixed-angle patella plate—A prospective observational study

IntroductionAnterior tension wiring using Kirschner wires (K-wires) is still considered the standard treatment for patella fractures, despite its high complication rate. The objective of this prospective clinical study was to evaluate intra- and perioperative complications as well as the clinical outcome of patients with patella fracture treated with a new developed bilateral, polyaxial, fixed-angle 2.7 mm patella plate.Patients and methodsBetween 2011 and 2014 all patients with a patella fracture were included in this prospective study and treated with a fixed-angle patella plate. Avulsion fractures of the inferior or superior pole of the patella were excluded. All fractures were classified according to the AO/OTA fracture classification. During a twelve-month follow up period all intra- and postoperative complications were recorded as well as the time until fracture healing. One year postoperatively the Lysholm Score, the pre- and postoperative Tegner Score, the Hospital for Special Surgery Knee Score (HSS), the Turba Score, the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the Bostman Score and the Iowa Knee Score were surveyed. Altogether, 20 patella fractures in 19 patients were included in this prospective study. The most frequent type of fracture, n = 10, was a simple transverse patella fracture (C1), followed by 7 comminuted patella fractures (C3) and 3 T-shaped patella fractures (C2).ResultsDuring the 12-month follow up period two patients treated with the patella plate had a complication. In one patient a superficial wound infection occurred, which was treated successfully with hardware removal and in one patient a fracture dislocation due to an implant failure occurred. X-rays demonstrated complete bony healing in all fractures on average 3.2 months postoperatively. All knee scores showed good to excellent clinical results one year postoperatively.ConclusionThe results of this first clinical study indicate that the fixed-angle patella plate is an effective and safe treatment option for patella fractures with a short operative learning curve. The treatment of communited patella fractures (C3) with a fixed-angle patella plate should be well-considered to avoid distending the indication and biomechanical properties.     

Integration of fluoroscopy-based guidance in orthopaedic trauma surgery – A prospective cohort study

Introduction

Computer-assisted guidance systems are not used frequently for musculoskeletal injuries unless there are potential advantages. We investigated a novel fluoroscopy-based image guidance system in orthopaedic trauma surgery.

Materials and methods

The study was a prospective, not randomised, single-centre case series at a level I trauma centre. A total of 45 patients with 46 injuries (foot 12, shoulder 10, long bones seven, hand and wrist seven, ankle seven and spine and pelvis four) were included. Different surgical procedures were examined following the basic principles of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF). Main outcome measurements were the number of trials for implant placement, total surgery time, usability via user questionnaire and system failure rate.

Results

In all cases, the trajectory function was used, inserting a total of 56 guided implants. The system failed when used in pelvic and spinal injuries, resulting in a total failure rate of 6.5% (n = 3) of all included cases. The overall usability was rated as good, scoring 84.3%.

Conclusion

The novel image-guidance system could be integrated into the surgical workflow and was used successfully in orthopaedic trauma surgery. Expected advantages should be explored in randomised studies.     

Vitamin D levels in Irish children with fractures: A prospective case–control study with 5 year follow-up

IntroductionTwenty-five-hydroxy-vitamin D3 (25-OH-vit D) is a prohormone that is essential for normal calcium homeostasis and bone metabolism. Understanding its role is an important component of the proper care of the pediatric orthopaedic patient. The aim of this study was to determine whether children in Ireland with fractures have increased prevalence of 25-OH-Vit D deficiency compared with age matched controls and to ascertain the relationship between a low 25-OH-vit D level and the incidence of fractures in Irish children. We hypothesised that children presenting to our centre following a fracture would have significantly lower 25-OH-vit D.MethodsA prospective case–control study at a large urban tertiary referral academic hospital located in Dublin, Ireland was completed over a 14 month period from June 2014 to August 2015. A total of 116 subjects, distributed as cases (n = 58) and controls (n = 58) were included in this study. Whole blood (10 ml) was taken in two serum bottles from each patient. Serum 25-hydroxy-vitamin D3 levels were measured. An age matched control group was generated from other children attending the hospital, who also had vitamin D levels measured for different clinical reasons. We followed up both the fracture and control group for the next 5 years to assess the repeat fracture rate.ResultsFifty-eight patients with a fracture requiring operative intervention, were included in the study. Statistical analysis was performed comparing to 58 age and sex-matched controls. The mean vitamin D level for the fracture group was 63.2 nmol/L (SD = 27.3), which was higher than the mean of the controls (62.5 nmol/L) (SD = 21.3) (p = 0.86), but this difference was found not to be statistically significant in unadjusted analysis. There was no statistically significant difference in the number of patients classified with low serum Vitamin D levels (<50 nmolL), with the fracture group consisting of 22 (37.9%) patients, and the control group of 17 patients (29.3%) (p = 0.33) with a level below 50 nmol/L. At five-year follow-up, 11 of the 58 patients (18.9%) in the fracture group went on to have a further fracture compared with eight patients (13.7%) from the control group. Out of these 11 from the fracture group five (45.45%) had been found to have a low serum 25-OH-Vit D level five years previously. Out of the eight controls that presented with a fracture within the five-year period, 3 (37.5%) had had a low vitamin D level at the origin of this study.ConclusionThe results of this study show that children presenting to our institution with low energy fractures have a prevalence of 38% 25-hydroxy-vitamin D deficiency. This study included children from age 1 to 16 primarily Caucasian encompassing all fracture types resulting from accidental trauma. Our findings suggest that in an Irish pediatric population vitamin D status may impact fracture risk with more than one-third being deficient in this review.     

Sickness absence and disability pension following breast cancer – A population-based matched cohort study

PurposeTo compare sickness absence and disability pension in a population-based cohort of women with breast cancer (n = 463) from 1 year pre-diagnosis until 3 years post-diagnosis with a matched control group (n = 2310), and to investigate predictors of sickness absence during the 2nd and 3rd year post-diagnosis.ResultsFollowing breast cancer, the proportion of disease-free women with sickness absence decreased post-diagnosis (1st–3rd year; 78%-31%-19%), but did not reach the pre-diagnostic level (14%; P < 0.05). Post-diagnosis, patients were more likely than controls to be sickness absent (1st–3rd year; P < 0.001). No between-group differences were observed for disability pension post-diagnosis (P > 0.05). Among patients, chemotherapy, baseline fatigue and pre-diagnosis sick days predicted sickness absence during the 2nd, 3rd, and 2nd and 3rd year post-diagnosis, respectively (P < 0.05).ConclusionsBreast cancer is associated with increased sickness absence 3 years post-diagnosis. In a clinical setting, prevention and treatment of side effects are important in reducing long-term consequences.     

Asymmetry in gait pattern following bicondylar tibial plateau fractures—A prospective one-year cohort study

IntroductionDespite the high number of studies evaluating outcomes following tibial plateau fractures, the literature lacks studies including the objective assessment of gait pattern. The purpose of the present study was to evaluate asymmetry in gait patterns at 12 months after frame removal following ring fixation of a tibial plateau fracture.Patients and methodsThe study design was a prospective cohort study. The primary outcome measurement was the gait patterns 12 months after frame removal measured with a pressure-sensitive mat. The mat registers footprints and present gait speed, cadence, as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population.ResultsTwenty-three patients were included with a mean age of 54.4 years (32–78 years). Patients presented with a shorter step-length of the injured leg compared to the non-injured leg (asymmetry of 11.3%). Analysis of single-support showed shorter support time of the injured leg compared to the non-injured leg (asymmetry of 8.7%). Moreover, analysis of swing-time showed increased swing-time of the injured leg (asymmetry of 8.9%). Compared to a healthy reference population, increased asymmetry in all gait patterns was observed. The association between asymmetry and health-related quality of life (HRQOL) showed moderate associations (single-support: R = 0.50, P = 0.03; step-length: R = 0.43, P = 0.07; swing-time: R = 0.46, P = 0.05).ConclusionCompared to a healthy reference population, gait asymmetry is common 12 months after frame removal in patients treated with external ring fixation following a tibial plateau fracture of the tibia.     

Middle-sized posterior malleolus fractures: Fixed versus non-fixed – A prospective randomized study

PurposeThis study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome.MethodsA prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10–25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years.ResultsDemographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001).ConclusionAlthough there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor.Level of evidenceLevel I; prospective randomized controlled study.     

Short- and long term hyposmia,hypogeusia, dysphagia and dysphonia after facial burn injury – A prospective matched cohort study

BackgroundFacial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns.MethodsIn a prospective observational controlled study, we evaluated hyposmia via the Sniffin’ Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments.ResultsFifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia.ConclusionHyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.     

Hip fractures in cyclist – a six-year cohort study at a single large volume trauma centre

Cycling has gained in popularity as a recreational activity and method or travel, in part due to its recognised health benefits in maintenance of good cardiovascular strength and also for environmental issues. As a consequence of this, there is unfortunately an increased number of cycling related injuries. One particular injury incurred is a proximal femoral fracture, but there is little information in the literature with regarding this and its management. This retrospective, single centre, observation study looks at the number of cycling injuries over a six-year period in those under the age of 80. 50 patients were identified at an occurrence of 4.5% of the hip fracture population. The majority were male (n=37, 74%) with an average age of 60. Operative treatment was used for 48 (96%) patients with the majority being treated with internal fixation (n=42, 84%) and arthroplasty for the remainder. Average hospital stay was 5.6 days. One patient continued to complain of pain and subsequently underwent a total hip arthroplasty. The mean follow up for these patients was 1033 days (range 1 year to 7 years). 47 (94%) had full return back to pre-injury levels. Given that cycling is likely to increase in the future, we recommend that early surgical fixation is a viable and functionally positive treatment management in these particular group of patients.ObjectivesThe aim of this retrospective observational study over a six-year period was to assess the incidence of hip fractures in those under the age of 80 following a cycling related injury, the definitive management and primary index surgery opted and to report the radiological and functional outcome of these patients with at least 1 year of follow up.DesignRetrospective, observational studySettingLarge hip fracture unit, Level 2 Trauma Centre, single centre.PatientsPatients under the age of 80 who sustained a proximal femoral fracture secondary to a fall and not attributable to pathological processes (namely malignancy and Paget's) were identified and followed up after 1 year.Results50 patients were identified over a six-year period of which 74% (n=37) were male and the remaining were female. 48 of these patients subsequently went on for operative management. Two patients presented late (7 days and 42 days from surgery) and were treated conservatively. The average hospital stay for these patients was 5.6 days, with index surgery occurring on average within 22 hours of admission. Mean follow up was 1033 days (range 1 year to 7 years) in all patients. Radiological union had occurred in all patients. One patient showed evidence of avascular necrosis but was asymptomatic.All but three patients had achieved the same level of mobility as pre-injury levels. All patients had the same level of social dependency. One patient continued to complain of pain and subsequently underwent a total hip arthroplasty.ConclusionsWe demonstrate that the majority of our patients undergo surgical fixation and demonstrate good functional and radiological outcomes at a mean follow up of 1033 days. This is likely as a result of good pre-morbid status in these patients and good bone stock at index intervention. This study is one of the first to show this within the literature in this cohort of elderly patients. The number of cycling related injuries in the elderly population is likely to increase and our recommendation is that early surgical fixation provides good functional outcome in this subset of patients.     

Open reduction and plating for displaced mid third clavicle fractures – A prospective study

IntroductionDisplaced middle third clavicle fractures were treated conservatively with figure of ‘8’ harness in the past. Current management trend in treating displaced clavicle fractures with internal fixation provide rigid immobilization and pain relief avoiding non-union, shortening and deformity. This study prospectively evaluates the functional outcome of 25 patients with clavicle fractures treated surgically.Materials and methods25 patients with displaced mid third clavicle fractures were included in the study. Open reduction and internal fixation with clavicular locking plate placed superiorly was done. Patients were followed up on 3, 6, 8, and 12 weeks. Functional outcome was assessed using DASH scores and Simple Shoulder Test (SST). Statistical analysis was done using One-way ANOVA.ResultsOut of the 26 clavicles operated (one patient had bilateral fracture), 6 were comminuted (23%) and the rest were 2 part displaced fractures. Interfragmentary screws were used in 3 cases with butterfly fragment. All fractures united (mean = 6.8 weeks). The DASH scores reduced to a significant negligible level by 8 weeks in all but 4 cases with comminution where it took longer than 8 weeks to reach negligible levels. The SST showed significant improvement in all cases by 8 weeks after surgery. All patients were satisfied with the outcome. 84% of patients returned to their work by 6 weeks.ConclusionPrimary plating of displaced mid third clavicle fractures with superiorly placed locking plate avoids complications of non-operative management and leads to early return to pre injury activities.     

Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty – A propensity matched cohort study

Patients with human immunodeficiency virus (HIV) are at higher risk for orthopedic related diseases due to dysregulation in bone metabolism and metabolic effects related to their medication regimen. Furthermore, the rate of hip arthroplasty in HIV patients is increasing. With the recent changes in THA methodologies and improvements in HIV treatment, there is a need for updated research analyzing hip arthroplasty outcomes in this high-risk patient population. In this study, we used a national database to evaluate postoperative outcomes in HIV patients undergoing THA compared to THA patients without HIV. We use a propensity algorithm to create a cohort of 493 HIV negative patients for matched analysis. Among the 367,894 THA patients included in this study, 367,390 patients were HIV negative and 504 were HIV positive. The HIV cohort had a lower mean age (53.34 vs 65.88, p < 0.001), lower proportion of females (44% vs 76.4%, p < 0.001), lower incidence of diabetes without complications (5% vs 11.1%, p < 0.001) and a lower incidence of obesity (0.544 vs 0.875, p = 0.002). In the unmatched analysis, the incidence of acute kidney injury (4.8% vs 2.5%, p = 0.004), pneumonia (1.2% vs 0.2%, p = 0.002), periprosthetic infection (3.6% vs 1%, p < 0.001), and wound dehiscence (0.6% vs 0.1%, p = 0.009) were higher in HIV cohort, most likely due to inherent demographic variances present in the HIV population. In the matched analysis, the rates of blood transfusion (5.0% vs 8.3%, p = 0.041) were lower in the HIV cohort. Other post-operative variables, such as rates of pneumonia, wound dehiscence, and surgical site infections were not statistically significant between the HIV positive population and HIV negative matched cohort. Our study found similar rates of postoperative complications in HIV positive and HIV negative patients. The rate of blood transfusions in HIV positive patients was also noted to be lower. Our data suggests that THA is a safe procedure in patients infected with HIV.     

A prospective study comparing bipolar endoscopic enucleation of prostate with bipolar transurethral resection in saline for management of symptomatic benign prostate enlargement larger than 70 g in a matched cohort

Purpose

This study aims to compare the efficacy and safety of bipolar endoscopic enucleation of prostate with transurethral resection in saline for large BPE greater than 70 g.

Methods

All patients from two urology centres who had bipolar enucleation or bipolar resection performed for large BPE greater than 70 g from December 2008 to April 2012 were prospectively assessed. The pre-operative and post-operative measures included IPSS, QOL score, uroflowmetry results, PSA and prostate volume. The perioperative measures were compared, and the post-operative complications/resumption of medical treatment for lower urinary tract symptoms were also assessed.

Results

There were 74 and 86 consecutive patients with bipolar enucleation and bipolar resection performed, respectively. No difference in pre-operative characteristics was observed between the two groups with mean prostate size 115 cc in each group. Comparing bipolar enucleation with bipolar resection, there was longer operative time (156 vs 87 min, p = 0.000), more haemoglobin drop (1.8 vs 1.1 g/dL, p = 0.006), but more prostate tissue resected (61.4 vs 45.7 g, p = 0.000). There was no difference in overall transfusion requirement and hospital stay. At 12 month after the procedure, patients with bipolar enucleation performed had better IPSS (6.4 vs 11.6, p = 0.032), QOL (1.7 vs 2.6, p = 0.040) and peak flow rate (19.5 vs 15.1 ml/s, p = 0.019). The post-operative complications had no significant difference between the two groups.

Conclusions

For surgical treatment of big BPE, bipolar endoscopic enucleation of prostate provided superior functional outcome than bipolar resection but required longer operative time.     

Greater intake of fruit and vegetables is associated with a lower risk of osteoporotic hip fractures in elderly Chinese: a 1:1 matched case–control study

Summary

In this case–control study, we examined the relationship between the consumption of fruit and vegetables and risk of hip fractures in 646 pairs of incident cases and controls in elderly Chinese. We found that greater consumption of both fruit and vegetables in men and vegetables in women was associated with a lower risk of osteoporotic hip fractures in elderly Chinese.

Introduction

The association between fruit and vegetable consumption and the risk of osteoporotic fractures remains controversial due to limited published evidence. The purpose of this study was to determine whether consuming fruits and vegetables has a protective effect against hip fractures.

Methods

Between January 2008 and December 2012, 646 (162 males, 484 females) incident cases (70.9?±?6.8 years) of hip fractures were enrolled from five hospitals, with 646 sex- and age-matched (±3 years) controls (70.7?±?6.8 years) from hospitals or the community. Face-to-face interviews were conducted to assess habitual dietary intakes using a 79-item food frequency questionnaire and various covariates by structured questionnaires.

Results

Multivariate conditional logistic regression analyses showed dose-dependent inverse correlations between the intake of total fruit (p-trend?=?0.014), total vegetables (p-trend <0.001), fruits and vegetables combined (p-trend?<?0.001) and the risk of hip fractures after adjustment for sociodemographic characteristics, dietary factors and other potential confounders. The adjusted odds ratios (95 % confidence interval) for hip fractures in the top quartiles (vs. the lowest quartiles) for the intake of fruits, vegetables and the combination of fruits and vegetables were 0.53 (0.32–0.87), 0.37 (0.23–0.60) and 0.25 (0.15–0.41), respectively. Stratified analyses showed that the benefits remained significant in males (p?=?0.001) but not in females (p?=?0.210) (p-interaction 0.045). Among the subcategories of fruits and vegetables, similar associations were observed for all subgroups except light-coloured fruits.

Conclusions

Our findings suggest that greater consumption of both fruits and vegetables in men and vegetables in women may decrease the risk of osteoporotic hip fractures in elderly Chinese.