Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures?

The optimum level of syndesmotic screw used in ankle fractures with a tibiofibular diastasis is not clear in the literature. In a retrospective cohort study, we evaluated the clinical and radiological outcomes in two groups of patients-those who had a syndesmotic screw placed through the syndesmosis itself (transsyndesmotic, 17 patients) and those who had a syndesmotic screw placed just above the syndesmosis (suprasyndesmotic, 19 patients). The study suggests that the two groups do not differ significantly in terms of clinical and radiological outcomes.     

Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes?

Deltoid ligament reconstruction following type B ankle fractures continues to generate a vivid discussion amongst trauma surgeons. There is a difference of opinion as to whether operative or non operative treatment should prevail. We therefore conducted a prospective comparative cohort study to determine whether it is necessary to routinely repair the injured deltoid ligaments. 41 Type B ankle joint fracture patients were enrolled, all the patients were associated with deltoid ligament ruptures and lateral/posterior-lateral dislocation of talus. After fixation of the lateral malleolus fracture, 12 patients were treated by superficial deltoid ligaments repairing, 16 patients with deep components augmentation, 13 patients had no direct surgical intervention. In the deep components group, the planter and the dorsi flexion was 3.2° (0-10°) and 8.8° (0-15°) less than the normal side. In the superficial components group, plantar and dorsi flexion was 0.8° (0-5°) and 4.2° (0-15°) less than the normal side. In the non-repairing group, the plantar and dorsi flexion was 2.4° (0-10°) and 5.6° (0-20°) less than the normal side. Overall, no significant statistical difference was observed comparing the 3 groups. In addition, no statistically significant inter-group differences were evident in terms of measurement of the ankle medial clear space and the clinical and functional outcomes recorded. In conclusion, the results of this study do not support routine exposure and repairing of the injured deltoid ligaments.     

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.     

Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

BackgroundDisplaced ankle fractures are initially closed reduced and splinted with the goal of restoring gross ankle alignment. The benefits of an exact closed reduction are unclear and possibly detrimental and unnecessary if multiple attempts are made. The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects post-operative wound complications.MethodsA retrospective analysis was performed of patients with isolated, closed, operative ankle fractures treated at two level 1 trauma centers who had an initial closed reduction performed on presentation. Patient demographics, fracture characteristics, data pertinent to the reduction, and post-operative wound complications were collected. A novel grading system to assess reduction quality was developed, applied, and evaluated for inter- and intra-observer agreement.Results161 patients met inclusion criteria for analysis. 17% (27/161) sustained a post-operative wound complication. There was no statistically significant association between wound complications and quality of preoperative closed reduction (p = 0.17) nor with multiple reduction attempts (p = 0.887). However, patients with poor initial reductions had a decreased mean time to surgery (1.4 ± 2.9 versus 4.7 ± 6.3 days, p = 0.03), which may have been protective. Interclass correlation coefficients for inter- and intra-rater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.ConclusionThere was no association between preoperative closed reduction quality and incidence of post-surgical wound complications in patients with operative ankle fractures when analyzing the variables assessed in this investigation. While initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary.     

Does operative fixation affect outcomes of displaced medial epicondyle fractures?

Purpose

Long-term functional results remain equivocal between operative fixation and closed management of displaced humeral medial epicondyle fractures. The purpose of this study was to determine whether a functional difference exists between treatment types.

Methods

One hundred and forty patients with a displaced medial epicondyle fracture between 2007 and 2014 met the inclusion criteria. Of this large cohort, only 12 patients agreed to return to clinic at a mean follow-up of 3 years for prospective evaluation. Data collection included radiographs, physical examination, validated outcome tools, and grip strength testing with a Jamar dynamometer.

Results

Both groups were comparable with regard to age, dominant side injured, length of follow-up, preinjury sports involvement, and initial displacement (10 mm operative vs. 9 mm nonoperative); however, half of the surgical group presented with an associated unreduced elbow dislocation versus 0 % in the nonoperative group. Both treatment methods resulted in high patient satisfaction and elbow function scores. There were four osseous nonunions (67 %) and one malunion (17 %) in the nonoperative group versus none in the operative group (p = 0.015). Patients treated nonoperatively had a nonsignificant decrease in grip strength (9 ± 6 lbs) as compared to operative patients (6 ± 5 lbs, medium effect size eta = 0.25, p = 0.25).

Conclusions

In this small cohort, operative management of displaced medial epicondyle fractures resulted in a higher rate of fracture union and return to sports. Other objective and subjective measures were similar between the two treatment groups.

     

Judging trauma center quality: does it depend on the choice of outcomes?

BACKGROUND: Trauma centers routinely benchmark their survival outcomes against a national norm using the TRISS methodology. However, the use of survival as a measure of the effectiveness of trauma care may be too limited in scope because it fails to capture information regarding functional outcomes. METHODS: The objective of this study was to develop a prediction model that allows hospitals to benchmark their functional outcomes in blunt trauma patients, and to determine whether the assessment of hospital "quality" depends on the choice of outcome measure: survival or survival combined with functional outcome. This retrospective cohort study was based on patients, aged 18 years or older, in the National Trauma Database who sustained blunt trauma in 1999 without associated head or spinal cord injury. We developed a sequential logistic model to predict the probability of a good functional outcome. The TRISS methodology was customized to this data set to obtain a survival model. Using each of these prediction models, we then obtained two standardized measures of hospital performance: one based on the number of survivors and the other based on the number of survivors with good functional outcomes. These standardized outcome measures were then used to identify low-performance and high-performance hospitals. The ranking based on these two different measures were compared. RESULTS: Fifteen of the 27 hospitals in the study cohort were categorized differently when their performance was benchmarked using survival versus functional outcome. Kappa analysis revealed minimal agreement between these two quality measures on the identity of hospital quality outliers (kappa = 0.04; p = 0.35). CONCLUSION: The evaluation of hospital quality depends on whether hospital performance is judged by looking at survival or at survival combined with functional outcome. Because functional status is an important outcome of major concern to survivors, it is important to include it in hospital performance assessment. Consideration should be given to including functional outcome in the evaluation of trauma center performance.     

Does concomitant vaginal prolapse repair affect the outcomes of the transobturator tape procedure in the long term?

Introduction and hypothesis

Little information is available on the effects of concomitant vaginal prolapse repair on the outcomes of the transobturator tape (TOT) procedure. The purpose of this study is to assess the results and complications of TOT when combined with vaginal prolapse repair with a long-term follow-up.

Methods

We conducted a retrospective cohort study of 232 female patients who underwent the TOT procedure at two institutions. There were two groups: group 1 consisted of patients who had undergone TOT alone and group 2 consisted of patients who had undergone concomitant vaginal prolapse repair. The outcomes were analyzed considering four postoperative parameters: objective cure, subjective cure, resolution of urgency urinary incontinence (UUI), and patient satisfaction. The mean follow-up was 66.3 months (range 60–85).

Results

A total of 117 patients in group 1 and 104 patients in group 2 were documented in this study. The subjective and objective cure rates were 87.17 %, 64.95 % in group 1 and 89.42 %, 68.26 % in group 2. Patient satisfaction rates (visual analog scale [VAS] score ≥80) were 71.79 and 83.65 % in groups 1 and 2 respectively (p?=?0.035). Complications were reported according to the Clavien–Dindo classification with grade I 7.7 %, grade II 69.2 %, grade IIIa 7.7 %, and grade IIIb 15.4 %, and grade I 9.5 %, grade II 47.6 %, grade IIIa 42.8 %, and grade IIIb 0 % in groups 1 and 2 respectively.

Conclusions

Concomitant vaginal prolapse repair with TOT does not have any negative effects on continence outcomes; on the contrary, it increases patient satisfaction.     

Does operative fixation of isolated fractures of ulna shaft results in different outcomes than non-operative management by long arm cast?

Objective

The optimal treatment for isolated fractures of ulnar shaft is debatable. The purpose of this study was to compare functional outcomes and radiological union in patients treated for isolated fractures of the ulnar shaft by open reduction and internal fixation and a long arm cast.

Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size?

BACKGROUND AND PURPOSE: In conventional transurethral resection of the prostate (TURP), perioperative morbidity resulting from causes such as blood loss and TUR syndrome increases with prostate size. Therefore, TURP is restricted to small and medium-sized glands. The present study aimed to find out whether perioperative parameters of holmium laser enucleation of the prostate (HoLEP) other than operation time and weight of resected tissue were dependent on prostate size. PATIENTS AND METHODS: A total of 384 patients were treated with HoLEP (holmium:YAG laser, 2.0 J, 40 or 50 Hz, 80 or 100 W, 550-nm bare fiber) for acute removal of obstructing benign hyperplastic tissue. Among them, 111 patients (28.9%) had prostates of <40 g (group 1), 152 (39.6%) had prostates of 40 to 79 g (group 2), and 121 (31.5%) had prostates of >/=80 g (range 80-260) (group 3). The perioperative outcomes of the three groups were compared. A total of 346 patients completed the 1-month postoperative assessment. RESULTS: The mean prostate sizes were 31.8 g, 56 g, and 98.7 g for groups 1, 2, and 3 (P<0.0001 group 1 v group 2 v group 3). The mean resected tissue weight was 19.5 g v 34.4 g (P= 0.009) v 70.1 g (range 50-220) (P< 0.0001). The mean operation time was 64.3 v 84.2 (P= 0.009) v 118.4 minutes (P< 0.0001). The mean hemoglobin loss was 0.9 v 1.2 (NS) v 1.9 g/dL (P< 0.001). The overall correlation between hemoglobin loss and prostate size in all patients was very weak (r = 0.229) and just exceeded the level of significance (r = 0.2). In all three groups, the median postoperative catheter time was 1 day, and the median postoperative hospital stay was 2 days. The HoLEP resulted in an immediate and significant improvement of American Urological Association Symptom Scores, peak urinary flow rates, and postvoiding residual urine volumes (P< 0.0001) 1 month after the operation, without significant differences between the groups. The rate of complications was similar in all three groups. None of the patients needed blood transfusions. There were no perioperative deaths. CONCLUSION: In HoLEP, perioperative morbidity and postoperative micturition improvement do not depend on prostate size. Therefore, in contrast to TURP, HoLEP is equally suitable for small, medium-size, and large prostate glands.     

Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score -1.6) and those with osteoporosis (34%, mean T-score -3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful.     

What are the radiological predictors of functional outcome following fractures of the distal radius?

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an 'acceptable' radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.     

Tibial fractures treated with circular fixation: does the use of olive wires at the fracture site improve healing?

Clinical experience and published studies suggest that oblique fractures of the tibia are associated with delayed healing and non-union. Experimental studies have attributed this to increased shear at the fracture site. We have adopted the practice of using supplementary olive wires to reduce shear when using circular fixation for these fractures. A complete cohort of 54 oblique tibial fractures treated with the Sheffield Ring Fixator (Orthofix, Verona) was reviewed to elucidate the effect of using additional olive wires on fracture healing/treatment times. Fifty patients were studied in the final analysis. With low-energy injuries, the use of olive wires reduced treatment times significantly (no olives: 37 weeks, olives: 22 weeks, P<0.05), although this was not seen with higher energy injuries (no olives: 44 weeks, olives: 39 weeks, P=NS). There was no evidence of additional complications related to their use. We recommend the use of additional olive wires in the circular fixation of these difficult fractures.     

Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise?

STUDY DESIGN: Prospective study. OBJECTIVES: Forty-five consecutive cases of thoracolumbar and lumbar burst fractures treated non-operatively were analyzed to correlate the extent of canal compromise at the time of injury with (i) the initial neurologic deficit and (ii) with the extent of neurological recovery at 1 year. The effect of spinal canal remodeling on neurological recovery was also analyzed. SETTING: University teaching hospital in south India. METHODS: The degree of spinal canal compromise and canal remodeling were assessed from computed tomography scans. The neurologic status was assessed by Frankel's grading. RESULTS: The mean canal compromise in patients with neurologic deficit was 46.2% while in patients with no neurological deficit it was 36.3%. The mean spinal canal compromise in patients with neurological recovery was 46.1% and 48.4% in those with no recovery. The amount of canal remodeling in patients who recovered was 51.7% and 46.1% in the patients who did not recover. None of these differences was statistically significant. CONCLUSION: This study shows that there is no correlation between the neurologic deficit and subsequent recovery with the extent of spinal canal compromise in thoracolumbar burst fractures.     

Does the placement of a FRECA gastrostomy at the time of laparoscopic fundoplication impact on outcome?

Aim  To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication. Methods  This is retrospective study of a single surgeon’s experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed. Results  Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3–24 months following placement. Conclusion  FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic.     

What influences the functional outcome of children at 6 months post-burn?

The contribution of demographic, injury, pre-morbid, and parent factors to a child's functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5-14 years with percent total body surface area (%TBSA) burns ranging from <1 to 35%, and their primary caregivers participated in the study. It was expected that pre-morbid and parent factors but not injury factors would have a significant impact on the functional outcome of children at 6 months post-burn. Injury factors included the percent of total body surface area burned, number of operative procedures, and source of the burn (i.e. flame burn, scald burn). Pre-morbid child factors included the presence or absence of behaviour problems, psychological or psychiatric problems, learning difficulty or developmental delay. Parent factors included anxiety, depression, coping processes, and social support. Whilst investigating the contribution of these factors to functional outcome, the effect of demographic factors (i.e. age, gender, family socioeconomic status, and the number of previous hospitalizations) was controlled for and investigated. Analyses included two hierarchical multiple regression analyses that supported the expected results. R was significantly different from zero at the end of each step in both hierarchical regression analyses, indicating that each group of factors added significantly to the fit of the model. After step 4 in the final regression model with all independent variables in the equation, R=0.85, F(18,49)=6.89, P<0.001.     

Does hospital structure influence the outcome of operative treatment of femoral neck fractures?

Data on 32 007 patients suffering from a medial fracture of the femoral neck have been collected between 1993 and 1999 in a database for external quality assurance organized by the chamber of physicians in Westfalia-Lippe. A statistical analysis (ANOVA, chi-square-test) has been performed to find out whether factors like specialization, annual volume or level of the hospital (primary, secondary or tertiary hospital) influence the outcome. RESULTS: Patients with higher preoperative risk-factors are treated more often in primary hospitals. These clinics perform conservative treatment significantly more often than tertiary hospitals (6.5 % vs. 3.8 %). Osteosyntheses are performed more often in departments specialized in traumatology (13 %) or tertiary hospitals (16.8 %). Preoperative length of stay was 0.5-0.7 days shorter in these hospitals. There is no significant difference in postoperative complications all together (23.2-25.6 %), but a significantly lower rate in postoperative complications after osteosynthesis performed by departments specialized in traumatology (11.3 % vs. 18.8 %). A volume load of more than 50 cases per year correlates with a significant decline in postoperative complications (22.5 % vs. 28.2 %). Risk adjusted mortality does not show significant differences among the different levels of hospitals. CONCLUSIONS: There are distinct differences regarding the way of treatment and procedural quality, but not concerning the short-term outcome between hospitals of different levels.