Functional outcome and general health status after treatment of AO type 43 distal tibial fractures

IntroductionDistal tibial fractures are uncommon, but they result in poor overall outcome. The objective of this study was to assess functional outcome and general health status after the treatment of distal tibial fractures and identify factors that affect these outcome measures.Patients and methodsA retrospective cohort study including 118 AO type 43 distal tibial fractures in 116 patients was conducted. With regard to articular involvement, fractures were classified as either simple (A1–B2, n = 70) or complex (B3–C3, n = 48). Twenty relevant demographic and operative variables were studied. Functional outcome, quality of life and pain were assessed using the Foot Function Index (FFI) and AOFAS ankle score, physical and mental SF-36, and Visual Analog Scale (VAS) questionnaires, respectively.ResultsOver 75% of patients experienced noteworthy loss of ankle function. The general health status assessment showed markedly affected quality of life with more than two-third of all responding patients suffering from pain every day. In fact, complex fractures and increased complication rate were associated with worse functional outcome, whereas prolonged time to definite surgery affected both functional outcome and general health status significantly.ConclusionsComplex distal tibial fractures were associated with poor functional outcome scores and delayed (-staged) surgery has been shown to prevent postoperative soft tissue problems. However, soft tissue injury associated with distal tibial fractures itself affected both the postoperative functional outcome and general health status as well. This should contribute to the understanding of treatment and outcome of distal tibial fractures.Level of evidence3.     

Tibio-talo-calcaneal fusion after limb salvage procedures—A retrospective study

BackgroundThe treatment of limb threatening trauma on the distal tibia or hindfoot often results in posttraumatic osteoarthritis requiring tibiotalocalcaneal (TTC) arthrodesis. The purpose of this study was to present a case series of patients undergoing various techniques of joint fusion after bone reconstruction and deformity correction as a salvage procedure. The study should help trauma surgeons making decisions in limb salvage and deformity correction in complex lower leg and foot injuries by presenting options and treatment strategies.Patients and methodsEight patients (4 male, 4 female) after TTC arthrodesis as a definitive procedure after polytrauma or monotrauma involving the distal tibia or hindfoot were the subject of this retrospective analysis. We included patients treated by external ring fixation (1 case), external fixation + wires (1 case), external fixation + screws (1 case) and intramedullary nailing (1 ante- and 5 retrograde; 1 bilateral, 4 unilateral). Initial trauma included open fractures, subtotal foot amputations and closed fractures with failed osteosynthesis and failed ankle joint replacement. Bone defects were treated with callus distraction or segment transport in 5 cases. Various angles were measured to assess foot deformities in the lateral radiographic view and clinical results were presented.ResultsIndependent, pain-free mobilisation with full weight bearing was achieved in all 8 patients. In terms of subjective outcome, all patients reported a highly satisfying result. Complete consolidation at the fusion site was achieved in 8 out of 9 cases with a high rate of adjacent joint arthritis. Angles measures in the lateral radiographs showed values typical for a pes cavus tendency.ConclusionTibio-talo-calcaneal (TTC) arthrodesis is a viable treatment option for severe post traumatic arthritis and deformity of the ankle and subtalar joint. Despite bad bone quality retrograde intramedullary nailing does provide acceptable results providing stability, low invasiveness and low infection rate. Simultaneous TTC-fusion and tibial lengthening using the Ilizarov ring fixator may be necessary when the surgeon is confronted with large bone defects – often followed by a nailing after lengthening procedure. This study shows that limb preservation after limb threatening trauma with hindfoot injury and multiple fractures of the lower extremity is recommenced as the method of choice with reasonable clinical results.Level of Evidence: IV, Case series     

Reconstruction of distal fibula with osteoarticular allograft after tumor resection

BackgroundInvolvement of distal fibula by benign aggressive and malignant tumors usually necessitates resection of the involved segment of fibula. Numerous techniques have been proposed to reconstruct the ankle joint after this procedure, which can result in complications. We introduce reconstruction of ankle joint by fibular osteoarticular allograft.MethodsReconstruction of the distal fibula after wide resection of tumor was carried out in four patients. There were two cases of Ewing sarcoma, one case of osteosarcoma and one giant cell tumor. After wide resection of tumor, we reconstructed the lateral side of the ankle joint by osteoarticular fibular allograft, which was applied and internally fixed with semitubular plate and screws. In the follow up period, we did assessment of complications, pain and ankle joint instability.ResultsThe mean age of our patients was 24.2 years (12–31). The mean follow-up was 3.2 years (1.5–6.7). In follow up visits there were no signs of infection or wound healing problems. Union was achieved in all patients.ConclusionIn cases of benign aggressive and malignant tumors involving the distal fibula, we can recommend resection of the distal fibula and reconstruction of the ankle with osteoarticular allograft of the distal fibula.Level of evidenceCase series level IV.     

Tibial torsion correlates with talar morphology

BackgroundThere is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles.MethodsPreoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs.ResultsMeasurements indicated mean external tibial torsion of 29.2 ± 9.1? and TNBA of 35.2 ± 7.5? medial. Tibiotalar tilt ranged from 48? varus to 23.5? valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ = ?0.576, p < .0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ = ?0.239, p = .014) and plantarflexion of the talo-first metatarsal angle (ρ = ?0.218, p < .025).ConclusionWe observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology.Level of evidenceLevel III.     

The geometrical axis of the talocrural joint—Suggestions for a new measurement of the talocrural joint axis

BackgroundDespite intensive research there is no consensus about the talocrural joint axis. The aim of the present study is a new method to determinate the geometric rotational axis of the talocrural joint.MethodsWe analyzed 98 CT-scans of full cadaver Caucasian legs. We generated three-dimensional reconstruction models of the talus. A best fitting cone was orientated to the talar articular surface. The geometric rotational axis was defined to be the axis of this cone.ResultsThe geometric rotational axis of the talocrural joint is orientated from lateral–distal to medial–proximal (85.6° ± 10 compared to anatomical tibial axis in torsional plane), from posterior–distal to anterior–proximal (81.43° ± 44.35 compared to anatomical tibial axis in sagittal plane) and from posterior–medial to anterior–lateral (169.2° ± 5.91 compared to intermalleolar axis in axial plane).ConclusionsThe consideration of our results might be helpful for better understanding of ankle biomechanics.     

Is adjunction of advanced platelet-rich fibrin (A-PRF) useful in first metatarsophalangeal joint arthrodesis? A retrospective cohort study

PurposeFirst metatarsophalangeal (MTPJ1) fusion represents the gold standard treatment for end-stage hallux rigidus (HR). The aim of this study was to assess efficacy and safety of A-PRF in promoting union after MTPJ1 arthrodesis. Our hypothesis was that the use of A-PRF may reduce the non-union rate and the time to fusion in the treatment of HR.Methods14 patients that had undergone MTPJ1 arthrodesis with A-PRF adjunction with 21 standard MTPJ1 fusions were retrospectively reviewed. The fusion rate and time to fusion (clinically and radiographically) were assessed at 6, 12 weeks and at the longest follow-up; the clinical status at final follow-up through forefoot AOFAS, EQ5d, SEFAS and VAS-pain scores; the complication rate.ResultsAt 6-weeks, bony union was achieved in 100% of patients in the A-PRF group compared to 70% in the control group, but this difference was not statistically significant (p = 0.22). At final follow-up (41 months), union rate in the control group reached 92% (one non-union). AOFAS, VAS and EQ-5d scores showed similar results for the two groups (p = 0.86, p = 0.12 and p = 0.61, respectively); only SEFAS score revealed a difference favoring the A-PRF group (p = 0.04). No revision surgery or complication was recorded in any group.ConclusionsA tendency for increased union rate was mainly found at 6 weeks in patients treated with MTPJ1 fusion associated to A-PRF compared to isolated fusion. The use of A-PRF was not associated with an increased complication rate at final follow-up.Level of evidenceLevel 3, therapeutic study, retrospective comparative study.     

Long-term radiographic appearance of calcium-phosphate synthetic bone grafts after surgical treatment of tibial plateau fractures

ObjectivesSynthetic bone grafts (SBGs) are widely used to fill bone defects after fracture reduction. This study assessed the long-term resorption of two different calcium phosphate products (A = ChronOS™ inject and B = Norian^® SRS^®; both DePuy Synthes, Oberdorf, Switzerland) used in the surgical treatment of tibial plateau fractures.DesignLong-term clinical and radiologic follow-up of 52 patients after surgical treatment of intraarticular tibial plateau fractures augmented with SBGs.SettingThe study was performed at a level 3 trauma center.PatientsBetween January 2000 and December 2006 a total of 52 patients with intraarticular tibial plateau fractures were operatively treated and augmented with SBGs consisting of a Brushite matix with β-TCP granules (SBG A) or hydroxylapatite with 4–6% carbonate content (SBG B). 46 patients could be contacted and 38 were included in the study. Half of the patients received SBG A and the other half SBG B.Main outcome measurementsLoss of reduction and SBG resorption was investigated by comparison of follow-up X-ray images to pre- and postoperative X-ray images. Furthermore, pain, activity level and knee function were evaluated by means of questionnaires and clinical examination.ResultsThe mean age of patients was 59.7 ± 12.5 years. The follow-up was 8.6 ± 0.9 years for SBG A and 11.6 ± 1.4 years for SBG B (p < 0.001). In most cases SBG A was completely resorbed in a homogenous pattern, while SBG B was still visible on the X-ray images revealing a peripheral resorption pattern. A loss of reduction (>2 mm) could be observed in two patients with SBG A and two patients with SBG B, although only one of them had an impaired knee function.ConclusionsThe composite SBG A reveals a comprehensive long-term resorption in comparison to SBG B. Nevertheless, both provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures.Level of evidenceCase series, Level IV.     

Pediatric pelvic ring injuries: How benign are they?

IntroductionWith an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.Patients and methodsThis Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4–16) and an average follow up of 28.6 months (range 6–101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.ResultsFor Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5 mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5 mm. Group 1 had more pelvic asymmetry (12.3 mm vs. 6.6 mm) and ring width difference (6.9 mm vs. 3.9 mm) on final X-rays as compared to Group 2. Children with 5–10 mm posterior sacral displacement had significantly more pain than children with 0–4 mm displacement (p = 0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p = 0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5 mm to 15 mm occurred.Discussion and conclusionIn pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.     

Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions

Study objectiveThe primary aim was to evaluate institutional anesthetic techniques utilized for postpartum tubal ligation (PPTL). Secondarily, academic institutions were surveyed on their clinical practice for PPTL.DesignAn institutional-specific retrospective review of patients with ICD-9 procedure codes for PPTL over a 2-year period was conducted. Obstetric anesthesia fellowship directors were surveyed on anesthetic management of PPTL.SettingLabor and delivery unit. Internet survey.Patients202 PPTL procedures were reviewed. 47 institutions were surveyed; 26 responses were received.MeasurementsTiming of PPTL, anesthetic management, postoperative pain and length of stay.Main resultsThere was an epidural catheter reactivation failure rate of 26% (18/69 epidural catheter reactivation attempts). Time from epidural catheter insertion to PPTL was a significant factor associated with failure: median [IQR; range] time for successful versus failed epidural catheter reactivation was 17 h [10–25; 3–55] and 28 h [14–33; 5–42], respectively (P = 0.028). Epidural catheter reactivation failure led to significantly longer times to provide surgical anesthesia than successful epidural catheter reactivation or primary spinal technique: median [IQR] 41 min [33–54] versus 15 min [12–21] and 19 min [15–24], respectively (P < 0.0001). Fifty-eight percent (15/26) of respondents routinely leave the labor epidural catheter in-situ if PPTL is planned. Sixty-five percent (17/26) and 7% (2/26) would not attempt to reactivate the epidural catheter for PPTL if > 8 h and > 24 h post-delivery, respectively.ConclusionsEpidural catheter reactivation failure increases with longer intervals between catheter placement and PPTL. Failed epidural catheter reactivation increases anesthetic and operating room times. Our results and the significant variability in practice from our survey suggest recommendations on the timing and anesthetic management are needed to reduce unfulfilled PPTL procedures.     

Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures

PurposeTo determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures.Materials and methodsA chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16–78) and the mean follow-up time was 7.6 (range 4.7–11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated.ResultsOf the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0–2) OA and 17 had severe (grade 3–4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8 mm vs 4.5 mm, p = 0.009). Fracture line extension to the lateral plateau (p = 0.68) or fracture comminution (p = 0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p = 0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2 mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation.ConclusionsThe amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.     

The “Road to Union” protocol for the reconstruction of isolated complex high-energy tibial trauma

IntroductionThe purpose of this study was to describe a standardized staged approach, “The Road to Union”, for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.MethodsThis retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson’s moment correlations.ResultsThirty-two patients with a mean age of 34.7 ± 14.2 years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66 ± 32 mm. The total EFT was 42.5 ± 14.8 weeks; the EFI measured 51.9 ± 25.3 days/cm, and the DCI measured 48.3 ± 21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r = 0.92, p = 0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.ConclusionThe findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.Level of evidenceLevel IV; case series     

Internal tibial torsion is related to syndesmosis injury in a large osteological collection

BackgroundThe long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion.MethodsA collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae.ResultsMean torsion of 236 specimens with syndesmotic injury was 6.2 ± 8.9 degrees, while that of control specimens was 7.9 ± 8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta = −0.051, P = 0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P = 0.035).ConclusionThis association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.     

Fragility fractures of the ankle in the elderly: Open reduction and internal fixation versus tibio-talo-calcaneal nailing: Short-term results of a prospective randomized-controlled study

IntroductionThe management of ankle fractures in the elderly remains unpredictable, secondary to their various co-morbidities. Although tibiotalocalcaneal (TTC) nailing has been an effective option for ankle arthrodesis due to ankle arthritis or Charcot arthropathy there are few reports regarding the use of TTC nail for the treatment of ankle fractures.PurposeAim of this study was to compare the results of ORIF versus TTC nailing for the treatment of unstable ankle fractures in the elderly. We hypothesized that the elderly may benefit from TTC nailing, as it allows the patient to be mobilized immediately after surgery and minimizes the risk of wound or bone problems.Patients and methodsThis was a prospective, randomized-controlled, comparative study. Between 2009 and 2015, 43 patients were treated with a TTC nail (Group A) and 44 with ORIF (Group B). The Olerud-Molander ankle score was obtained and intraoperative-postoperative complications, length of hospital stay, mobility status and reoperation rate were recorded. The nail fixation was performed with the TrigenR hindfoot nail after closed reduction. ORIF was performed, using a 1/3 tubular plate and 3.5 mm screws for the lateral malleolus and two 4.0 mm cannulated screws for the medial.ResultsMortality rate at one year was 13.9% for Group A and 18.1% for Group B. Mean follow-up was 14 months (12–18 m). There were no intraoperative complications. Three complications in Group A (8.1%) and twelve (33.3%) in Group B were encountered postoperatively (p < 0.05). There was significant shorter hospital stay in Group A (5.2 ± 3.1d) than in Group B (8.4 ± 5.2d). In Group A, 28 patients returned to their pre-injury mobility status (75.6%) while 9 declined one level of the mobility scale (24.3%). In Group B, 26 patients remained at the same mobility level (72.2%) and 10 declined one level (27.7%). There was no significant difference between the postoperative OMAS scores in the two Groups (56.9 ± 9.85 and 56.6 ± 9.3 respectively).ConclusionsWe believe that TTC nailing is a safe and effective method of treatment of unstable ankle fractures in the elderly because it has a low risk of complications and restores function and mobility allowing an immediate return to full weight-bearing.     

Natural history of medial clavicle fractures

BackgroundFractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre.MethodsA retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV).ResultsSixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n = 53), with a median age of 53.5 years (interquartile range (IQR) 37.5–74.5 years). The most common mechanism of injury was motor vehicle accident (n = 28). The in-hospital mortality rate was 4.4%.The fracture pattern was almost equally distributed between extra articular (n = 35) and intra-articular (n = 33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n = 31). All fractures were initially managed non-operatively, with a broad arm sling.Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome.Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1–6 years). The mean ASES score was 80.3 (SD 24.8, range 10–100,), and the mean SSV score was 77.0 (SD 24.6, range 10–100).ConclusionSixty eight patients with medial clavicle fractures were identified over a 5 year period, with excellent functional results seen following conservative management.     

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals

PurposeInguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%–6.3%).MethodsWe evaluated adolescent patients (12–18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications.ResultsA total of 144 patients were enrolled. One hospital (n = 9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41–412.90, p < 0.01) and braided suture (OR 12.10, CI 1.54–95.25, p = 0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results.ConclusionLaparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons.Type of studyPrognosis study (retrospective study)Level of evidenceLevel II     

Hepatic dysfunction: A common occurrence in severely injured patients

BackgroundHepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes.MethodsA retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2 μmol/l (2 mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded.ResultsTwo hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15 days [inter-quartile range 6–19] vs 6 days [IQR 3–11] p < 0.001), prolonged length of stay (median 19 days [IQR 8.5–31] vs 7 days [IQR 3–13] p < 0.001), and higher mortality rate (31.3% vs. 14.7% p = 0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p < 0.001). The only drugs associated with HD were piperacillin-tazobactam (p < 0.001) and enalapril (p = 0.04). On multivariable analysis however, HD was not associated with mortality.ConclusionHD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.     

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

IntroductionThis study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects from 3 to 10 cm in length.MethodsIn a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10 cm were included. Group A was treated with bone transport and Group B with acute shortening/lengthening. All patients were treated by Ilizarov methods for gradual correction as bi-focal or tri-focal treatment; the treating surgeon selected either transport or acute shortening based on clinical considerations. The principle outcome measure was the external fixation index (EFI); secondary outcome measures included functional and bone results, and complication rates.ResultsThe mean size of the bone defect was 7 cm in Group A, and 5.8 cm in Group B. The mean time in external fixation in Group A was 12.5 months, and in Group B was 10.1 months. The external fixation index (EFI) measured 1.8 months/cm in Group A and 1.7 months/cm in Group B (P = 0.09). Minor complications were 1.2 per patient in the transport group and 0.5 per patient in the acute shortening group (P = 0.00002). Major complications were 1.0 per patient in the transport group versus 0.4 per patient in the acute shortening group (P = 0.0003). Complications with permanent residual effects (sequelae) were 0.5 per patient in the transport group versus 0.3 per patient in the acute shortening group (P = 0.28).ConclusionsWhile both techniques demonstrated excellent results, acute shortening/lengthening demonstrated a lower rate of complications and a slightly better radiographic outcome. Bone grafting of the docking site was often required with both procedures.Level of evidence: Level III; Retrospective comparative study     

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BackgroundModern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).MethodsFor this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.ResultsThe USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p < 0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17–29] vs. 21 [17–26], p < 0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61–1.48, p = 0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2–11] vs. 2 [2–7] days, p = 0.006) but had a shorter hospital stay (median [IQR] 6 [3–13] vs. 8 [4–16] days, p < 0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p < 0.0001), and had a higher readmission rate (8% vs. 4%, p = 0.01).ConclusionAlthough several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.     

Estenosis anastomóticas benignas en la cirugía radical del cáncer de recto. Resultados del tratamiento con dilatación hidrostática

IntroductionBenign anastomotic strictures after rectal cancer surgery are common and their treatment can vary from conservative measures to surgical resection.Patients and methodsBetween March 2001 and August 2008, 422 patients with rectal cancer underwent anterior resection and 83.8% were treated with primary anastomosis. Anastomotic stricture has been defined as the inability to pass a colonoscope. Hydrostatic balloon dilation was performed. Results of success and failure dilation were assessed.ResultsTwenty-six patients (7.34%) with anastomotic stricture were treated; 16 men and 10 women, with a median age of 66 years (57 – 74). A total of 26 anterior resections were performed, as well as 10 end-to-end anastomosis, 10 side-to-end, 4 j-pouch and 2 pouch coloplasties. The median stricture height was 10 cms (4 – 12). Thirteen patients had preoperative radiotherapy (50%), and 9 patients had an ileostomy (34.7%). The median time of diagnosis was 6 months (3 – 10). The diagnosis was made by: rectal digital examination in 19.2%, colonoscopy 23.1% and clinical symptoms in 57.7%. The median number of dilation sessions required was 2 (1 – 4). The median of follow-up was 39 months (23 to 49). Results were successful 88.5,% and unsuccessful in 11.5%. Morbidity was 3.8% (one perforation after dilation). There was no mortality.ConclusionsBenign anastomotic strictures after rectal cancer surgery are frequent (7.05%), develop symptoms (52.9%) and can be successfully treated by hydrostatic dilation in more than 88% patients.