Prior surgical fixation of proximal humerus fractures is associated with increased complications following subsequent reverse shoulder arthroplasty

BackgroundThe objective of this study was to compare complication rates between patients undergoing reverse shoulder arthroplasty (RSA) after a prior open reduction and internal fixation (ORIF) for proximal humerus fracture (PHF) to those undergoing RSA as a primary treatment for PHFs, glenohumeral osteoarthritis, or rotator cuff tear arthropathy (CTA).MethodsPatients who underwent RSA between 2015 and 2020 were identified in the Mariner database. Patients were separated into 3 mutually exclusive groups: (1) RSA for osteoarthritis, rotator cuff tear, or CTA (Control-RSA); (2) RSA as a primary treatment for PHF (PHF-RSA); and (3) RSA for patients with prior ORIF of PHFs (ORIF-RSA). Ninety-day medical and 2-year postoperative surgical complications were identified. In addition, patients in the PHF-RSA group were subdivided into those undergoing RSA for PHF within 3 months of the fracture (acute) vs. those treated greater than 3 months from diagnosis (delayed). Multivariate regression was performed to control for differences in comorbidities and demographics.ResultsA total of 30,824 patients underwent primary RSA for arthritis or CTA, 5389 patients underwent RSA as a primary treatment for a PHF, and 361 patients underwent RSA after ORIF of a PHF. ORIF before RSA was associated with an increased risk of overall revision (odds ratio [OR] 2.45, P = .002), infection (OR 2.40, P < .001), instability (OR 2.43, P < .001), fracture (OR 3.24, P = .001), minor medical complications (OR 1.59, P = .008), and readmission (OR 2.55, P = .001) compared with the Control-RSA cohort. RSA as a primary treatment for PHF was associated with an increased risk of 2-year revision (OR 1.60, P < .001), infection (OR 1.51, P < .001), instability (OR 2.84, P < .001), and fracture (OR 2.54, P < .001) in addition to major medical complications (OR 2.02, P < .001), minor medical complications (OR 1.92, P < .001), 90-day emergency department visits (OR 1.26, P < .001) and 90-day readmission (OR 2.03, P < .001) compared with the Control-RSA cohort. The ORIF-RSA group had an increased risk of periprosthetic infection (OR 1.94, P = .002) when compared with the PHF-RSA cohort. There were no differences in medical or surgical complications in the RSA-PHF cohort between patients treated in an acute or delayed fashion.ConclusionRSA following ORIF of a PHF is associated with increased complications compared with patients undergoing RSA for nonfracture indications. Prior ORIF of a PHF is also an independent risk factor for postoperative infection after RSA compared with patients who undergo RSA as a primary operation for fracture. The timing of RSA as a primary operation for PHF does not appear to impact the rates of postoperative medical and surgical complications.     

DHS和PFNA固定治疗老年股骨粗隆间骨折的疗效

目的对比动力髋螺钉(dynamic hip screw,DHS)治疗和股骨近端抗旋髓内钉(proximal femoral nail anti-rotation,PFNA)固定治疗老年股骨粗隆间骨折疗效。方法纳入本院收治的45例采用PFNA固定治疗的老年股骨粗隆间骨折患者作为研究组,研究时间为2017年11月-2018年11月;回顾性分析2016年11月-2017年11月在我院采用DHS治疗的45例老年股骨粗隆间骨折患者的临床资料,作为对照组。记录两组的相关手术指标,观察手术并发症情况。结果研究组的手术时间和骨折愈合时间均短于对照组,术中出血量明显少于对照组,术后疼痛VAS评分均明显低于对照组(P<0.05)。对照组的并发症发生率高于研究组(P<0.05)。结论PFNA固定治疗比DHS治疗老年股骨粗隆间骨折更加安全有效,值得临床借鉴和应用。     

Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery

Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.     

A comprehensive 3D CT based classification of intertrochanteric fracture

IntroductionDespite advancements in surgical techniques complications like implant failure is very common after the fixation of intertrochanteric fractures. Classifying these complex fractures based on plain radiographs underestimates the complexity of these fractures which in turn leads to complications. We propose a comprehensive classification of the intertrochanteric fractures based on 3D Non Contrast Computed Tomography (3D NCCT) scan.Material and methodsA total of 102 patients (51 males and 51 females) with intertrochanteric fractures were included in this study conducted over a time period of 22 months in a Tertiary care center in North India. NCCT proximal femur of the intertrochanteric fracture patients was done to formulate a new CT classification system and classify all fractures. Intra and inter-observer reliability was tested using kappa variance.ResultsNew classification system was proposed which included 3 main and a total of 6 groups. All the fractures were classifiable into the new system. Kappa variance of the study showed a good intra and interobserver reliability (0.95 and 0.90) proving clinical agreement of the classification.ConclusionThis new 3D-CT based classification has the advantages of being easy, comprehensible with high intra and inter-observer reliability. This 3DCT based classification can prove to be useful to detect occult intertrochanteric fractures undetectable in plain radiographs as well as choosing the optimum treatment plan.     

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BackgroundThe purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).MethodsAfter IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.ResultsAmong 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028–3012] and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).ConclusionsIn this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Level of EvidenceDiagnostic Study, Level III.     

Tyrosinemia type 1 in pediatric nephrology: Not always straightforward

The main clinical features of tyrosinemia type 1 usually appear in the first months of life, including fever, diarrhea, vomiting, liver involvement, growth failure, and renal proximal tubulopathy with subsequent hypophosphatemic rickets. An early diagnosis is crucial in order to provide specific management and to prevent complications. Here, we report on two cases referred primarily to pediatric nephrologists for the diagnosis of “neonatal tubulopathy” and management of “X-linked hypophosphatemia (XLH),” respectively. Our aim is to emphasize that (1) even a mixed tubulopathy can reveal tyrosinemia, and (2) tyrosinemia is a classic differential diagnosis of XLH that should not be forgotten, especially in the era of the anti-FGF23 burosumab.     

肱骨骨不连的手术治疗

目的探讨肱骨骨不连的手术治疗方法及疗效。方法1998年12月～2005年5月共收治肱骨骨不连患者25例,均为肱骨骨折内固定术后发生骨不连,其中3例并发骨髓炎,6例合并不同程度肱骨骨缺损,骨缺损长度为3～6cm。骨不连病程8个月～5年。15例行吻合血管游离腓骨移植,10例采用加压交锁髓内针进行肱骨固定并辅以自体骨植骨。结果术后25例均得到随访,时间6个月～6年2个月。吻合血管游离腓骨移植组中移植的腓骨段均与肱骨干形成骨性愈合,平均骨性愈合时间为3．1个月；交锁髓内针组平均骨愈合时间为3．8个月。按Crates和Whittle肩肘关节功能评价标准,腓骨移植组：优9例,良4例,差2例；交锁髓内针组：优5例,良3例,差2例。结论应用加压交锁髓内针辅以自体骨移植对硬化性肱骨骨不连是一种有效的外科治疗方法；对合并骨髓炎、大段骨缺损及严重骨质疏松的肱骨骨不连,采用吻合血管游离腓骨移植可一期进行修复与重建。     

下肢复杂骨折交锁髓内钉治疗粉碎骨折螺钉辅助固定的意义

[目的]探索在交锁髓内钉治疗下肢复杂骨折中粉碎骨折块辅助固定的意义。[方法]下肢复杂骨折78例根据AO分型均为C型骨折，通过交锁髓内钉内固定，辅以拉力螺钉固定。[结果]术后摄片骨折及骨折块达解剖或功能复位，随诊6～24个月，优良率为94．88％（74／78例）。[结论]四肢复杂骨折治疗中，粉碎骨折块的螺钉辅助固定能够加强交锁髓内钉的稳定性，减少断钉、断棒现象，有利于骨折愈合。