Trends in surgical treatment of femoral neck fractures in the elderly / Tendências no tratamento cirúrgico das fraturas do colo do fêmur em idosos

ABSTRACT Objective To analyze recent demographic and medical billing trends in treatment of femoral neck fracture of American elderly patients. Methods The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2006 to 2015, for patients aged 65 years and older, using the Current Procedural Terminology codes 27130, 27125, 27235, and 27236. Patient demographics, postoperative complications, and frequency of codes were compared and analyzed over time. Our sample had 17,122 elderly patients, in that, 70% were female, mean age of 80.1 years (standard deviation±6.6 years). Results The number of cases increased, but age, gender, body mass index, rates of diabetes and smoking did not change over time. Open reduction internal fixation was the most commonly billed code, with 9,169 patients (53.6%), followed by hemiarthroplasty with 5,861 (34.2%) patients. Combined estimated probability of morbidity was 9.8% (standard deviation±5.2%), and did not change significantly over time. Postoperative complication rates were similar between treatments. Conclusion Demographics and morbidity rates in femoral neck fractures of elderly patients did not change significantly from 2006 to 2015. Open reduction internal fixation was the most common treatment followed by hemiarthroplasty.

RESUMO Objetivo Analisar tendências recentes demográficas e de faturamento médico no tratamento de fraturas do colo do fêmur em idosos americanos. Métodos O banco de dados National Surgical Quality Improvement Program, do American College of Surgeons, foi analisado de 2006 a 2015, para pacientes com idade igual ou superior a 65 anos, usando os códigos de Current Procedural Terminology 27130, 27125, 27235 e 27236. Dados demográficos dos pacientes, complicações pós-operatórias e frequência de códigos foram comparados e analisados ao longo do tempo. A amostra teve 17.122 pacientes geriátricos, sendo 70% do sexo feminino, com média de idade de 80,1 anos (desvio padrão±6,6 anos). Resultados O número de casos aumentou no período, mas idade, gênero, índice de massa corporal e taxas de diabetes e tabagismo não mudaram ao longo do tempo. A fixação interna de redução aberta foi o código faturado mais comum, com 9.169 pacientes (53,6%), seguido por artroplastia parcial do quadril, com 5.861 (34,2%) pacientes. A probabilidade estimada combinada de morbidade foi de 9,8% (desvio padrão±5,2%) e não mudou significativamente ao longo do tempo. As taxas de complicações pós-operatórias foram semelhantes entre os tratamentos. Conclusão Os dados demográficos e as taxas de morbidade relacionadas às fraturas geriátricas do colo do fêmur não apresentaram mudança significativa entre 2006 e 2015. A redução aberta e a fixação interna foram as opções de tratamento mais comuns, seguidas da artroplastia parcial do quadril.

Fixation of undisplaced fractures of the neck of femur with multiple cannulated screws

Treatment of fracture neck of the femur varies according to patient's age and the pattern of the fracture. Multiple cannulated screws [MCS] have been commonly used to treat femoral neck fractures. In this retrospective study we evaluated the outcome of the use of this technique in the treatment of undisplaced fracture neck of femur. In this retrospective chart review study, we revised the files and medical records of the cases of stable fracture neck of femur which had been treated by MCS in patients who were admitted to King Abdul Aziz Specialist Hospital and King Faisal Hospital, Al Taif, Saudi Arabia from January 2007 to December 2011. Sixteen patients with impacted and undisplaced fracture of the neck of femur were treated with multiple cannulated screws. The mean follow up was 26 months; mean age was 38 years [range 14-58 years]. Thirteen/16 patients [81.25%] were satisfied with the excellent results of the treatment. Two patients [12.5%] showed non- union and valgus osteotomy, compression of the fracture and rigid internal fixation were used to promote union. One case developed avascular necrosis and treated by total hip Arthroplasty. Fixation with cannulated screws usually is adequate for most femoral neck fractures specially the undisplaced type with acceptably low incidence of complications

Spino-pelvic fixation for vertically unstable type C fractures of the pelvis

Evaluating the radiological and functional results of surgical treatment of unstable pelvic injuries by spinopelvic fixation. The purpose of this study was to find out whether the surgical technique can reduce fractures of the sacrum and dislocations of the sacroiliac joint and provide pelvis with stable fixation. Ten vertical shearing pelvic fractures were treated by pedicular screw placement in L5 vertebra and in the wing of the ilium. According to Tile's classification system, there were 10 type C fractures [8 type C1, one type C2 and one type C3]. The patients were evaluated by plain radiographs at a mean follow-up period of 2 years [range 1-3 years] after surgery. The patients had a mean age of 37.3 years at the time of surgery. The fracture was reduced by skeletal traction under general anesthesia and in prone position. A pedicular screw was placed in L5 vertebra on the same side of the fracture. Another screw was placed into the pelvic wing from PSIS [posterior superior iliac spine] toward AIIS [anterior inferior iliac spine]. A molded titanium rod connected these two pedicular screws. This study supports the use of screw and rod system for posterior fixation of the VS injuries of the pelvis

Evaluation of the results of treatment of transverse patellar fractures with cancellous screws

Tension band wiring [TBW] is the most common method used to treat displaced transverse patellar fractures. While TBW is very efficient to compress the fracture during knee flexion, it is not that effective during knee extension. The aim of this study is to evaluate the results of treatment of transverse patellar fractures with cancellous screws. Twenty patients with displaced transverse patellar fractures were treated by open reduction and fixation by small set cancellous screws. The mean age of patients was 36.6 +/- 1 7.4 years. There were sixteen males. Road traffic accidents accounted for the majority of trauma. The mean time lapse before surgery was 4.5 days. Two screws were used in sixteen, three screws in three and four screws in one patient. The mean time to clinical union was 9 +/- 2.3 weeks while the mean time to radiological union was 13 +/- 3.6 weeks. All Patients completed six months follow up period. Using a modified Hospital for Special Surgery [HSS] knee scoring system, thirteen patients were excellent, five good and two fair results. Patients improved throughout the follow up period. Results were not affected by age, sex, time lapsed before the operation, and the number of screws used. Complications included prominent hardware in one patient, limited range of movements in six patients in which one developed 20° extensor lag. We concluded that the use of cancellous screws in the treatment of transverse patellar fractures yielded satisfactory outcome with low rate of complications in most cases

Transarticular C1-C2 screws fixation for traumatic atlanto-axial instability

This is a retrospective study of 11 patients diagnosed with traumatic atlanto axial instability that was treated with transarticular C1-C2 screws but without supplemental posterior wiring. After a mean follow up of 25 months. Ten patients [91%] reported no pain related to their neck, while 1 patient had residual neck pain that was aggravated by neck movement. The overall fusion rate was [91%]: as 10 patients out of 11 patients showed a definite bridging fusion mass on X-rays. In conclusion using posterior C1-C2 fusion by transarticular screws with morselized autograft but without additional wiring for traumatic atlantoaxial instability is associated with excellent clinical and radiological outcomes without the need for external halo immobilization

Accuracy of transpedicular screws placement in scoliosis

Transpedicular screw fixation of the spine in scoliosis is still not very popular. Although biomechanically superior, it carries the risk of wrong placement which may lead to serious complications. A modified method of screw insertion was suggested where the screw was put under vision and feeling. The aim of this study is to assess the accuracy of placement of transpedicular screws in scoliosis. Comparison between the traditional method of screw insertion [depending on anatomical landmarks] and the modified method will be conducted. Also the safest sites of screw placement will be studied trying to find the best sites of screw placement in adolescent idiopathic scoliosis for King I and II types. 248 screws were inserted in 45 patients of King I and II adolescent idiopathic scoliosis. Postoperatively, patients were evaluated clinically and radiologically for curve correction and neurological condition. Each vertebra instrumented was examined for degree of rotation, its location and its position in the curve. Also method of screw insertion was reported. Each screw was examined for its point of entry, direction, length and its containment inside the pedicle. Results were statistically analyzed. Percent correction of thoracic curve was 55.6%, while that of lumbar was 50%. Only two factors significantly affected correction: number of vertebrae included and number of sublaminar wires used. One patient developed irritation of L3 root that improved after removal of offending screw. The average number of screws used was 5.51 screws. Modified method was used to insert 67 thoracic screws out of 248 screws. Twenty three [9.7%] screws were misplaced while wrong point of entry was encountered in 31 occasions [12.5%] and inappropriate direction of the screws in 27 times [10.9%]. Most of these wrong screw applications were in the lower end of the curve. Inadequate screw length was encountered in 16 cases [6.5%]. The factors that affect accurate placement of screws were analyzed. The factors that significantly affect it include: level of instrumentation [higher incidence in lower lumbar], method of screw insertion [modified method gave significantly better results], type of the curve [King II gave better results] and number of screws inserted [the more the number of screws inserted in the patient, the more is the incidence of misplaced screws]

Fracturas de la meseta tibial: importancia de la clasificación para el diagnóstico, tratamiento y pronóstico / Fractures of the tibial plateau: importance of the classification for diagnosis, treatment and prognosis

Las fracturas de meseta tibial incluyen el cartílago articular, la epífisis y la metáfisis. El tratamiento es controversial, en la actualidad tiende a ser más quirúrgico y tiene como objetivo lograr estabilidad, buena alineación y prevenir los cambios degenerativos. Se analizaron las fracturas de meseta tibial manejadas en el Hospital ABC de marzo de 1995 a noviembre de 1998, incluyendo aquellas con compromiso articular relacionadas o no con otras fracturas y excluyendo aquellas sin compromiso articular, fracturas condrales únicas y pacientes que no pudieran asegurar el seguimiento. El estudio se llevó a cabo con 39 pacientes, 27 masculinos, 12 femeninos (edad promedio 44.1 años). Los resultados se analizaron con base en la clasificación de Schatzker. El tratamiento conservador reportó 67 por ciento de buenos resultados para las tipo I. Se realizó tratamiento quirúrgico en 92.65 por ciento de los pacientes. El tratamiento con pequeñas incisiones y colocación de tornillos bajo fluroscopía es adecuado en las fracturas Schatzker I y IV no lo es para fracturas con hundimiento. El tratamiento artroscópico se recomienda únicamente en trazos sin desplazamiento o con trazo simple con ligero hundimiento. El levantamiento en masa con colocación de injerto y fijación interna mediante reducción abierta es el tratamiento ideal en las fracturas Schatzker II, III, IVB, V, VI. Las complicaciones fueron infección profunda en dos casos, no consolidación en tres y hundimiento en seis.La clasificación de las fracturas de meseta tibial es importante, brinda una guía diagnóstica, terapéutica y pronóstica en una fractura controvertida.

Fracturas pertrocantereas: osteosíntesis con tornillo deslizante de Richards / Trocantheric fractures: osteosynthesis DHS device

Se efectuó estudio prospectivo en 139 pacientes operados de fracturas pertrocantéreas de fémur en el Hospital Militar de Santiago, que fueron intervenidos entre enero de 1984 y diciembre de 1989 y fueron seguidos durante un año. La casuística está formada por 22 hombres (15,83 por ciento) y 117 mujeres 84,17 por ciento con un promedio de edad de 77,4 años. Se usó la clasificación de Massie-Evans siendo 48,2 por ciento estables y 51,8 por ciento inestables. Se analiza el tratamiento efectuado: A) Osteosíntesis DHS con reducción anatómica en 74,8 por ciento y B) Osteosíntesis DHS con osteotomia de Dimon Hughston en 25,8 por ciento. Los resultados clínicos se evaluaron según la escala de Harris, obteniéndose un 56,14 por ciento buenos, 38,6 por ciento regular y 5,26 por ciento malos Hubo. 5,76 por ciento complicaciones generales y 8,63 por ciento por defectos de técnica