Acute respiratory distress syndrome after treating ipsilateral femoral shaft and neck fracture with reamed intramedullary nailing in an asymptomatic COVID-19 patient.

Currently, it is quite difficult to determine the best timeframe of operative treatment, as well as conduct surgery on asymptomatic COVID-19 patients due to misunderstandings and unawareness of the patient's inflammation state. Caution needs to be taken in specific patient cohorts, particularly those with femoral shaft fractures, who are more likely to develop diseases like acute respiratory distress syndrome after a procedure like intramedullary nailing. In this case report, a 36-year-old patient suffered a motorcycle accident in which he suffered an ipsilateral femoral shaft and neck fracture of the hip. The patient's screening test for COVID-19 was positive before admission. Because the patient did not display any COVID-19-related symptoms upon arrival to the hospital, surgical fixation with a reamed intramedullary femoral nail was performed. Despite having a successful post-surgical outcome, the patient was diagnosed with acute respiratory distress syndrome 36 h after surgery, recovering fully after about 2 weeks. To prevent subsequent complications such as acute respiratory distress syndrome in a high inflammatory state patient like COVID-19, the respiratory status and the degree of systemic inflammation should be considered precisely when determining the surgical timing and method.

Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life-being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer's three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck-shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant-Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant-Murley score (p = 0.0048; Student's t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.

Decision-making and treatment results of complex proximal humeral fractures in geriatric patients: retrospective study from a level 1 trauma centre

Proximal humeral fractures are common in elderly, but despite the high incidence, optimal treatment is still discussed and remains a topic of controversy. Nonoperative treatment continuous to be the main modality. However, due to advancements in surgical technology with new techniques and implants, operative treatment could lead to better outcomes and less complications, even in older patients. Decision-making in elderly should incorporate comorbidities, activity level and patient expectations. This study was performed with the intention to find out, if there is a significant difference in treatment strategy and number of operations, in the last five years. Patients older than 65 years with proximal humeral fractures were included. Retrospective analysis of radiographic material and post-injury data was performed, from patients treated in 2015, 2019 and 2020. Last two years were also compared separately to exclude the effect of Coronavirus disease 2019 (COVID-19) pandemic. Epidemiological data assessment, fracture type and treatment strategy were analysed for corresponding years. Statistical analysis was focused on complex three-and four-part fractures. There were no statistically significant differences regarding incidence between the analysed years. Low energy fall was the mechanism of injury in majority of patients. Patients with tuberosity fractures were in average younger than patients in other groups. Although there were more computed tomography (CT) scans done in younger elderly patients, there was no significant difference in number of CTs compared to older patients (year 2015: p = 0.246;year 2019: p = 0.710, year 2020: p = 0.849). The number of operative interventions was the lowest in 2019 (p = 0.498) and the same was for the osteosynthesis using intramedullary nails (p = 0.014). Frequency of reversed shoulder arthroplasty surgeries is increasing, but the difference is not significant (p = 0.390). Both operative and nonoperative treatment result in similar range of motion (ROM) measurements (p = 0.164 for anteflexion. p = 0.163 for abduction), however the groups were not comparable regarding exact fracture types. In the analysed period of 5 years, epidemiology and treatment strategy of proximal humeral fractures did not change. Nonoperative approach remained the main treatment modality. No significant difference was noted in number of interventions or implants used, although there seemed to be an increased trend towards treatment with reverse shoulder arthroplasty (RSA) in complex fractures. A strong correlation was observed between radiographic indications for conservative treatment and actual implementation of it. However, when surgical treatment was indicated using the same radiological criteria, there were more than half of patients, who were not operated on. Radiologic indications are thus not enough for decision-making in treatment of three-and four-part fractures, and patient factors, such as comorbidities and pre-injury activity level, play a major role. Copyright © 2023 The Author(s). Published by MRE Press.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget.

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

An Overview of Rate of Infection and Mortality in Femur Fracture Patients and its Fixation during Covid-19 Pandemic

Aim: To observe the workload of fractures of the femur (shaft and distal femur) and their fixations along with complications in terms of infection and mortality at our hospital during COVID 19 pandemic. Study design: Prospective study. Place and duration of study: Dept of Orthopaedic, Ghurki Trust Teaching Hospital, Lahore from 01-03-2020 to 31-07-2020 Methodology: One hundred and thirty-one diagnosed patients with femur fracture (shaft and distal) during pandemic period of COVID were enrolled. Demographic data included (age, sex, implant type, surgical site infection (SSI) and mortality).Since study was done during COVID-19 pandemic, positivity of COVID symptoms was noted as yes/no on data collection proforma. Results: There were 105 (80.15%) males while 26 (19.84%) were females with mean age was 39.20±13.02 years. Majority of the surgical interventions were done based on Intramedullary nailing 74.05%, the second prevalent surgeries were done on AO external fixation 8.4%. Infection rate was observed in 7(5.32%) patients. No mortality was seen in any of the cases. Four infected cases were observed after intramedullary nailing procedure, two from AO external fixation and one after locking plate. Conclusion: There is no significant higher complication rate due to COVID-19 pandemic to patients whom femur fracture fixation was done. None of admitted patient suffered COVID-19 symptoms during hospitalization. It was only pointless fear about orthopaedic intervention during this interval.

Fracture in a Person with Spinal Cord Injury with Heterotopic Ossification due to Improper Exercise in Pandemic: A Case Report

Fractures following inappropriate exercises are rarely reported in Spinal Cord Injury (SCI) population. During pandemic physical inactivity and barriers to access to rehabilitation facility are conspicuous. Authors report a case of femur fracture following improper exercise and its interrelationship with Heterotopic Ossification (HO) and impact of pandemic. A 23-year-old male with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade C tetraplegia presented with operated left femur shaft fracture following care-partner administered sudden improper exercise. X-ray of left hip and femur revealed HO around left hip joint and intramedullary nailing of shaft of femur. Routine rehabilitation protocol for SCI was followed especially focusing on safety home-exercise precaution program during pandemic time. To the best of our knowledge, this is the first case report of long bone fracture in a person with SCI following improper exercise which is influence by pandemic situation. Here, we described the causation of fracture in perspective of the vicious cycle of HO, improper exercise and pandemic impact. Further studies are required to find out appropriate precautionary guidelines regarding exercise during pandemic times for people with SCI.

Should we operate on all patients with COVID-19 and proximal femoral fractures? An analysis of thirty, sixty, and ninety day mortality rates based on patients' clinical presentation and comorbidity: a multicentric study in Northern Italy.

PURPOSE: This study aims to evaluate 30-60-90-day mortality of operated proximal femur fractures (PFFs) suffering from COVID-19 and correlation with patients' clinical presentation and comorbidities. METHODS: Between February 1, 2020, and December 31, 2020, patients with COVID-19 infection and surgically treated PFF were included. Patients' demographic characteristics, oxygen (O2) therapy, comorbidities, and AO type fracture were collected. Chi-square test or Fisher test and hazard ratio were used to assessing the correlation between mortality rate, patient characteristics, and COVID-19 status. Kaplan-Meyer curve was used to analyze 30-60-90-day mortality. Level of significance was set as p < 0.05. RESULTS: Fifty-six patients (mean age of 82.7 ± 8.85 years) were included. Thirty-day mortality rate was 5%, which increased to 21% at 60 days and 90 days. Eleven patients died, eight due to AO type A-like and three due to AO type B-like fractures. No significant difference in mortality rate between patients with cardiopulmonary comorbidity or no cardiopulmonary comorbidity was found (p = 0.67); a significant difference in patients with chronic obstructive pulmonary disease (COPD) or history of pulmonary embolism (PE) and patients without COPD was found (p = 0.0021). A significant difference between asymptomatic/mild symptomatic COVID-19 status and symptomatic COVID-19 status was found (p = 0.0415); a significant difference was found for O2 therapy with < 4 L/min and O2 therapy ≥ 4 L/min (p = 0.0049). CONCLUSION: Thirty-day mortality rate of COVID-19 infection and PFFs does not differ from mortality rate of non-COVID-19 PFFs. However, patients with pre-existing comorbidities and symptomatic COVID-19 infection requiring a high volume of O2 therapy have a higher incidence of 60-90-day mortality when surgically treated.

Evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool in a real-time simulation setting (Distributed Interactive Simulation): a randomized controlled trial.

INTRODUCTION: Working time regulations, senior led service delivery and increasing complexity of surgical technology has led to significant strains in surgical training. Additionally, the current COVID-19 pandemic has placed substantial limitations on surgical training worldwide. Contact free, remote, web-based, validated learning tools which are easily accessible and allows repeated, sustained practice are the need of the hour. Cognitive Task Analysis (CTA) have been used extensively to train pilots and military personnel and has shown excellent early results within orthopaedic training. We designed a femoral nailing CTA tool which showed objective benefits in the enhancement of cognitive knowledge in medical students. The aim of this study was to evaluate the effectiveness of this CTA tool to enhance practical skills in orthopaedic trainees in a real time interactive simulation setting (Distributed Interactive Simulation (DIS)). METHODS: This was a double blinded, randomized controlled trial. 14 junior orthopaedic residents who met the inclusion criteria were recruited in the study. They were randomized into two equal groups. The intervention group were given the CTA learning tool, the control group were given a standard operative technique manual used for antegrade femoral intramedullary nailing. The participants were assessed on a high-fidelity phantom femur model with actual femoral nailing instruments in a simulation mobile operating theatre where the candidate had a simulation patient, an acting anesthetist and a scrub nurse (DIS). They were assessed using the modified Objective Structured Assessment of Technical Skills (OSATS) rating scale which has been validated for orthopaedic trauma. RESULTS: The median OSATS score in the intervention group was 49 (±4.93, range 39-55) compared to 17 in the control group (±14.98, range 12-51). The median improvement was by 32 points (p = 0.02). The ICC between the two raters was 0.977. CONCLUSIONS: This study has demonstrated objective benefits of a novel femoral nailing CTA tool in the enhancement of practical skills for junior trainees in the DIS setting. This adds to the growing evidence supporting the use of CTA in orthopaedic training. This tool can be accessed remotely, is contact free and allows repeated sustained practice which is key in simulation training.

Calcaneal skeletal traction versus elastic intramedullary nailing of displaced tibial shaft fractures in children.

BACKGROUND: The objective of this study was to compare the outcomes and complications of patients who underwent either the calcaneal skeletal traction (CST) or the elastic intramedullary nails (EIN) procedure. METHODS: We retrospectively reviewed data of patients who underwent EIN or CST surgery for tibia shaft fracture at our center from 2013 to 2018. The patient demographics, fracture characteristics, radiographic information, length of hospital stay, and medical expenses were recorded. All patients were clinically followed-up until they started to walk or for at least 6 months. The treatment outcomes and postoperative complications of the two procedures were compared. RESULTS: Overall, 186 patients who underwent EIN and CST were included in the study. The EIN patients had more low-energy mechanism of injury. In radiographic evaluation, significant differences were observed in distributions of fracture classification and location. Moreover, associated fibula fractures were higher in the EIN group than in the CST group. The CST procedure had faster surgical time, cast duration and lower expenses, and longer hospitalization time. Although they required more clinical visits, patients in the EIN group began exercising and endured weight-bearing earlier than those in the CST group. The average time for bone healing was 68.5 days in the EIN group, and 69.6 days in the CST group. However, the CST provided slight better results of coronal correction than EIN. Moreover, CST patients had less malalignment (> 5°) in complications. None had delay union, nonunion, and shortening over 10 mm at final assessment. CONCLUSIONS: Both EIN and CST patients showed similar treatment outcomes. Hence, not only the characteristics of the patient and fracture, but also the individual's situation and expectation should be considered when choosing the best approach.