The impact of obesity on polytraumatized patients with operatively treated fractures.

INTRODUCTION: The objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients. METHODS: This was a prospective cohort study at a level I trauma centre from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as having an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 were included with 85 being obese. The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality. RESULTS: Obesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P = 0.04), increased ICU admissions (83.5% vs. 68.6%; P = 0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P = 0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P = 0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P = 0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P = 0.03) and ARF (P = 0.024). CONCLUSIONS: This study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group.

Mobile-bearing versus fixed-bearing total knee arthroplasty: a meta-analysis of randomized controlled trials.

OBJECTIVE: The purpose of this study was to perform a meta-analysis comparing mobile-bearing with fixed-bearing total knee arthroplasty (TKA) in terms of all-cause revision rates, aspetic loosening, knee functional scores, range of motion and radiographic lucent lines and osteolysis. METHODS: PubMed, Cochrane Library, Google Scholar and Web of Science were searched up to January 2020. Randomized controlled trials that compared primary mobile-bearing with fixed-bearing TKA, reporting at least one of the outcomes of interest, at a minimum follow-up of 12 months were included. All outcomes of interest were pooled at short-term (< 5 years), mid-term (5 to 9 years) and long-term (> = 10 years) follow-up intervals. RESULTS: A total of 70 eligible articles were included in the qualitative and statistical analyses. There was no difference between mobile-bearing or fixed-bearing TKA at short-term, mid-term and long-term follow-ups in all outcome measures including all-cause revision rate, aseptic loosening, oxford knee score, knee society score, Hospital for Special Surgery score, maximum knee flexion, radiographic lucent lines and radiographic osteolysis. CONCLUSION: The current level of evidence demonstrated that both mobile-bearing and fixed-bearing designs achieved excellent outcomes, yet it does not prove the theoretical advantages of the mobile-bearing insert over its fixed-bearing counterpart. The use of either design could therefore be supported based on the outcomes assessed in this study. LEVEL OF EVIDENCE: Level II, Therapeutic.

Long head of biceps tenotomy versus tenodesis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To compare tenotomy versus tenodesis for the treatment of long head of the biceps tendon pathologies. The primary outcome was the shoulder functional outcome. The secondary outcomes consisted of postoperative pain, elbow flexion and forearm supination strengths and postoperative complications. METHODS: PubMed, MEDLINE, Google Scholar and Web of Science were searched until April 2020. Included studies were randomized controlled trials with a minimum 12 months' follow-up. RESULTS: Both treatments had similar improvement on the Constant-Murley score at 6 months and 12 months. However, tenotomy had a significantly lower Constant-Murley score at two years with a mean difference of -1.13 (95% confidence interval -1.9, -0.35). Furthermore, tenotomy had a risk ratio of 2.46 (95% confidence interval 1.66, 3.64) for developing Popeye's deformity. No significant difference was detected in other functional outcomes, pain, or elbow flexion and forearm strength indices. DISCUSSION: Tenodesis and tenotomy are both well-established techniques that similarly yield satisfactory outcomes. Despite that tenodesis had a statistically significant better Constant-Murley score at two years, this was clinically irrelevant. With the current evidence, we recommend either technique for the management of the long head of the biceps tendon pathologies. LEVEL OF EVIDENCE: Therapeutic, Level II.

Hyperbaric oxygen therapy for the treatment of Steinberg I and II avascular necrosis of the femoral head: a report of fifteen cases and literature review.

PURPOSE: This article aimed to report a case series of pre-collapse avascular necrosis of the femoral head treated with hyperbaric oxygen and review the most recent literature on the topic. METHODS: The data from a prospectively followed registry of 15 patients with Steinberg I and II avascular necrosis of the femoral head was collected. Functional outcome, pain scores, and radiographic changes at an average follow-up of 22 months were analyzed and reported. RESULTS: Thirteen patients had satisfactory outcome at final follow-up with an average Oxford hip score of 37.3, pain scores were significantly improved at final follow-up (P < 0.001), and 26.7% of hips progressed to collapse on follow-up radiographs with no complications reported in all patients. CONCLUSION: Hyperbaric oxygen treatment for pre-collapse avascular necrosis of the femoral head is considered a safe alternative with satisfactory clinical and radiological outcomes and low complications rate.

The safety of outpatient total shoulder arthroplasty: a systematic review and meta-analysis.

PURPOSE: To meet the increasing demands of total shoulder arthroplasty (TSA) while reducing its financial burden, there has been a shift toward outpatient surgery. This systematic review and meta-analysis aimed to evaluate the safety of outpatient TSA. METHODS: The primary objective was to compare re-admission rates and postoperative complications in outpatient versus inpatient TSA. The secondary objectives were functional outcomes and costs. PubMed, Google Scholar, and Web of Science were searched until March 28, 2020. The inclusion criteria were studies reporting at least complications or readmission rates within a period of 30 days or more. RESULTS: Ten level III retrospective studies were included with 7637 (3.8%) and 192,025 (96.2%) patients underwent outpatient and inpatient TSA, respectively. Outpatient TSA had relatively younger and healthier patients. There were no differences between outpatient and inpatient arthroplasty for 30- and 90-day readmissions. Furthermore, unadjusted comparisons demonstrated significantly less total and major surgical complications, less total, major, and minor medical complications in favour of outpatient TSA. However, subgroup analyses demonstrated that there were no significant differences in all complication if the studies had matched controls and regardless of data source (database or nondatabase studies). The revision rates were similar between both groups at a 12-24 months follow-up. Two studies reported a significant reduction in costs in favour of outpatient TSA. CONCLUSION: This study highlights that outpatient TSA could be a safe and effective alternative to inpatient TSA in appropriately selected patients. It was evident that outpatient TSA does not lead to increased readmissions, complications, or revision rates. A potential additional benefit of outpatient TSA was cost reduction.

The role of ulnar nerve subcutaneous anterior transposition during open reduction and internal fixation of distal humerus fractures: a retrospective cohort study.

PURPOSE: To compare the rates of ulnar nerve neuropathy following ulnar nerve subcutaneous anterior transposition versus no transposition during open reduction and internal fixation (ORIF) of distal humerus fractures. METHODS: This was a retrospective cohort study at an academic level I trauma centre. A total of 97 consecutive patients with distal humerus fractures underwent ORIF between 2011 and 2018. All included patients were treated with plates (isolated lateral plates excluded) and had no pre-operative ulnar neuropathy. Subcutaneous ulnar nerve anterior transposition was compared versus no transposition at the time of ORIF. The main outcome measure was the rate of ulnar nerve neuropathy. The secondary outcomes were the severity of the ulnar nerve neuropathy and the rate of ulnar nerve recovery. RESULTS: Twenty-eight patients underwent subcutaneous ulnar nerve anterior transposition during ORIF, whereas 69 patients had no transposition. Transposition was associated with significantly higher rates of ulnar nerve neuropathy (10/28 versus 10/69; P = 0.027). An adjusted logistic regression model demonstrated an odds ratio of 4.8 (1.3, 17.5; 95% CI) when transposition was performed. Ulnar nerve neuropathy was classified as McGowan grades 1 and 2 in all neuropathy cases in both groups (P = 0.66). Three out of ten cases recovered in the transposition group, and five out of ten cases recovered in the no transposition group over a mean follow-up of 11.2 months (P = 1.00). CONCLUSION: We do not recommend performing routine subcutaneous ulnar nerve anterior transposition during ORIF of distal humerus fracture as it was associated with a significant 5-fold increase in ulnar nerve neuropathy.

Destructive Osteonecrosis of the Femoral Head After a Single Intra-Articular Corticosteroid Injection: A Report of Two Cases.

INTRODUCTION: Accelerated femoral head avascular necrosis after a single dose intra-articular steroid injection is a rare pathology. Few cases were reported in the literature. Most cases were managed with total hip arthroplasty. CASE PRESENTATION: In this study, we report two rare cases of destructive osteonecrosis of the femoral head. Both patients presented with hip osteoarthritis that failed nonoperative measures. A single intra-articular corticosteroid injection was administered for each patient. Both patients had femoral head destruction and significant resorption at 14 and 11 weeks, respectively. Septic arthritis was ruled out by blood tests and joint aspiration. Total hip arthroplasty (THA) was undertaken and histology reports confirmed the osteonecrosis. The postoperative follow-up was uneventful with satisfactory hip function. DISCUSSION AND CONCLUSION: Destructive osteonecrosis of the femoral head is a rare catastrophic potential complication of intra-articular corticosteroid injection. Hence, physicians must consider this complication when counseling patients before an intra-articular corticosteroid hip injection.

Open Reduction and Internal Fixation Versus Nonsurgical Treatment in Displaced Midshaft Clavicle Fractures: A Meta-Analysis.

OBJECTIVES: To compare open reduction and internal fixation (ORIF) and nonsurgical treatment outcomes in displaced midshaft clavicle fractures. DATA SOURCES: PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched in September 2017. STUDY SELECTION: Inclusion criteria were randomized controlled trials reporting nonunion, shoulder functional outcomes, and subsequent surgery rates or pain scores. We excluded studies with patients younger than 16 years, maximum follow-up less than 9 months, and inaccessible full text. DATA EXTRACTION: Extracted data included the first author, publication year, number of patients, number of nonunions, Constant scores, disabilities of the arm, shoulder, and hand (DASH) scores, number of subsequent surgeries, and pain measured using the visual analog scale. DATA SYNTHESIS: The risk ratio of nonunion was 0.15 [95% confidence interval (CI), 0.08-0.31] in ORIF compared with that of nonsurgical treatment. Constant and DASH scores were significantly better in ORIF up to 6 months. The mean difference (MD) in DASH scores at 12 months was statistically insignificant in both treatments (MD, -4.19; 95% CI, -9.34 to 0.96). Constant scores remained significant in ORIF (MD, 4.39; 95% CI, 1.03-7.75). Subsequent surgeries and pain scores were similar in both treatments. CONCLUSIONS: Significant reduction in nonunions and favorable early functional outcomes are associated with ORIF. Nevertheless, late functional outcomes, subsequent surgeries, and pain scores are similar to those of nonsurgical treatment. Although patients treated with ORIF mainly had subsequent elective plate removals, nonsurgically treated patients had more surgical fixations for nonunions. As a result, there remains inconsistent evidence regarding the best treatment for displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.