Improving stability of locking compression plates through a design modification: a computational investigation.

Femoral shaft fractures are common in both the young and elderly due to high-impact trauma and low-impact trauma, respectively. Its treatment by indirect reduction through use of locking compression plates (LCPs) has been on the rise. The LCP possess several advantages in fracture fixation, combining angular stability through use of locking screws with misalignment correction and fracture reduction onto the plate through use of conventional screws. However, there have been cases of plate breakage and fracture non-unions to warrant a study to improve its stability. A design modification is suggested for mid-diaphyseal fractures, whereby unused screw holes are removed. The structural stability of the modified and commercially available LCP is computationally analyzed using finite element modelling and a comparison made in terms of mechanical performance across different fracture lengths. A critical fracture length for which the commercially available LCP is functional as a fixator for mid-diaphyseal fractures was established. The maximum von Mises' stress attained by the commercially available LCP rose to as high as 105 MPa, whereas for the modified LCP, it did not exceed 25 MPa. As expected, these stresses were also found at screw holes, nearest to the fracture site. Critical fracture length allows clinicians to quantitatively distinguish between mid-diaphyseal fractures that can or cannot be treated by the use of LCP fixation. It is also believed that the proposed design modification will substantially increase the fatigue life of the fixator, especially at screw holes nearest to the fracture region, where most fatigue fractures are known to occur and will consequently be functional for greater fracture lengths.

Functional improvement of self-care in the elderly after hip fracture: is age a factor?

INTRODUCTION: The aging population is growing rapidly in Asia resulting in an increased number of hip fractures being managed surgically. Though there is evidence of improved quality of patient care and outcomes with well-established models of care, we do not know if the functional recovery in activities of daily living among this group of patients is also dependant on age. We hypothesize that there will be a difference in Modified Barthel Index (MBI) scores between the 'older old' (>85 years) and the 'younger old' (<85 years). PATIENT AND METHODS: Hip fracture patients (>60 years) treated surgically were divided into Group A (below 85 years) and Group B (above 85 years). Demographic data, Charlson's Comorbidity Index (CCI) score, time to surgery and length of stay (LOS) were recorded. To assess the recovery in activities of daily living, the MBI scores were measured for the following intervals; pre-fall, at discharge, at 6-month and at 1-year follow-up. RESULTS: The mean age for Group A (n = 120) was 77 years (60-85) and the mean age for Group B (n = 59) was 91.8 years (86-108). There was no significant difference in the mean CCI (A: 1.14, B: 1.24), mean time to surgery (A: 72.3 h, B: 79.9 h) and mean LOS (A: 10.8 days, B: 10.3 days). The MBI scores were significantly different (P < 0.05) for the pre-injury scores (A = 91.5, B = 84.4); however, there was no significant difference for scores measured at discharge (A = 57.5, B = 52.7), at 6 months (A = 74.6, B = 69.3) and at 1 year (A = 82.2, B = 73.2). Though there was a significant improvement, the scores at 1 year were significantly lower than the pre-injury score for both groups. CONCLUSION: We conclude that age is not a factor in determining functional recovery with regard to activities of daily living in an integrated model of care for geriatric hip fracture patients.

Orthogeriatric model for hip fracture patients in Singapore: our early experience and initial outcomes.

INTRODUCTION: The aging population is growing rapidly in Asia resulting in an increased number of fragility fractures. Studies have shown that an integrated model of care for the elderly can improve the quality of patient care and outcomes. This report describes our concept, initial experience and short-term outcomes of the integrated model of care that was established in managing geriatric hip fractures in Tan Tock Seng Hospital, Singapore. PATIENT AND METHODS: An integrated care pathway model was implemented. The principle of the model is based on (a) timely admission, review, surgery, rehabilitation, transfer, (b) multidisciplinary approach and (c) integration of a care manager. Hip fracture patients (>60 years) were included in our study and were followed up for 1 year. Demographic data, Charlson comorbidity index (CCI), time to surgery, length of stay and modified Barthel index (MBI) scores were recorded. RESULTS: The mean age was 82 years (62-108) with a female predominance (75 %). The mean CCI was 1.8. Time to admission was 3.7 h and mean time taken to be reviewed by an integrated care manager was 21.7 h. Close to 40 % of patients were operated within 48 h with a median time to surgery of 36.7 h. Mean length of stay was 10 days with an inpatient and 1-year mortality rate of 2.3 and 5.9 %, respectively. Complication rate was 5.1 % (urinary tract infection and wound infection) and MBI scores at 1 year revealed significant functional improvement of 95 % (p < 0.01). CONCLUSION: Our integrated model of care for hip fractures can lead to satisfactory outcomes. Though the time to surgery and length of stay can be improved further, our initial results have shown a reasonable time to admission and review by a care manager. Besides a low complication and mortality rate, functional improvement was significant post-operatively.

Clinical outcomes of distal femoral fractures in the geriatric population using locking plates with a minimally invasive approach.

BACKGROUND: Fractures of the distal femur comprise 4% to 6% of all femoral fractures. Elderly patients are predisposed to low-energy fractures due to osteoporosis. Treatment of these fractures in the elderly group remains a challenge. Our hypothesis is that locking plates inserted with minimally invasive plate osteosynthesis (MIPO) techniques will produce better results compared to those inserted by open technique. The objective of this study is to evaluate the clinical outcomes of MIPO technique using locking plates in the elderly patients. MATERIALS AND METHODS: A total of 24 elderly patients (mean age 73 years) with distal femur fractures treated using the MIPO technique (2007-2010) were reviewed retrospectively. Parameters analyzed included classification of fracture, time to fracture union, knee range of motion, functional knee score (Knee Society Score-Functional) at 6 months, and other significant complications. One patient was lost to follow-up. RESULTS: In all, 88% of the fractures were extraarticular. The mean time to union was 13.48 (range: 8-28) weeks. Mean range of motion achieved at 6 months and beyond was 100° ranging from 0 to 30 (extension) to 90 to 140 (flexion). Functional knee scores at 6 months from fixation were satisfactory (mean score 88.8). There were no cases of implant failure, nonunion, and infection. In all, 6 (25%) patients developed deep vein thrombosis (DVT) in the early postoperative period, all of which were below the level of the knee joint. CONCLUSION: Locking plates inserted using MIPO techniques in elderly patients with distal femur fractures appear to be promising based on clinical outcome measurements. However, there was a high incidence of DVT noted.

Necrotising fasciitis caused by adulterated traditional Asian medicine: a case report.

Necrotising fasciitis can be life threatening, requiring prompt diagnosis and surgical debridement. We report a case of necrotising fasciitis caused by an adulterate traditional Asian medication--Jamu Pegal Linu, containing toxic levels of phenylbutazone and dipyrone. The patient presented with severe neutropenia and sepsis. An urgent extensive debridement was carried out (within 6 hours of presentation). Repeated debridements were performed on days 2 and 5, augmented with antibiotics and granulocyte colony-stimulating factor.