The Effect of Type of Femoral Component Fixation on Mortality and Morbidity after Hip Hemiarthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events. QUESTIONS/PURPOSES: The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model. RESULTS: The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis. CONCLUSIONS: While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed.

Outcome of trauma and orthopaedic surgery at a UK District General Hospital during the Covid-19 pandemic.

INTRODUCTION: There are suggestions that elective surgery performed during the incubation period of COVID-19 infection may cause an immediate impairment of cell-mediated immunity, leading to high morbidity and mortality. However is contrasting data about the associated mortality. Since the outbreak, our unit has maintained a prospective database recording Trauma and Orthopaedic surgical activity. Our aim was to share our experience of the first 3 months with prospective data on outcome of essential surgery during the covid-19 peak. Our focus in this report was on the mortality rate as services begin to open. Methods: We prospectively collected data during the peak of the pandemic in the UK, for fracture neck of femur patients (NOF) the most commonly performed surgical procedure and the most vulnerable during this period. We compared this Covid-19 cohort of NOFs against a cohort of NOF's during the same time in 2019 and another cohort of NOF's in 2020 outside the lockdown period to compare mortality rates and give a broader perspective. RESULTS: During the period March 1, 2020 to May 31, 2020, total of 206 patients were operated. Ninety-four fracture NOF and another one hundred twelve essential surgical procedures were performed. In the NOF cohort, there were nine patients that died. Three of them were covid-19 positive, one was not tested and the rest five were covid-19 negative. There was no mortality reported in the non NOF group. Conclusion: In our unit, during the lock down period, mortality rate in patients undergoing fracture NOF was not significantly different from a similar cohort earlier in the year and similar period last year. We have not observed any mortality, to date in the Non NOF procedures carried out.

Walking impairments after severe tibia plateau fractures. A gait pattern analysis.

PURPOSE: Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the short-term gait alternations after severe tibia plateau fractures treated with circular Ilizarov frame. MATERIALS & METHODS: Gait pattern evaluation was performed to patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI), three to six months after the frame removal. Gait evaluation performed by using a force plate in a walking platform at self selected speeds. Data collected from two walking tasks for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12v2) and COST data were also collected. RESULTS: The gait pattern of sixteen patients (aged 48.8 ± 13.3 years), following treatment with circular Ilizarov frame for severe tibia plateau fractures (Schatzker IV-VI) was analysed. The tests were performed at an average of 10.4 months after the initial treatment. SF-12v2 Mental scores have returned to normal (mean 55.8 ± 11.9) but physical scores remained impaired (mean 40.6 ± 11.3). COST scores reached average levels (mean 54.1 ± 19.8). A one-way repeated measures ANOVA was conducted to compare the GRFs and gait timing data of the affected limb with the normal one. Single limb support interval was significantly reduced to the affected limb (p < 0.001) and terminal stance phase was prolonged for the normal limb (p = 0.05). The rest of the GRF and gait timing data did not reach significant differences. CONCLUSIONS: During the early stages of rehabilitation following severe tibia plateau fractures treated with circular Ilizarov frame, the gait pattern returns to normal curve morphology, but with reduced single limb support and terminal stance phases at the affected knee. Mental status returns to normal but symptoms and function remain impaired.

Titanium Kirschner Wires Resist Biofilms Better Than Stainless Steel and Hydroxyapatite-coated Wires: An In Vitro Study.

AIM: External fixation surgery is frequently complicated by percutaneous pin site infection focused on the surface of the fixator pin. The primary aim of this study was to compare biofilm growth of clinically isolated pin site bacteria on Kirschner wires of different materials. MATERIALS AND METHODS: Two commonly infecting species, Staphylococcus epidermidis and Proteus mirabilis, were isolated from patients' pin sites. A stirred batch bioreactor was used to grow these bacteria as single culture and co-cultured biofilms on Kirschner wires made of three different materials: stainless steel, hydroxyapatite-coated steel and titanium alloy. RESULTS: We found that the surface density of viable cells within these biofilms was 3x higher on stainless steel and 4.5x higher on hydroxyapatite-coated wires than on the titanium wires. CONCLUSION: Our results suggest that the lower rates of clinical pin site infection seen with titanium Kirschner wires are due to, at least in part, titanium's better bacterial biofilm resistance. CLINICAL SIGNIFICANCE: Our results are consistent with clinical studies which have found that pin site infection rates are reduced by the use of titanium relative to stainless steel or hydroxyapatite-coated pins. HOW TO CITE THIS ARTICLE: McEvoy JP, Martin P, Khaleel A, et al. Titanium Kirschner Wires Resist Biofilms Better Than Stainless Steel and Hydroxyapatite-coated Wires: An In Vitro Study. Strategies Trauma Limb Reconstr 2019;14(2):57-64.

Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients.

BACKGROUND: There is a general consensus on the management of femoral fractures in children younger than two years and adolescents older than sixteen years. The best treatment for patients younger than sixteen years of age is still debatable. Titanium Elastic Nails (TEN), is widely used with some evidence, nonetheless, we undertook a systematic meta-analysis to assess the efficacy of TEN compared to Spica cast for the management of femoral shaft fracture in children aged between 2 to 16 years old. METHODS: A computer literature search of PubMed, Scopus, Web of Science, CINAHL and Cochrane Central was conducted using relevant keywords. We included clinical trials and observational studies that compared TEN versus Spica cast; Records were screened for eligible studies and data were extracted and synthesized using Review Manager version 5.3 for Windows. Our search found 573 unique articles. After screening the abstract and relevant full text, 12 studies with a total of 1012 patients were suitable for the final analysis. RESULTS: In terms terms of union (in weeks), the reported effect sizes favoured the TEN group in two included studies only. Moreover, the overall standardized mean difference in sagittal (SMD -0.48, 95% CI [-0.70 to -0.26], P<0.001) and coronal angulations (SMD -0.66, 95% CI [-1.00 to -0.31], P<0.001) favored TEN fixation in management of femoral fractures younger than 16 years. The reported length of hospital stay was not consistent across studies. The overall risk ratio of malalignment (RR=0.39, 95% CI [0.27 to 0.57], P<0.001) favored the TEN as well as walking independently. Based on our analysis, TEN treatment is superior to traction and hip spica for femoral fractures in patients younger than 16 years old. CONCLUSION: Based on our analysis we recommend the use of TEN fixation in management of pediatric femoral fractures in patients younger than 16 years.

Chertsey Outcome Score for Trauma: Development and validation of a new unifying patient reported outcome measure for orthopaedic trauma.

PURPOSE: Lately there is an increasing tendency of using Patient Reported Outcome Measures (PROMs) as a final indicator of the outcome of many surgical treatments in orthopaedics and in other medical specialties. Currently there are many outcome scores in orthopaedics and most of them are site specific. In the contrary there is a lack of trauma specific outcome scores. METHODS: We have designed a new PROM especially for orthopaedic trauma patients, in order to measure in what extent the patients manage to return to their pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after treatment for any injury. RESULTS: A total of 60 Chertsey Outcome Score for Trauma (COST) questionnaires were gathered in our outpatients department. The participants were 57% male (aged 46.81 years ± 18.5 years) and the questionnaires collected at mean 10 months post-injury. A Cronbach's Alpha value of 0.89 was identified for the whole construct. The three dimensions of the scale had good internal consistency as well (Cronbach's Alpha test values 0.74, 0.84 and 0.81 for symptoms, function and mental status respectively). Strong/moderate correlation (Spearman's Rho test 0.43-0.65) was observed between the respective physical/mental dimensions of the COST and SF-12v2 questionnaires. CONCLUSION: There is a need among the orthopaedic trauma society for a specific PROM of trauma. COST is a useful and easy to use tool for every trauma surgeon.

Outcomes of the Ilizarov frame use in elderly patients.

AIM: The use of circular frame is widely accepted. This is an outcome review on use of circular Ilizarov frame in elderly patients. MATERIALS & METHODS: Data from all patients treated with an Ilizarov circular frame between January 2002 and December 2014, who were 65 years of age or over at surgery was collected. Seventy Ilizarov circular frames were applied during this period in our unit at a mean age of 71.2 years. Clinical, radiological and quality of life questionnaire (SF-12) data were gathered. Mortality, complication and revision data were also collected. RESULTS: Indications of application of Ilizarov frame were fractures (53%), non-unions (19%), deformity correction (7%) and ankle fusions (21%). Mean period of time in the frame was 184.4 ± 84.2 days. Mortality and complication rates were low (5-7%) at a mean follow-up 4.2 years. There was no case of septic arthritis or newly induced deep infection. Physical and Mental components of SF-12 questionnaire returned to normal for that age group. There was no difference between the subgroups (tibia plateau fractures, pilon fractures, ankle fusions, non-unions, deformity correction and miscellaneous trauma) concerning the physical and mental subjective (PCS and MCS SF-12 component) outcomes (p > 0.05). CONCLUSIONS: Ilizarov circular frame as a definitive treatment of many kinds of trauma and orthopaedic conditions can be safely and reliably used in the elderly with good quality of life results.

Hospital stay and blood transfusion in elderly patients with hip fractures.

Neck of femur (NOF) fractures in elderly patients are the most frequent condition which an orthopaedic surgeon confronts nowadays. The incidence of these fractures is increasing as the population continues to age. These patients absorb the majority of the resources in the hospitals, as their healthcare demands are increased. This study included all patients who were admitted to our hospital between January and October 2015 following a neck of femur fracture. A total of 336 patients were included (72.3% female). We gathered demographic and hospitalisation data from patients' files. Haemoglobin (Hb) levels at admission and transfusion data were also collected. Male patients appeared to have a relatively higher risk of mortality than females (p=0.01). Patients with high ASA grade (IV) had a higher mortality rate (p=0.01). Age, delay of surgery, type of surgery, AMTS and Hb at admission and type of fracture on the other hand did not have a significant impact on mortality (p>0.05). Patients who needed transfusion during their hospitalisation had significantly lower Hb at admission (p=0.044). More specifically, patients who had Hb<110 at admission were more likely to need transfusion (p<0.001). Hospitalisation of patients who needed transfusion was significantly prolonged. In our effort to deliver the best services to our patients, this study considers transfusing the elderly patients with low Hb at admission (Hb<110) pre-operatively, with a view to increasing their reserves for the operation and potentially speeding up the rehabilitation process and decreasing their hospitalisation time.

Comminuted supracondylar femoral fractures: a biomechanical analysis comparing the stability of medial versus lateral plating in axial loading.

The aim of this study was to compare the biomechanical properties of medial and lateral plating of a medially comminuted supracondylar femoral fracture. A supracondylar femoral fracture model comparing two fixation methods was tested cyclically in axial loading. One-centimetre supracondylar gap osteotomies were created in six synthetic femurs approximately 6 cm proximal to the knee joint. There were two constructs investigated: group 1 and group 2 were stabilized with an 8-hole LC-DCP, medially and laterally, respectively. Both construct groups were axially loaded. Global displacement (total length), wedge displacement, bending moment and strain were measured. Medial plating showed a significantly decreased displacement, bending moment and strain at the fracture site in axial loading. Medial plating of a comminuted supracondylar femur fracture is more stable than lateral plating.

A new assessment for syndesmosis injury - The 'Chertsey test'.

INTRODUCTION: If a syndesmosis injury is not detected, or not treated appropriately, it can lead to pain and arthritis. Various techniques have been described to look for the presence of a syndemosis injury. If concern is raised regarding malreduction, the most recognised way of checking accuracy of the reduction (of the fibula into the incisura) is bilateral postoperative ankle CT scans. This not only exposes the patient to further radiation, but can normally only be done once the surgery is completed and so if adjustment is needed, this requires a further operation, encompassing further surgical risks. We developed a simple assessment, which both gives accurate intra-operative demonstration of an injury to the syndesmosis and also can check how well the fibula has been reduced (if required), without the need for further radiological investigation or surgical intervention. The objectives were to test how easy it was to perform the test and apply it to a number of different ankle fractures. METHODS: Peri-operatively, 2-4ml of contrast medium was injected into the ankle joint in cases where there was concern about injury to the syndesmosis. If there was a 'positive' test, and a 'blush' of dye leaked into the surrounding soft tissues, then fixation of the syndesmosis was performed (as per the surgeon's preferred technique). After fixation was completed, a further injection of contrast medium was injected to see if the fibular had been anatomically reduced into its incisura. The test was performed on 15 ankles. RESULTS: There were no difficulties in performing the test and no complications reported. The test clearly demonstrated where there had been an injury to the syndesmosis and also confirmed the accurate reduction of the fibula when there had been stabilisation of the syndesmosis. CONCLUSIONS: It has proved to be an easy and reliable adjunct to ankle fixation surgery and may have further indications.

The variability in the external rotation axis of the distal femur: an MRI-based anatomical study.

Commonly used total knee arthroplasty (TKA) systems utilising measured resection techniques default to 5°-7° valgus for the distal cut relative to the anatomical axis and 3° external rotation of the femoral component relative to posterior condylar axis (PCA). Rotational errors of the femoral component are associated with pain, patella maltracking and a poorer outcome. We analysed MRI scans from patients undergoing TKA using patient-specific instrumentation to assess coronal and rotational alignment from landmarks identified on the scans. One hundred and eight scans in 59 males and 49 females were studied with age range 35-93 years (mean 67.9 years). We found 91 % of patients had a femoral valgus angle between 5° and 7° (mean angles 5.9°), while only 24 % had an external rotation angle between 2.5° and 3.5° relative to PCA. There was no statistical significance in rotation between males and females although outliers tended to be female. Mean Whiteside's angle was 92.9° (87.8-98). This study highlights the variations in external rotation between patients undergoing TKA using the PCA as a reference for rotation. This may be a contributing factor in implant malalignment and patient dissatisfaction.

Experimental model for controlling shear using the Ilizarov frame.

OBJECTIVE: This study has been designed to ascertain whether a standard configuration Ilizarov tibial frame can control shear motion at the fracture site of an oblique fracture within acceptable limits for axial micro-motion, and therefore promote bony union. If not, are there simple modifications to the frame design that can achieve this? METHODS: Four Ilizarov frame designs were tested on a load test rig. Fracture site shear displacement was measured using a clip gauge attached to an automated data recording system. FINDINGS: The standard Ilizarov frame allowed 4mm of fracture site displacement at 340N of load. Our fourth frame design, the locked olive frame, allowed a maximum of 0.61mm displacement at 700N. INTERPRETATION: This is one of only two studies to look at circular frame fracture site control in oblique fractures. This is the only study to characterise Ilizarov frame stiffness in oblique fractures. We have shown that the standard Ilizarov frame design is inadequate for control of oblique fractures in this mechanical model. Our data show that with the application of simple principles, the Ilizarov frame can be modified to provide better fracture site control. These frame designs can be applied clinically to reduce fracture site shear motion in oblique fractures, resulting in improved union rates.

The Ilizarov method for the treatment of complex tibial fractures and non-unions in a mass casualty setting: the 2005 earthquake in Pakistan.

We report our experience in treating victims of the recent earthquake disaster in Pakistan. Our experience was based on two humanitarian missions to Islamabad: one in October 2005, 10 days after the earthquake, and the second in January 2006. The mission consisted of a team of orthopaedic surgeons and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov external fixators. We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit, we treated 12 injured limbs in 11 patients. Four of these patients were children. All cases consisted of complex multifragmentary fractures associated with severe crush injuries. All fractures involved the tibia, which were treated with Ilizarov external fixators. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening. During a second visit, we reviewed all patients treated during our first mission. In addition, we treated 13 new patients with complex non-unions. Eight of these patients were deemed to be infected. All patients had previous treatment with monolateral fixators as well as soft tissue coverage procedures, except one patient who had had an IEF applied by another team. All these patients had revision surgery with circular frames. All patients from both groups were allowed to fully weight-bear post-operatively, after a short period of elevation to allow the flaps to take. Overall, all fractures united except one case who eventually had an amputation. Four patients had a corticotomy and lengthening, and three of them had a successful restoration of limb length. The fourth patient was the one with the eventual amputation.

The reliability of red flags in spinal cord compression.

BACKGROUND: Acute low back pain is a common cause for presentation to the emergency department (ED). Since benign etiologies account for 95% of cases, red flags are used to identify sinister causes that require prompt management. OBJECTIVES: We assessed the effectiveness of red flag signs used in the ED to identify spinal cord and cauda equine compression. PATIENTS AND METHODS: It was a retrospective cohort study of 206 patients with acute back pain admitted from the ED. The presence or absence of the red flag symptoms was assessed against evidence of spinal cord or cauda equina compression on magnetic resonance imaging (MRI). RESULTS: Overall, 32 (15.5%) patients had compression on MRI. Profound lower limb neurologic examination did not demonstrate a statistically significant association with this finding. The likelihood ratio (LR) for bowel and bladder dysfunction (sensitivity of 0.65 and specificity of 0.73) was 2.45. Saddle sensory disturbance (sensitivity of 0.27 and specificity of 0.87) had a LR of 2.11. When both symptoms were taken together (sensitivity of 0.27 and specificity of 0.92), they gave a LR of 3.46. CONCLUSIONS: The predictive value of the two statistically significant red flags only marginally raises the clinical suspicion of spinal cord or cauda equina compression. Effective risk stratification of patients presenting to the ED with acute back pain is crucial; however, this study did not support the use of these red flags in their current form.

The effect of isotonic saline on the strength of bone cement during the polymerisation period.

It is common practice to irrigate the wound in hip and knee replacement surgery during the working and setting phases of cement polymerisation. We sought to establish whether the addition of normal saline during the various stages of polymerisation would affect bone cement strength. Cement specimens were moulded to the dimensions defined in ISO 5833: 2002 and tested in an electro-mechanical test machine with a calibrated 50 kN load cell at a compression rate of 24 mm/min. The results suggest that the compressive strength of bone cement is not affected by the presence of saline following the initiation of polymerisation. However, saline added to the mix prior to the initiation of polymerisation increased its porosity and significantly decreased its strength. This may explain why vacuum mixing is important as it removes water vapour.

A biomechanical comparison of plate configuration in distal humerus fractures.

OBJECTIVES: Our aim was to test the hypothesis that two plates placed parallel to each other are stronger and stiffer than plates placed perpendicular to each other for fixation of a distal humerus fracture model. METHODS: We created an artificial distal humeral fracture model by osteotomizing two groups of identical epoxy resin humera. Screw and plate constructs were built to mimic osteosynthesis. In the first group, 3.5-mm reconstruction plates were placed parallel to each other along each of the medial and lateral supracondylar ridges. In the second group, 3.5-mm reconstruction plates were placed perpendicular to each other with a medial supracondylar ridge plate and a posterolateral plate. Stiffness and strength data of the two constructs were obtained by testing to failure with sagittal plane bending forces. RESULTS: The parallel plate group (n = 7) had a mean stiffness of 214.9 +/- 43.3 N/mm and a mean strength of 304.4 +/- 63.5 N. The perpendicular plate group (n = 8) had a mean stiffness of 138.3 +/- 44.6 N/mm and a mean strength of 214.9 +/- 43.3 N. These differences were significant (Student's t test, P < 0.05). CONCLUSIONS: As theoretically expected, a parallel plate configuration is significantly stronger and stiffer than a perpendicular plate configuration when subjected to sagittal bending forces in a distal humerus fracture model.