Cutaneous hypoesthesia following plate fixation in clavicle fractures.

BACKGROUND: We report the functional impact and natural history of cutaneous hypoesthesia after plate internal fixation for mid shaft clavicle fractures with a horizontal skin incision from year 2009 to 2011. MATERIALS AND METHODS: 38 patients had complete followup data with an average followup period of 23.2 months (range 8-43 months). The impact of supraclavicular nerve injury was studied by assessment of the incidence, functional impact and natural history of numbness with detailed review of the case records and phone questionnaires. RESULTS: The incidence of postoperative numbness was 55.3% (n = 21). Most patients reported the numbness to be at its worst within the first operative month. At the time of worst numbness, 28.6% (n = 6/21) of patients reported the numbness to be severe while 42.9% (n = 9/21) reported moderate numbness and 28.6% (n = 6/21) reported mild numbness. Fifteen of these patients described increased awareness of numbness during contact with straps or clothes. Two patients were significantly bothered by this numbness; 4 patients stated that it was a moderate bother while 7 patients considered it a mild bother. A total of 8 patients reported that they were not bothered at all by the numbness. An overwhelming majority of affected patients (90.5%, n = 19/21) reported an improvement in the severity of numbness felt over time. At the last followup, the incidence of numbness declined from 55.3% to 36.8% with 7 patients reporting complete resolution of numbness. The numbness however was found to persist in 66.7% of patients. Only 1 patient reported continued severe numbness. The awareness of numbness with straps and clothing was severe in 5 patients. None of the patients were significantly bothered by this numbness. CONCLUSIONS: Cutaneous sensory loss is a common occurrence following plate fixation of the clavicle and might have been under reported in the literature. The numbness improves in the vast majority, but commonly persists to some degree for up to 2 years and maybe permanent. However, only a small minority eventually considered the numbness a significant "bother" and to affect them while wearing clothing or when in contact with shoulder straps.

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.

Retrograde cement arteriovenogram of nutrient vessels following hemiarthroplasty of the hip.

Retrograde cement extrusion into the nutrient vessels of the femur is a rare phenomenon in uncomplicated cemented hemiarthroplasty of the hip; this is a report on three cases. Routine postoperative radiographs showed a continuous dense linear opacity arising from the posterior medial region of the femur. Computed tomography (CT) scans revealed no evidence of a cortical break in the femur and confirmed our suspicion of retrograde cement extrusion into the nutrient vessels of the femur. Post-operative recovery was uneventful with no complications of cement thromboembolism. Our findings in three cases suggest that cement retrograde extrusion into nutrient vessels following hemiarthroplasty is a benign complication of modern cementing techniques involving pressurisation. The site of cement extrusion into the nutrient foramina displays a constant topography. We recommend that a CT scan of the femur be done on detection of a radio-opaque density on postoperative radiographs to differentiate an extraosseous breach from an intra-vascular extrusion of cement. The theoretical complications of cement embolism and thrombosis should be kept in mind and looked for clinically.

Surgical hand antisepsis-a pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub.

INTRODUCTION: The surgeon uses different methods of surgical hand antisepsis with the aim of reducing surgical site infections. To date, there are no local studies comparing the efficacy of iodine hand scrub against newer alcohol-based hand rubs with active ingredients. Our pilot study compares a traditional aqueous hand scrub using 7.5% Povidone iodine (PVP-I) against a hand rub using Avagard: 61% ethyl alcohol, 1% chlorhexidine gluconate. The outcome measure is the number of Colony Forming Units (CFU) cultured from 10-digit fingertip imprints on agar plates. MATERIALS AND METHODS: Ten volunteers underwent 2 hand preparation protocols, with a 30-minute interval in between-Protocol A (3-minute of aqueous scrub using PVP-I) and Protocol B (3-minute of hand rub, until dry, using Avagard). In each protocol, fingertip imprints were obtained immediately after hand preparation (t(0)). The volunteers proceeded to don sterile gloves and performed specific tasks (suturing). At one hour, the gloves were removed and a second set of imprints was obtained (t(1)). RESULTS: Four sets of fingertip imprints were obtained. All 10 participants complied with the supervised hand preparation procedures for each protocol. CFUs of initial fingertip imprints (t(0)): The median CFU counts for initial imprint was significantly higher in the PVP-I treatment (median = 6, Inter Quartile Range (IQR) = 33) compared to the Avagard treatment (median = 0, IQR = 0, P <0.001). CFUs of fingertip imprint at 1 hour (t(1)): The median CFU counts for second imprint (t(1)) was significantly higher in the PVP-I treatment (median = 0.5, IQR = 11) compared to the Avagard treatment (median = 0, IQR = 0, P = 0.009). Our results suggest that the Avagard was more efficacious than aqueous PVP-I scrub at reducing baseline colony counts and sustaining this antisepsis effect. CONCLUSION: Alcohol hand rub with an active compound, demonstrated superior efficacy in CFU reduction. Based on our results, and those pooled from other authors, we suggest that alcohol-based hand rubs could be included in the operating theatre as an alternative to traditional surgical scrub for surgical hand antisepsis.