Can the use of an evidence-based algorithm for the treatment of intertrochanteric fractures of the hip maintain quality at a reduced cost?

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions.

The posterior Monteggia lesion with associated ulnohumeral instability.

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation.

Evolving trends in the care of polytrauma patients.

Management of polytrauma patients has changed considerably in recent years. This is in keeping with the developments that have occurred in the fields of fracture fixation techniques and intensive care. Prior to the 1970s, patients with multiple injuries were treated non-operatively, as it was believed that they were too ill to withstand surgery. Around this time, literature appeared to suggest that these patients had high rates of complications as a result of prolonged recumbency. Fracture fixation techniques were also developing rapidly, and these events led to the advent of early fracture stabilisation of multiply injured patients, known as early total care. In the following decade, the surgical world came to recognise that early stabilisation of skeletal injuries produced poor results in certain patients. The concept of 'damage control' surgery was introduced for multiply injured patients. The current era may give way to new methods as our understanding of the pathophysiology of polytrauma improves.

The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail.

To compare the intrinsic stability of two distal interlocking screw orientations for tibial nailing of distal third tibial diaphyseal fractures without isthmal support, six Depuy (Warsaw, Indiana) tibial intramedullary nails were implanted in simulated distal tibiae. The constructs received both two parallel (medial to lateral) and two perpendicular (one medial to lateral, one anterior to posterior) distal interlocking screws in a random order Angular, translational, and torsional displacements of the nails were measured in response to 70 N proximal applications of anterior, posterior, medial, and lateral loads, and a 7.7 Newton-meter torsional load. There were no differences in medial or lateral angulations between the screw orientations (average: 2.5 degrees, p > 0.8). Angulation in the sagittal plane (anterior and posterior) was slightly less for parallel screw fixation (1.6 degrees versus 2.4 degrees), but this was not statistically significant (p > 0.1). Rotational angulation was higher in the parallel (average: 9.9 degrees) versus the perpendicular (average: 8.1 degrees) screw orientation, but these results were not statistically significant (p > 0.1). Pure translation did not occur in either the parallel or perpendicular screw orientations. These results indicate that fixation stability of these tibial intramedullary nails is not significantly influenced by distal interlocking screw orientation in response to sagittal, coronal, or rotational forces.

Outcome after open reduction and internal fixation of Lisfranc joint injuries.

BACKGROUND: Open reduction and internal fixation has been recommended as the treatment for most unstable injuries of the Lisfranc (tarsometatarsal) joint. It has been thought that purely ligamentous injuries have a poor outcome despite such surgical management. METHODS: We performed a retrospective study of patients who underwent open reduction and screw fixation of a Lisfranc injury in a seven-year period. Among ninety-two adults treated for that injury, forty-eight patients with forty-eight injuries were followed for an average of fifty-two months (range, thirteen to 114 months). Fifteen injuries were purely ligamentous, and thirty-three were combined ligamentous and osseous. Patient outcome was assessed with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score. RESULTS: The average AOFAS midfoot score was 77 points (on a scale of 0 to 100 points, with 100 points indicating an excellent outcome), with patients losing points for mild pain, decreased recreational function, and orthotic requirements. The average MFA score was 19 points (on a scale of 0 to 100 points, with 0 points indicating an excellent outcome), with patients losing points because of problems with "leisure activities" and difficulties with "life changes and feelings due to the injury." Twelve patients (25 percent) had posttraumatic osteoarthritis of the tarsometatarsal joints, and six of them required arthrodesis. The major determinant of a good result was anatomical reduction (p = 0.05). The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes despite anatomical reduction and screw fixation. CONCLUSIONS: Our results support the concept that stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores.

An unusual case of hip disability--(a case report).

An unusual case of postero-superior periarticular irritation of the hip joint of six months' duration due to an extension of a pre-sacral foreign body granuloma in an 18 year old unmarried girl is presented. Two wooden sticks which probably were inserted pervaginally by a village midwife to induce an abortion for an unwanted pregnancy had found its way to presacral region. The scanning of the vaginal fornix indicated a possible route through which the sticks might have been migrated.