Assessing the impact of fracture pattern on transfusion requirements in hip fractures.

PURPOSE: Hip fractures in the elderly represent a major source of morbidity and mortality, with allogeneic blood transfusions (ABTs) associated with increased mortality. This study assesses the ABT requirements between the most common patterns of hip fracture; intertrochanteric (IT) and intracapsular (IC). The impact of operation type on transfusion rates was also assessed. METHODS: A retrospective study was performed for all patients entered on the national hip fracture database over 1 year in a teaching hospital. Records of 559 patients were reviewed and, following exclusion criteria, 474 were evaluated (198 IT, 276 IC). Baseline haematological parameters and ABTs were identified using hospital systems. Analysis was performed in SPSS, using independent samples t tests, one-way ANOVAs and Chi square tests. RESULTS: Patient groups were matched on gender, anaesthetic type, American Society of Anesthesiologist (ASA) grade, cognitive score and coagulation parameters. A significantly greater proportion of IT patients required an ABT during admission (39.4 vs. 22.5 %, p < 0.001). For IT fractures a greater proportion of patients required an ABT when undergoing an intramedullary nail operation compared with those requiring a dynamic hip screw (67.4 vs. 32.0 %, p < 0.001). Similarly, for IC fractures transfusion rates in patients undergoing an internal fixation were significantly lower than those undergoing hemiarthroplasty or arthroplasty (9.4 vs. 26.4 vs. 20.8 %, p = 0.033). CONCLUSION: Patients with IT hip fractures are significantly more likely to require an ABT than those with IC hip fractures. Patients undergoing an intramedullary nail for IT fractures have significantly higher transfusion rates than for other types of operation.

The treatment of a rupture of the Achilles tendon using a dedicated management programme.

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings. The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed. Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (sd 14), 64.9 (sd 15) (n = 135), six months 67.8 (sd 16), 73.8 (sd 15) (n = 103) and nine months (72.4; sd 14) 72.3 (sd 13) (n = 43). The programme realised estimated cost savings exceeding £91,000 per annum. The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs.

Intense pulsed light treatment of chronic mid-body Achilles tendinopathy: A double blind randomised placebo-controlled trial.

We conducted a randomised controlled trial to determine whether active intense pulsed light (IPL) is an effective treatment for patients with chronic mid-body Achilles tendinopathy. A total of 47 patients were randomly assigned to three weekly therapeutic or placebo IPL treatments. The primary outcome measure was the Victorian Institute of Sport Assessment - Achilles (VISA-A) score. Secondary outcomes were a visual analogue scale for pain (VAS) and the Lower Extremity Functional Scale (LEFS). Outcomes were recorded at baseline, six weeks and 12 weeks following treatment. Ultrasound assessment of the thickness of the tendon and neovascularisation were also recorded before and after treatment. There was no significant difference between the groups for any of the outcome scores or ultrasound measurements by 12 weeks, showing no measurable benefit from treatment with IPL in patients with Achilles tendinopathy.

Anatomy of pilon fractures of the distal tibia.

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.

Interface pressure produced by the traction post on a standard orthopaedic table.

Lower limb traction is applied with counter traction in the groin. The resultant tissue pressures can be high and may result in skin necrosis or nerve palsies. Volunteers were positioned on a fracture table and traction applied to the left leg. Perineal contact pressures were measured using pressure transducers connected to a laptop computer. Pressure readings and pain scores were recorded with different types of padding, whilst the leg was repositioned. Maximal pressures exceeded the 70 mmHg limit known to cause tissue damage. Larger (10 cm) padding devices significantly reduced the pressures. When employing the perineal traction post, care should be taken to pad this carefully to avoid the sequelae of high tissue pressure.

An audit of tunnel position in anterior cruciate ligament reconstruction.

We audited 114 primary anterior cruciate ligament (ACL) reconstructions. Notes were reviewed and tunnel positions assessed on lateral and AP radiographs. A literature review established optimal tunnel position. Sixteen surgeons performed 57 arthroscopic and 57 open reconstructions, using 24 hamstring and 90 bone-tendon-bone autografts. Eighty-five sets of radiographs were available for review. Sixty-five percent of femoral tunnels and 59% of the tibial tunnels were malpositioned in the sagittal plane. Guidelines for best practice are required for key procedures in each speciality. Tunnel position in ACL reconstruction can be easily measured and should be correct in at least 90% of cases.