CT-guided vs. fluoroscopically guided transforaminal epidural steroid injections for lumbar radiculopathy: a comparison of efficacy, safety and cost.

INTRODUCTION: There are no formal guidelines for whether CT-guided or fluoroscopy-guided TFESI should be undertaken for patients with symptoms of lumbar nerve root irritation and corresponding nerve impingement. Here, we sought to compare the efficacy, safety and cost of computer tomography (CT)-guided and fluoroscopically guided transforaminal epidural steroid injection (TFESI). MATERIALS AND METHODS: All patients who underwent lumbar TFESI at our institution between June 2016 and June 2018 were identified. Six-week follow-up outcomes were categorised. The radiation doses and associated cost was retrieved from our institution's costing system. RESULTS: One hundred and sixteen patients were included (CT-50; fluoroscopy-56). There were no complications. More patients were discharged 6 weeks after CT-guided lumbar TFESI when compared with fluoroscopically guided TFESI (CT-23, fluoroscopy-14 (P = 0.027)). There was no difference in the number of patients who were referred to surgery (P = 0.18), for further pain management (P = 0.45), or for further TFESI (P = 0.43). The effective radiation dose was significantly higher for CT-guided TFESI (CT-5.73 mSv (3.87 to 7.76); fluoroscopy-0.55 mSv (0.11 to 1.4) (P < 0.01)). The total cost for CT-guided lumbar TFESI was £237.50 (£235 to £337), over £800 less than under fluoroscopic guidance (£1052 (£892.80 to £1298.00), P < 0.01)). Removing cost associated with staff and theatre use (staffing, theatre, medical indemnity and overheads) revealed CT-guided lumbar TFESI to be less expensive than if the procedure was fluoroscopy-guided-CT-guided: £132.6 (130.8 to 197.5); fluoroscopy: £237.4 (£209.2 to £271.9) (P = 0.019). CONCLUSIONS: CT-guided TFESI was associated with a higher discharge rate, a lower cost, but a ten times higher radiation dose when compared with fluoroscopically guided TFESI. Prospective studies are required to compare the efficacy of these procedures and to investigate how the radiation dose of CT-guided TFESI can be reduced without jeopardising efficacy or safety.

Locking plates versus retrograde intramedullary nails in the treatment of periprosthetic supracondylar knee fractures. A retrospective multicenter comparative study.

INTRODUCTION: Biomechanical studies demonstrated the superiority of retrograde supracondylar intramedullary nails (RIN) against locking plates (LP) for the treatment of periprosthetic supracondylar femoral fractures (PSFs); however, clinical results are still conflicting. This study aimed to compare LP and RIN, as well as, cemented and uncemented nails in the treatment of PSFs regarding fracture healing, complications and functional results. MATERIALS AND METHODS: A retrospective multicenter analysis of 60 PSFs classified as Rorabeck type I or II was performed. Thirty-one cases were treated with LP while in 29 cases RIN were used. Out of the latter, 14 had nailed cementoplasty, while 15 an uncemented nail. RESULTS: The two groups were comparable concerning gender, ASA score, operated side, follow-up time, fracture type and mechanism of injury. The LP was significantly younger than the RIN group. Forty-six cases had fracture union at an average of six months, 11 were healed between seven and twelve months (delayed unions), and three developed non-unions. There was no significant difference in the median union time between RIN and LP groups (six vs five months, p = 0.707) or cemented and uncemented nailing groups (5.5 vs six months, p = 0.354). The RIN group had fewer delayed unions or non-unions than LP group; however, not reaching significance (4 vs 10, p = 0.190). Complications were fewer but non-significantly different between cemented and uncemented nails (one vs five, p = 0.481). The mean postoperative flexion was comparable between RIN and LP groups (99.1° vs 94.9°, p = 0.547) or cemented and uncemented nails (102° vs 96.3°, p = 0.4). The mean Oxford Knee Score did not differ between LP and RIN groups (30.8 vs 31.3, p = 0.93) as well as between cemented and uncemented nails (31.5 vs 30.6, p = 0.801). DISCUSSION: PSFs with good bone stock can be treated equally with LP or RIN. Nails demonstrated advantages concerning the fracture healing potential. Orthopaedic surgeons need to be trained in both treatment options to manage PSFs. Cemented nails may increase stability and healing capacity in elderly osteoporotic patients; however, further studies are needed.

Treatment of developmental dislocation of hip: does changing the hip abduction angle in the hip spica affect the rate of avascular necrosis of the femoral head?

Avascular necrosis (AVN) of the femoral head is a serious complication in the management of developmental dislocation of the hip. Increasing the abduction angle increases its stability but compromises the vascularity of the femoral head. From our database of 240 children treated for developmental dislocation of hip by the two senior authors between 1998 and 2008, we defined two groups of children who underwent closed or medial open reduction of the hip after a failed Pavlik treatment or if patients presented late. In group 1, the reduced hip was immobilized in around 90° flexion, 60° abduction, and 0-10° internal rotation. In group 2 the hip was immobilized in around 45° of hip abduction with flexion and internal rotation as before. The first and second authors independently analysed these two groups blinded to the hip abduction angle. Our hypothesis was that a reduction in the hip abduction angle would reduce the incidence of AVN in the second group without compromising the stability. All eligible children were included, and there were 42 children in group 1 and 44 children in group 2. An almost equal number of children underwent closed and medial open reduction in both the groups. The age at reduction was a mode of 6 months (range 6-13 months) and 7 months (range 7-12 months), respectively. The abduction angle in the first group had a mode of 60° (range 52-70°) and the second group had a mode of 45° (range 38-50°). Radiographic evidence of AVN as described by Salter and colleagues was seen in eight children (19%) in the first group and seven children (16%) in the second group (P=0.78). Redislocation occurred in one child in the second group and none in the first group. In summary, the results show a nonsignificant reduction in the incidence of AVN when the hip abduction angle was reduced with no significant increased risk of redislocation.

A meta-analysis of amputation versus limb salvage in mangled lower limb injuries--the patient perspective.

This meta-analysis evaluates the quality of life in post-traumatic amputees in comparison with limb salvage. Studies included in this meta-analysis had a minimum of 24 months of follow-up and used a validated quality-of-life outcome assessment scale (Short Form-36 or Sickness Impact Profile) for physical and psychological outcomes. Two reviewers performed the search and data extraction independent of each other. A total of 214 studies were identified; 11 fulfilled the inclusion criteria; thus, 1138 patients were available for meta-analysis (769 amputees and 369 cases of reconstruction). The meta-analysis demonstrated that lower limb reconstruction is more acceptable psychologically to patients with severe lower limb trauma compared with amputation, even though the physical outcome for both management pathways was more or less the same.