High Percentage of Complications and Re-Operations Following Dynamic Locking Plate Fixation with the Targon® FN for Intracapsular Proximal Femoral Fractures: An Analysis of Risk Factors.

The ideal surgical treatment of femoral neck fractures remains controversial. When treating these fractures with internal fixation, many fixation constructs exist. The primary aim of this study was to evaluate the incidence and specific risk factors associated with complication and re-operation following fixation of intracapsular proximal femoral fractures using the Targon-FN system (B.Braun Melsungen AG). A secondary aim was to identify if lateral prominence of the implant relative to the lateral border of the vastus ridge was a specific risk factor for elective plate removal. Methodically, a retrospective case series was conducted of all consecutive adult patients treated at a single level 1 trauma center in Switzerland for an intracapsular proximal femoral fracture with the Targon-FN. Demographic data were collected. Patients with a follow-up of less than three months were excluded. Complications as well as plate position were recorded. Statistical analysis to identify specific risk factors for re-operation and complications was performed. In result, a total of 72 cases with intracapsular femoral neck fractures were treated with the Targon-FN locking plate system between 2010 and 2017. Thirty-four patients (47.2%) experienced one or more complications. The most common complication was mechanical irritation of the iliotibial band (ITB) (23.6%, n = 17). Complications included intraarticular screw perforation (6.9%, n = 5), avascular necrosis (5.6%, n = 4), non-union (5.6%, n = 4) among others. In total, 46 re-operations were required. Younger age, fracture displacement and time to postoperative weight bearing were identified as risk factors for re-operation. In conclusion, intracapsular femoral neck fractures treated with the Targon-FN system resulted in a high rate of post-operative complication and re-operation. Statistical analysis revealed patient age, fracture displacement, time to postoperative full weight bearing were risk factors for re-operation. The main limitation is the limited number of cases and a short follow-up of less than 12 months in a subgroup of our patients.

Swiss chocolate and free beverages to increase the motivation for scientific work amongst residents: a prospective interventional study in a non-academic teaching hospital in Switzerland.

BACKGROUND: The success of a clinical trial depends on its recruitment of eligible patients; therefore, the recruitment period requires special attention. We hypothesized that with a new approach focused on continuous information and gratification, resident motivation to participate in scientific work will increase and recruitment rates will improve. METHODS: Our new recruitment approach was applied to the recruitment phase of two prospective randomized trials (registered at the German Clinical Trials Register). Randomization of these trials was performed first using blinded envelopes; later a soft drink machine was used as the delivery tool of randomization as a lighthearted motivation to join scientific work and to reward the resident with free soft drinks for each recruitment. Residents were informed about the trial via a lecture and by mail. To increase interest everyone received Swiss chocolate. With a multiple choice survey we investigated the success of our actions at 6 and 12 months. Recruitment rates of the trials were evaluated and associated with the motivational approaches. RESULTS: Our residents rated their awareness of the trials with median 9 (IQR 7;9) during the first and 8 (IQR 5;9) during the second survey and their interest in scientific work with median 7 (IQR 4;8) and 6 (IQR 5;8). The percentage of residents feeling highly motivated improved from 58% to 70%. The recruitment rates stayed stably high over time with 73% and 72% in trial 1 and 90% and 85% in trial 2; 24% of residents stated their motivation could be increased by gratifications. CONCLUSIONS: After implementation of our new recruitment approach we found positively motivated residents and high recruitment rates in the corresponding trials. We propose this procedure may help to ensure the successful initiation of clinical trials. Larger studies testing this approach are warranted.

Comparison of fracture healing and long-term patient-reported functional outcome between dorsal and volar plating for AO C3-type distal radius fractures.

PURPOSE: This study aimed to evaluate the differences in long-term functional outcome and radiographic fracture healing between volar and dorsally approached comminuted intra-articular distal radius fractures (DRF) (AO C3-type). METHODS: A retrospective, age-matched, case-control study with a 1:2 allocation ratio was conducted in 84 patients C3-type DRFs patients who underwent either dorsal locking plating (DLP) group (n = 28) or volar locking plating (VLP) group (n = 56). Standardized wrist radiographs (posterior-anterior and 15° lateral) were assessed immediately postoperative and at final follow. To evaluate for loss of reduction standard radiographic measurements were performed. Fracture healing was assessed radiologically. Patient-reported outcomes were assessed with the patient-related wrist evaluation and the EQ-5D-3L for health-related quality of life. Patient satisfaction was assessed with the use of a numeric analog scale ranging from 0 (not satisfied) to 100 (very satisfied). RESULTS: All fractures united within 3 months postoperatively. Average age was 59 ± 12 years. Fifty-five patients (66%) participated in the follow-up survey at an average of 76.6 ± 23.8 months. DLP group showed a significant change in sagittal tilt compared with VLP group (3.4 ± 3.0° vs - 0.4 ± 4.1°, p < 0.001). No significant difference in other radiographic and long-term functional outcome was found between both groups (p > 0.05). CONCLUSION: Dorsal locking plating fixation in C3-type DRFs resulted in a minimal, but statistically significant, volar collapse of sagittal tilt compared with volar locking plating fixation. However, this difference in volar collapse did not significantly influence the long-term clinical outcome.

Intraoperative evaluation of acetabular cup position during anterior approach total hip arthroplasty: are we accurately interpreting?

INTRODUCTION: Intraoperative radiographic evaluation during total hip arthroplasty (THA) has shown to improve the accuracy of acetabular component placement, however, differences in interpretation based on radiographic technique has not been established. This study aims to determine if differences exist in the interpretation of acetabular component abduction and anteversion between different radiographic projections. METHODS: 55 consecutive direct anterior THAs in 49 patients were prospectively enrolled. Target anteversion and abduction was defined by the Lewinnek zone. Fluoroscopy was used to direct acetabular component placement intraoperatively. After final cup implantation, fluoroscopic posterior-anterior hip and pelvis images were obtained for analysis. After completion of the procedure, an anterior-posterior plain pelvis radiograph was obtained in the operating room. Acetabulum component abduction and anteversion were postoperatively determined using specialised software on each of the 3 image acquisition methods. RESULTS: Average acetabular cup abduction for intraoperative fluoroscopic posterior-anterior hip (FH), intraoperative fluoroscopic posterior-anterior pelvis (FP), and postoperative, standard, anteroposterior pelvis radiographs (PP) was 40.95° ± 2.87°, 38.87° ± 3.82° and 41.73° ± 2.96° respectively. The fluoroscopic hip and fluoroscopic pelvis tended to underestimate acetabular cup abduction compared to the postoperative pelvis (p < 0.001). Average acetabular cup anteversion for FH, FP, and PP was 19.89° ± 4.87°, 24.38° ± 5.31° and 13.36° ± 3.52° respectively. Both the fluoroscopic hip and fluoroscopic pelvis overestimated anteversion compared to the AP pelvis, with a 6.38° greater mean value measurement for FH (p < 0.001), and an 11° greater mean value measurement for FP (p < 0.001). CONCLUSIONS: Fluoroscopic technique and differences between radiographic projections may result in discrepancies in component position interpretation. Our results support the use of the fluoroscopic posterior-anterior hip as the choice fluoroscopic imaging technique.

Interprosthetic femoral fractures: management challenges.

Interprosthetic femur fractures are a rare but serious complication following total hip and knee arthroplasty. Classification systems have focused not only on diagnosis but also on treatment algorithm. Critical to the evaluation of patients with these fractures are an assessment of fracture location, bone quality, and the presence of stemmed implants. The gold standard for fracture fixation is locked plating with bicortical and unicortical screws, supplemented with wires or cables as needed. For patients with compromised bone stock or insufficient bony area for fixation, allograft augmentation with struts or interprosthetic sleeves may be used. For fractures with severe bone loss, conversion to a megaprosthesis or total femur replacement may be warranted.

Quantitative Effect of Pelvic Position on Radiographic Assessment of Acetabular Component Position.

BACKGROUND: Intraoperative fluoroscopy aims to improve component position in total hip arthroplasty. Measurement bias related to image quality, however, has not been quantified. We aim to quantify measurement bias in the interpretation of acetabular component position as a function of pelvis and fluoroscopic beam position in a simulated supine total hip arthroplasty model. METHODS: Posterior-anterior pelvis and hip images were obtained using a previously described pelvic model with known acetabular component position. Pelvic position was varied in 5° increments of pelvis rotation (iliac-obturator) and tilt (inlet-outlet), and in 1 cm increments from beam center in cranial-caudal and medial-lateral planes. Multiple regression analyses were conducted to evaluate the relationship between the resulting bias in interpretation of component position relative to pelvis position. RESULTS: Anteversion and abduction measurement bias increased exponentially with increasing deviation in rotation and tilt. Greater bias occurred for anteversion than for abduction. Hip centered images were less affected by pelvis malposition than pelvis centered images. Deviations of beam center within 5 cm in the coronal plane did not introduce measurement bias greater than 5°. An arbitrarily defined acceptable bias of ±5° for both abduction and anteversion was used to identify a range of optimum pelvic positioning each for hip and pelvis centered imaging. CONCLUSION: Accurate measurement of acetabular component abduction and anteversion, especially anteversion, is sensitive to proper pelvic position relative to the chosen radiographic plane. An acceptable measurement bias of ±5° is achieved when the pelvis is oriented within a newly identified range of optimum pelvic positioning.

The Impact of Metabolic Syndrome on 30-Day Complications Following Total Joint Arthroplasty.

BACKGROUND: The arthroplasty population increasingly presents with comorbid conditions linked to elevated risk of postsurgical complications. Current quality improvement initiatives require providers to more accurately assess and manage risk presurgically. In this investigation, we assess the effect of metabolic syndrome (MetS), as well as the effect of body mass index (BMI) within MetS, on the risk of complication following hip and knee arthroplasty. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for total hip or knee arthroplasty cases. Thirty-day rates of Centers for Medicare and Medicaid Services (CMS)-reportable complications, wound complications, and readmissions were compared between patients with and without a diagnosis of MetS using multivariate logistic regression. Arthroplasty cases with a diagnosis of MetS were further stratified according to World Health Organization BMI class, and the role of BMI within the context of MetS was assessed. RESULTS: Of the 107,117 included patients, 11,030 (10.3%) had MetS. MetS was significantly associated with CMS complications (odds ratio [OR] = 1.415; 95% confidence interval [CI], 1.306-1.533; P < .001), wound complications (OR = 1.749; 95% CI, 1.482-2.064; P < .001), and readmission (OR = 1.451; 95% CI, 1.314-1.602; P < .001). When MetS was assessed by individual BMI class, the MetS + BMI >40 group was associated with significantly higher risk of CMS complications, wound complications, and readmission compared to the lower MetS BMI groups. CONCLUSION: MetS is an independent risk factor for CMS-reportable complications, wound complications, and readmission following total joint arthroplasty. The risk attributable to MetS exists irrespective of obesity class and increases as BMI increases.

A Rare Case of an Irreducible Patella Dislocation.

Reports of irreducible patellar dislocations are exceedingly sparse throughout the literature. Obvious radiographic or physical exam findings including fracture or inversion of the patella are often present to explain the block to reduction. Not described previously in the literature is the instance of an irreducible patella dislocation in the setting of innocuous appearing injury imaging. We present a case of a healthy thirty-two-year-old female who sustained an irreducible lateral patella dislocation while participating in a dance aerobics class. Closed means of reduction were unsuccessful, necessitating open reduction. Intraoperative findings suggest incarceration of a nondisplaced fracture and a chondral defect as the block to reduction. Following open reduction, the patient has had no further episodes of pain or instability related to the patella at one-year follow-up. Irreducible patellar dislocations are exceedingly rare injuries, where associated osseous or chondral lesions may necessitate open reduction despite innocuous appearing initial imaging. A high index of suspicion to proceed with open reduction may limit repeated attempts at closed reduction and further injury.

Inter-Rater and Intra-Rater Repeatability and Reliability of EOS 3-Dimensional Imaging Analysis Software.

BACKGROUND: Quantifying ideal component position for the acetabulum and stem during total hip arthroplasty (THA) has been described by many methods. A new imaging method using low-dose digital stereoradiography, the EOS imaging system, is a biplanar low-dose X-ray system that allows for 3-dimensional modeling of lower limbs and semiautomated measurement of pelvic parameters and implant alignment. METHODS: Twenty-five patients who underwent primary THA by a single surgeon between October 2014 and December 2014 were retrospectively selected. Only patients with unilateral THA without associated spine pathologies were included, totaling 16 right hips and 9 left hips. There were 8 men and 17 women in the cohort, with a mean age of 67 years (range, 53-82). Three individuals performed measurements of pelvic parameters and implant alignment on 3 separate occasions. An interclass correlation of >0.75 was accepted as evidence of excellent agreement and a confirmation of measurement reliability. RESULTS: Before reviewing patient radiographs, 4 pelvic phantom models were analyzed using the EOS 3-dimensional software to verify accuracy. All anatomic and implant measurements performed by the 3 independent reviewers showed interobserver and intraobserver agreement with interclass correlation >0.75. CONCLUSION: Three-dimensional modeling of hip implants with the EOS imaging system is a reasonable option for the evaluation of component position after THA.