Adam Tucker

Predictors for Readmission up to 1 Year Following Hip Fracture

Background: At Altnagelvin, a district general hospital in Northern Ireland, we have observed that a significant number of hip fracture admissions are later readmitted for treatment of other medical conditions. These readmissions place increasing stress on the already significant burden that orthopedic trauma poses on national health services. Objectives: The aim of this study was to review a series of consecutive patients managed at our unit at least 1 year prior to the onset of the study. Also, we aimed to identify predictors for raised admission rates following treatment for hip fracture. Patients and Methods: We reviewed a prospective fracture database and online patient note system for patient details, past medical history, discharge destination and routine blood tests for any factors that may influence readmission rates up to 1 year. Data were analyzed using SPSS software. Results: Over 2 years, 451 patients were reviewed and 23 were managed conservatively. There was a 1-year readmission rate of 21%. Most readmission diagnoses were medical including bronchopneumonia, falls, urosepsis, cardiac exacerbations and stroke. Prolonged length of stay and discharge to a residential, fold or nursing home were found to increase readmission rate. Readmission diagnoses closely reflected the perioperative diagnoses that prolonged length of stay. Increased odds radio and risk of readmission were also found with female gender, surgery with a cephalomedullary nail, hip hemiarthroplasty or total hip replacement, time to surgery < 36 hours, alcohol consumption, smoking status, Hb drop > 2 g/dL and also if a blood transfusion was received. Conclusions: Our results indicate that hip fracture treatment begins at acute fracture clerk in, with consideration of comorbid status and ultimate discharge planning remaining significant predictors for morbidity and subsequent readmission.

Incidence and recognition of peroneal tendon dislocation associated with calcaneal fractures

BACKGROUND Questions abound regarding natural history and medicolegal implications of untreated peroneal tendon dislocation (PTD) associated with calcaneal fractures. METHODS We retrospectively analyzed CT scans and anteroposterior ankle radiographs of 79 consecutive calcaneal fractures presenting over 4 years at a single institution. RESULTS Nineteen patients (24%) had associated PTD, which was initially missed in 10 (53%). Bony fleck was present in 11 (13.75%). Soft tissue swelling at lateral malleolar level, present on radiographs of 18 tendon dislocators (95%), raises likelihood of PTD with increasing specificity the greater the swelling. In 6 patients, surgeons failed to identify on CT spontaneously relocated tendons that then peeped around the posterolateral fibula, a finding not appreciable on 3-dimensional volume-rendering. CONCLUSIONS Despite a significant association of PTD with calcaneal fractures, it still passes unrecognized all too frequently. Anatomical fracture fixation does not guarantee stable tendon reposition. Further studies are required to elucidate functional outcome of untreated PTD.

Pre-requisites for optimum centering of a tibiotalocalcaneal arthrodesis nail

BACKGROUND Purpose of study was to compare nail alignment, incidence of stress riser and fracture with straight and curved nails of different lengths. METHODS We conducted a retrospective review of consecutive, initially 13 straight and subsequently 15 curved nails implanted in 17 men and 11 women. Angles of incidence and reflection subtended by nail tip with inner tibial cortex were measured. Cortical hypertrophy was assessed on follow-up radiographs. RESULTS Angles of incidence and reflection were greater with short straight nails, less with long straight nails and stayed close to zero with long curved nails. Stress fractures occurred in 2 patients with straight nails at the level of the proximalmost tibial screw. Cortical hypertrophy was present in 7 patients with straight nails and in only 1 patient with a curved nail (p=0.01). CONCLUSIONS Both nail length and inbuilt valgus contribute to better central positioning within the tibia. However, cortical stress reactions occur less frequently with curved nails.

The changing face of fractures of the hip in Northern Ireland: a 15-year review

Aims We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant. Patients and Methods Since 01 January 2001 data about every fracture of the hip sustained in an adult have been collected centrally in Northern Ireland. All adults with such a fracture between 2000 and 2015 were included in the study. Temporal changes in their demographics, the mode of treatment, and outcomes including mortality were analysed. Results The incidence of fractures of the hip, in Northern Ireland, rose from 54 in 100 000 in 2000 to 86 in 100 000 in 2015. If these trends continue, we predict this rising to 128 in 100 000 in 2030. We found that these patients are becoming older and increasingly frail, as assessed by the American Association of Anesthesiology grade. Complex extracapsular fractures have become more common since 2009, which may explain the increased use of cephalomedullary nails. Despite increasing frailty, the 30‐day and 12‐month rates of mortality fell significantly (p = 0.002 and 0.001, respectively). Conclusion Fractures of the hip are becoming more common and more complex in an aging, increasingly frail population. We expect these trends to continue. This will place an increasing economic and clinical strain on healthcare systems. Forward planning is essential to put systems in place that can deal with the increasing demand.

Managing extremely distal periprosthetic femoral supracondylar fractures of total knee replacements - a new PHILOS-ophy

We report two cases where a proximal humeral locking plate was used for the fixation of an extremely distal, type III peri-prosthetic femoral fractures in relation to a total knee replacement (TKR). In each case there was concern regarding the fixation that could be achieved using the available anatomic distal femoral plates due to the size and bone quality of distal fragment. The design of the Proximal Humeral Internal Locking System (PHILOS) allows nine 3.5-mm locking screws to be placed over a small area in multiple directions. This allowed a greater number of fixation points to be achieved in the distal fragment. Clinical and radiological short-term follow-up (6-12 mo) has been satisfactory in both cases with no complications. We suggest the use of this implant for extremely distal femoral fractures arising in relation to the femoral component of a TKR.

The lateral malleolar bony fleck classified by size and pathoanatomy: The IOFAS classification

BACKGROUND This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs. METHODS Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans. RESULTS In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III. CONCLUSIONS Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.

Metal on metal (MoM) hip arthroplasty: An observational study on the effect of bearing contact surface area and contact pressure on metal ion levels

Metal on metal wear has attracted significant media attention in recent years, owing to the issues associated with adverse reactions to metal ion debris, with subsequent revision arthroplasty procedures. To date, implant orientation has been the key. Studies on ceramic implants have utilised mathematical models in order to assess contact surface areas and pressures generated within the hip joint and their correlation to wear. To date, this has not been undertaken in metal on metal hips. We applied a previously published Hertzian ball in plane model to a cohort of metal on metal hip replacement patients from a single surgeon practice to evaluate the effect of contact pressures on metal ion levels. Statistical analysis was performed using SPSS v20. A total of 58 patients, with a male preponderance (65%), from a single surgeon practice were identified and recruited. Anaverage age of 52 (±9) years, mean body mass index 28.91 kg/m2 (±4.41) with no proportional difference between groups were noted (p > 0.05). Mean ion levels were calculated for both cobalt 34.93(±21.90) nmol/L and chromium 40.10(±25.85) nmol/L. Implant orientation was recorded and, using the method described, contact pressures were calculated. Correlation testing revealed that abduction angle was significantly associated with cobalt (r=0.344, p = 0.040) and chromium (r = 0.336, p = 0.045) levels, but that the contact pressures were not associated with metal ion levels (Co, r = −0.033, p = 0.803, Cr, r = −0.095, p = 0.479).Our results reinforce that it is neither the body mass index nor the contact surface area or pressure generated that increases metal ion level, and that abduction angle remains essential in metal ion generation. The surgeon should be vigilant in ensuring correct implant orientation intra-operatively in order to reduce metal ion generation.

Leaflet repair and valve sparing (inclusion technique) aortic root repair: reference to the latest principles

Up to 150 words summarising the case presentation and outcome (this will be freely available online). A Marfan case with dilated aortic root and prolapsed leaflets underwent aortic repair. The non-coronary leaflet-measured effective height was 7 mm (prolapsing) and was lifted up to 10 mm with a centrally placed plicating sutures. The right coronary leaflet had a geometric height of 17 mm (restricted) and was enlarged up to 21 mm with an autologous pericardial patch. The enlarged root was repaired with an inclusion technique. The final result showed a competent valve. This report outlines the feasibility of aortic repair provided one adheres to the principles of aortic valve repair.

Radiological signs of a true lunate dislocation

Perilunate dislocations are high-energy injuries that are uncommon. The literature suggests that up to 25% of cases may be missed.1 ,2 Here we present an acute lunate dislocation in a young man who fell from a height of 12 feet onto an extended, outstretched right hand. Plain radiographs demonstrated classical signs of a perilunate dislocation (figures 1 and 2). He also sustained fractures of the radial and ulnar styloid, indicating a variant of a greater arc injury.3 Following a failed closed reduction the patient proceeded to open reduction and …

A novel technique for repairing a large diaphragmatic defect with no costal attachments.

Chronically ruptured diaphragms are difficult to diagnose. Often they are asymptomatic but convey a high risk for incarceration, and therefore surgical repair is mandatory. In the following case report, we present an abnormal 10×12 cm diaphragmatic defect whereby there was no anterior edge to the defect. This posed a challenge as to how to repair. We present a novel technique that facilitates sound solution through a thoracotomy approach.