Andrew Bucknill

Predictors of mortality following severe pelvic ring fracture: Results of a population-based study

INTRODUCTION Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system. METHODS Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. RESULTS There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). CONCLUSIONS The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

Nerve fibers in lumbar spine structures and injured spinal roots express the sensory neuron-specific sodium channels SNS/PN3 and NaN/SNS2

Study Design. This prospective study examined the innervation of lumbar spine in tissues from patients with lower back pain and spine nerve roots from patients with traumatic brachial plexus injuries. Objectives. To demonstrate the presence of nerve fibers in lumbar spine structures and spine nerve roots, and to determine whether they express the sensory neuron-specific sodium channels SNS/PN3 and NaN/SNS2. Summary of Background Data. The anatomic and molecular basis of low back pain and sciatica is poorly understood. Previous studies have demonstrated sensory nerves in the facet joint capsule and prolapsed intervertebral disc, but not in the ligamentum flavum. The voltage-gated sodium channels SNS/PN3 and NaN/SNS2 are expressed by sensory neurone that mediate pain, but their presence in the lumbar spine is unknown. Methods. Tissue samples of ligamentum flavum (n = 32), facet joint capsule (n = 20), intervertebral disc (n = 15), and spine roots (n = 8) were immunostained with specific antibodies to protein gene product 9.5 (a panneuronal marker), SNS/PN3, and NaN/SNS2. Results. Protein gene product 9.5 immunoreactive nerve fibers were detected in 72% of the ligamentum flavum specimens and 70% of the facet joint capsule specimens, but in only 20% of the intervertebral disc specimens. The study detected SNS/PN3- and NaN/SNS2-positive fibers, respectively, in 28% and 3% of the ligamentum flavum specimens and 25% and 15% of the facet joint capsule specimens. Numerous SNS/PN3- and NaN/SNS2-positive fibers were found in the acutely injured spine roots, and some were still present in the dorsal roots in the chronic state. Conclusions. As the findings showed, SNS/PN3- and NaN/SNS2-immunoreactivity is present in a subset of nerve fibers in lumbar spine structures, including ligamentum flavum, and in injured spine roots. Selective SNS/PN3- and NaN/SNS2-blocking agents may provide new therapy for back pain and sciatica.

Adverse Outcomes Associated With Elective Knee Arthroscopy: A Population-Based Cohort Study

PURPOSE The aims of this study were to quantify the frequency of adverse outcomes after elective knee arthroscopies in Victoria, Australia, and to identify risk factors associated with adverse outcomes. METHODS We performed a retrospective, longitudinal cohort study of elective orthopaedic admissions using the Victorian Admitted Episodes database, a routinely collected public and private hospital episodes database linked to death registry data, from July 1, 2000, to June 30, 2009. Adverse outcome measures included pulmonary embolism (PE), deep vein thrombosis (DVT), hemarthrosis, effusion and synovitis, cellulitis, wound infection, synovial fistula, acute renal failure, myocardial infarct, stroke, and death. Patients were excluded if they had an additional procedure performed during the arthroscopy admission. We identified complications during the admission and within readmissions up to 30 days after the procedure. PE, DVT, and death within 90 days of the arthroscopy episode were also examined. We used logistic regression analysis to identify risk factors associated with complications. RESULTS After we excluded 16,807 patients (8.5%) with an additional procedure during their admission, there were 180,717 episodes involving an elective arthroscopy during the period studied. The most common adverse outcomes within 30 days were DVT (579, 0.32%), effusion and synovitis (154, 0.09%), PE (147, 0.08%), and hemarthrosis (134, 0.07%). The 30-day orthopaedic readmission rate was 0.77%, and there were 55 deaths (0.03%). Within 90 days of arthroscopy, we identified 655 events of DVT (0.36%) and 179 PE events (0.10%). Logistic regression analysis identified that potential risk factors for complications were older age, presence of comorbidity, being married, major mechanical issues, and having the procedure performed in a public hospital. CONCLUSIONS Our study found 6.4 adverse outcomes per 1,000 elective knee arthroscopy procedures (0.64%), with the 3 most common complications being DVT, effusion and synovitis, and PE. We have also identified risk factors for adverse outcomes, particularly chronic kidney disease, myocardial infarction, cerebrovascular accident, and cancer. LEVEL OF EVIDENCE Level III, retrospective cohort study.

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

The imaging and classification of severe pelvic ring fractures: Experiences from two level 1 trauma centres

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young-Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young-Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Trends in elective knee arthroscopies in a population-based cohort 2000-2009

Objective: To assess the use of elective knee arthroscopy procedures for all adults 20 years and older, and for adults with a concomitant diagnosis of osteoarthritis (OA) in Victoria.

Fluoroscopically assisted computer navigation enables accurate percutaneous screw placement for pelvic and acetabular fracture fixation.

Percutaneous fixation of pelvic and acetabular fractures are technically demanding procedures, and high rates of screw misplacement and potential neurovascular complications have been reported. One hundred and sixty two screws from a prospectively collected database were analysed to evaluate the accuracy of a fluoroscopically assisted computer navigated technique to insert a cannulated screw to treat pelvic and acetabular fractures. Actual screw position and trajectory with the intraoperative surgical plan stored in the navigation computer. The actual screw position differed from the surgical plan by a mean of 3.9 mm, with a mean 1.4 degree difference in screw trajectory. Post operative CT analysis of patients showed 10 screws perforated cortical bone. Our results show that the use of computer navigation can aid in the accurate placement of percutaneous screws along a predefined plan. It is still possible to incorrectly place a screw and great care needs to be taken with the surgical plan and also to understand the complex anatomy of the bony pelvis.

The substantial personal burden experienced by younger people with hip or knee osteoarthritis

OBJECTIVE To compare Health-Related Quality of Life (HRQoL) and psychological distress in younger people with hip or knee osteoarthritis (OA) to age- and sex-matched population norms, and evaluate work limitations in this group. METHOD People aged 20-55 years with hip or knee OA were recruited from major hospitals (n = 126) and community advertisements (n = 21). HRQoL was assessed using the Assessment of Quality of Life (AQoL) instrument (minimal important difference 0.06 AQoL units) and compared to population norms. Psychological distress was assessed using the Kessler Psychological Distress Scale (K10) and the prevalence of high/very high distress (K10 score ≥22) was compared to Australian population data. Work limitations were evaluated using the Workplace Activity Limitations Scale (WALS). RESULTS Considering most participants had a relatively recent OA diagnosis (<5 years), the extent of HRQoL impairment was unexpected. A very large reduction in HRQoL was evident for the overall sample, compared with population norms (mean difference -0.35 AQoL units, 95% CI -0.40 to -0.31). Females, people aged 40-49 years, and those with hip OA reported average HRQoL impairment of almost 40% (mean reductions -0.38 to -0.39 AQoL units). The overall prevalence of high/very high distress was 4 times higher than for the population (relative risk 4.19, 95% CI 3.53-4.98) and 67% reported moderate to considerable OA-related work disability, according to WALS scores. CONCLUSIONS These results clearly demonstrate the substantial personal burden experienced by younger people with hip or knee OA, and support the provision of targeted services to improve HRQoL and maximise work participation in this group.

Subtrochanteric fracture: the effect of cerclage wire on fracture reduction and outcome.

INTRODUCTION Subtrochanteric neck of femur fractures are a challenge to treat due to anatomical and biomechanical factors. Poor reduction, varus deformity, nonunion and return to theatre risks are high. A cerclage wire can augment an intramedullary nail to help fracture reduction and construct stability. Concerns exist regarding the use of cerclage wire on fracture zone vascularity. The aim of this study was to assess the benefits and adverse outcomes associated with the use of cerclage wiring. PATIENTS AND METHODS A 7-year retrospective review of all subtrochanteric fractures at a Level 1 trauma centre was performed. Pathological fractures, those associated with bisphosphonate use and segmental fractures were excluded. A clinical and radiographic review was performed. Our primary outcome measure was a composite of the major complications of this surgery, defined as either return to theatre for fixation failure, nonunion or implant failure. Fracture displacement, angulation and quality of reduction were measured as secondary outcome measures. Specific complications of the use of cerclage wiring were also reported. RESULTS One hundred and thirty four cases met the inclusion criteria for primary outcome. Reduction was achieved closed in 51.9% (n=70), open in 33.3% (n=45) and open with cerclage wire in 14.8% (n=20). Overall there were a total of 13 (9.7%) major complications. No cases with cerclage wire had a return to theatre. If cerclage wire was not used the major complication rate was 11.4%. Fracture displacement (11.0mm vs. 7.69mm) and distraction were related to return to theatre (p<0.05). Cerclage wire use improved fracture displacement (3.2mm vs. 8.8mm), angulation and quality of reduction (p<0.05). CONCLUSIONS Anatomical reduction is the key to success of subtrochanteric fractures. Cerclage wire use results in better fracture reduction. Some subtrochanteric fractures can be successfully treated with indirect reduction alone. If fractures cannot be reduced closed, reduction should be achieved by open methods. If a fracture is opened, a cerclage wire should be used, if the fracture pattern allows.

Awareness of psychological and relationship problems amongst brain tumour patients and its association with carer distress.

The aim of this research was to investigate if brain tumour patients underestimate the severity of their impairments and the impact of this behaviour on carer distress . This study also aimed to identify the support services that patients and carers experiencing distress would find most beneficial.