Anthony Adili

Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis.

OBJECTIVE To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection. DESIGN Quantitative systematic review of prospective, randomized controlled trials. DATA IDENTIFICATION MEDLINE and SCISEARCH computer searches provided lists of published randomized clinical trials from 1969 to 1998. Extensive hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts, and personal files identified additional studies. STUDY SELECTION AND DATA EXTRACTION Of 676 citations initially identified, sixty proved potentially eligible, of which four published and five unpublished randomized trials met all eligibility criteria. Each of three investigators assessed study quality and abstracted relevant data. RESULTS The pooled relative risk of reamed versus nonreamed nails (nine trials, n = 646 patients) was 0.33 [95% confidence interval (CI), 0.16 to 0.68; p = 0.004]. The absolute risk difference in nonunion rates with reamed IM nailing was 7.0 percent (95% CI, 1 to 11 percent). Thus, one nonunion could be prevented for every fourteen patients treated with reamed IM nailing [number needed to treat (NNT) = 14.28]. The risk ratios for secondary outcome measures were: implant failure, 0.30 (95% CI, 0.16 to 0.58; p < 0.001); malunion, 1.06 (95% CI, 0.32 to 3.57); pulmonary embolus, 1.10 (95% CI, 0.26 to 4.76); compartment syndrome, 0.45 (95% CI, 0.13 to 1.56); and infection, 0.98 (95% CI, 0.21 to 4.76). Sensitivity analyses suggested that reported rates of nonunion and implant failure were higher in studies of lower quality. The type of long bone fractured (tibia or femur), the degree of soft tissue injury (open or closed), study quality, and whether a study was published or unpublished did not significantly alter the relative risk of nonunion between reamed and nonreamed IM nailing. CONCLUSIONS There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.

Randomized Controlled Trials of Surgical Interventions

Background and Objectives:Surgical trials pose many methodological challenges often not present in trials of medical interventions. If not properly accounted for, these challenges may introduce significant biases and threaten the validity of the results. Methods:We systematically reviewed the significance of randomized controlled trials in the evaluation of surgical interventions, discussed the methodological challenges encountered in designing and conducting randomized controlled trials of surgical treatments, and proposed possible solutions to overcome these challenges. Conclusions:Many barriers and issues of surgical trials affecting internal validity can be overcome with proper methodology, and in most cases these issues do not restrict their conduct. Researchers should consider their research question carefully and design a surgical trial that contains features appropriate for the question. In doing so, they must ensure that the trial is valid, feasible, and affordable—a difficult feat, but one well worth the challenge.

High and low pressure pulsatile lavage of contaminated tibial fractures : an in vitro study of bacterial adherence and bone damage

OBJECTIVE This study was designed to examine the effect of pulsatile irrigation on microscopic bone architecture and its time-dependent efficacy in removing adherent slime-producing bacteria from cortical bone. DESIGN Using an in vitro model, ten-millimeter transverse cut sections from five human tibiae were contaminated with Staphylococcus aureus and subjected to either high pressure pulsatile lavage (HPPL; seventy pounds per square inch, normal saline) or low pressure pulsatile lavage (LPPL; fourteen pounds per square inch, normal saline) or served as controls. Alteration of bony architecture was quantified by using a previously described ordinal scale and histomorphometric analysis of each transverse cut section of tibia. To assess the time-dependent effectiveness of pulsatile lavage in removing adherent bacteria from bone, ten-millimeter transverse cut sections from ten canine tibiae were contaminated with S. aureus and subjected to high or low pressure pulsatile lavage immediately or after one, three, or six hours. Scanning electron microscopy and bacterial cultures were used to assess the removal of adherent bacteria. RESULTS HPPL resulted in significantly greater macroscopic damage than was seen with LPPL or in controls (ANOVA, p < 0.001). Histomorphometry revealed that HPPL was associated with significantly larger and more numerous fissures or defects in the cortical bone when compared with low pressure irrigation (p < 0.001). However, high and low pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface (p = 0.87). Both high and low pressure lavage were effective in removing adherent bacteria from bone at three hours irrigation delay, but only high pressure lavage removed adherent bacteria from bone at six hours delay. CONCLUSION In this in vitro study, compared with HPPL, LPPL led to less structural damage and was equally effective in removing bacteria within three hours debridement delay; however, the efficacy of LPPL at six hours debridement delay is questionable. This finding may have clinical significance in the development of infection following open tibial fractures.

High Pressure Pulsatile Lavage of Contaminated Human Tibiae: An In Vitro Study

OBJECTIVE This study was designed to examine the effect of high pressure pulsatile lavage (HPPL) on bone destruction and propagation of bacteria in experimentally contaminated human tibiae. METHODS Using an in vitro model, nine human tibiae from above-knee amputations were tested. A mid-diaphyseal tibial shaft fracture was created, and each end of the fracture was contaminated with bacteria (six tibiae with Staphylococcus aureus, three tibiae with Escherichia coli). The proximal end was designated as the control and the distal end was the test site. The test site was debrided by HPPL (seventy pounds/square inch, 1,200 milliliters/minute, 1,050 cycles/minute) with three liters of normal saline, whereas the control site did not receive any form of irrigation. Serial sections at increasing distance from the fracture site were cultured and the numbers of bacterial colony-forming units (CFUs) were determined at each level. The degree of macroscopic architectural change in each serial section was graded on an ordinal scale. RESULTS Analysis of culture data revealed a reproducible pattern of bacterial propagation into the intramedullary canal. Peak bacterial seeding occurred at two to three centimeters from the fracture site (p = 0.023, Wilcoxon signed rank test). The degree of bone destruction varied proportionally with the depth into the canal and was found to be predictive of the extent of bacterial propagation determined by culture data. CONCLUSION In an in vitro model of a contaminated fracture, HPPL resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone. These observations might have clinical significance.

Femoral head resurfacing for the treatment of osteonecrosis in the young patient.

We reviewed the clinical and radiographic results of 29 consecutive femoral head resurfacing procedures in 28 patients with avascular necrosis done from February 1997 until April 2000. There were 18 males and 10 females with an average age of 31.6 years (range, 12-48 years). The average Harris hip score significantly improved from 48.1 points preoperatively to 79.3 points at last followup. At final followup, 17 patients (18 hips [62%]) reported feeling much better or better than they did before hemiresurfacing. The overall survivorship was 75.9% at 3 years. Eight hips (27.6%) were converted to a total hip arthroplasty (THA) at an average 18 months (range, 8-43 months) after resurfacing. The results of this study suggest that femoral head resurfacing in a young patient with ON can greatly improve symptoms. The majority of patients were satisfied with the procedure but outcomes are unpredictable with only 62.5% of patients reporting satisfaction and good pain relief at last followup. We continue to offer this procedure in young patients with large necrotic lesions with the understanding that this procedure provides somewhat unpredictable pain relief; however, hemiresurfacing avoids the negatives associated with a bearing surface.

The Biomechanical Effect of High-pressure Irrigation on Diaphyseal Fracture Healing In Vivo

Objectives To evaluate the effect of both high-pressure pulsatile lavage and bulb syringe irrigation on the biomechanical parameters of fracture healing using an in vivo open noncontaminated diaphyseal femoral fracture model in rats. Background The utility of high-pressure pulsatile lavage irrigation on soft tissue debridement has been extrapolated to a similar perceived benefit in the debridement of bone. However, there have been several reports of a possible deleterious effect that high-pressure pulsatile lavage may have on bone architecture, intramedullary bacterial and contaminant seeding, and fracture healing. Although a previous in vivo histologic study suggests damage to bone architecture and impairment of early bone formation, it remains unclear whether these microscopic findings translate to a detectable decline in the biomechanical strength of the healing fracture. To our knowledge, there have been no reports of the in vivo effects high-pressure pulsatile lavage on fracture healing in open diaphyseal fractures. Materials and Methods Using sterile technique, standard open transverse mid-shaft femur fractures were created in thirty-six rats randomized into three groups: a control group underwent retrograde intramedullary pinning only; a bulb syringe irrigation group and a high-pressure pulsatile lavage group underwent identical procedures as the control group, except that the osteotomy site was irrigated with bulb syringe irrigation and high-pressure pulsatile lavage, respectively, before insertion of the intramedullary pin. Six rats from each group were killed at three weeks and six weeks, and the femora was mechanically tested in bending. Results Mechanical testing of the thirty-six femora revealed that the peak bending force (17.7 ± 10.2 N) and stiffness (21.2 ± 5.1 N/mm) of the healing fracture in the high-pressure irrigation group were significantly lower at three weeks when compared with the control (peak force, 28.1 ± 5.9 N; stiffness, 31.4 ± 5.8 N/mm) and the bulb syringe (peak force, 27.7 ± 3.3 N; stiffness, 23.6 ± 4.5 N/mm) irrigation groups (p < 0.05). The 37 percent lower peak bending force and 32 percent lower stiffness in the high-pressure pulsatile lavage group after three weeks of fracture healing were not present in the femora tested at six weeks. The high-pressure pulsatile lavage group did reveal a trend toward a lower peak bending force and stiffness after six weeks of fracture healing when compared with the control and bulb syringe irrigation groups, but the differences were not statistically significant at the 95 percent level. Conclusions The use of high-pressure pulsatile lavage in open noncontaminated diaphyseal femur fractures in rats has a significant negative impact on the mechanical strength of the fracture callous during the early phases (three weeks) of fracture healing. However, it appears that the early deleterious effect of high-pressure pulsatile irrigation is not apparent in the late phases (six weeks) of fracture healing. Further study is required to evaluate the effect of high-pressure pulsatile lavage on fracture healing in the presence of wound contamination, fracture comminution, and soft tissue damage. Clinical Significance The findings of this study suggest that selective use of high-pressure irrigation in the management of open fractures appears warranted. In situations in which high-pressure lavage may be deleterious to bone healing, alternative strategies that optimize bacterial removal from soft tissues while preserving bone architecture will need to be investigated.

Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures.

UNLABELLED Nine children (average age, 13.1 years) with 10 displaced type III tibial-eminence fractures were reviewed with an average follow-up of 3.5 years. The fractures were treated with arthroscope-assisted reduction and suture fixation. Nine of the 10 knees demonstrated meniscal interposition at the fracture site that contributed to unsuccessful closed reduction. At follow-up, subjective knee function was excellent in all cases, and no clinical or objective evidence of knee laxity or instability was detected in any patient. All patients demonstrated full range of motion of the affected knee compared with the contralateral side. CLINICAL SIGNIFICANCE Arthroscopic reduction and fixation allow early mobilization; assists in defining and treating associated knee pathology; assists in fracture reduction; and reduces the morbidity associated with arthrotomy.

Do patients perceive a link between a fragility fracture and osteoporosis

BackgroundTo evaluate factors associated with whether patients associate their fracture with future fracture risk.MethodsFragility fracture patients participated in a telephone interview. Unadjusted odds ratios (OR, [95% CI]) were calculated to identify factors associated with whether patients associate their fracture with increased fracture risk or osteoporosis. Predictors identified in univariate analysis were entered into multivariable logistic regression models.Results127 fragility fracture patients (82% female) participated in the study, mean (SD) age 67.5 (12.7) years. An osteoporosis diagnosis was reported in 56 (44%) participants, but only 17% thought their fracture was related to osteoporosis. Less than 50% perceived themselves at increased risk of fracture. The odds of an individual perceiving themselves at increased risk for fracture were higher for those that reported a diagnosis of osteoporosis (OR 22.91 [95%CI 7.45;70.44], p < 0.001), but the odds decreased with increasing age (0.95 [0.91;0.99], p<0.009). The only variable significantly associated with the perception that the fracture was related to osteoporosis was self-reported osteoporosis diagnosis (39.83 [8.15;194.71], p<0.001).ConclusionMany fragility fracture patients do not associate their fracture with osteoporosis. It is crucial for physicians to communicate to patients that an osteoporosis diagnosis, increasing age or a fragility fracture increases the risk for future fracture.

Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial

Background: A hip fracture causes bleeding, pain and immobility, and initiates inflammatory, hypercoagulable, catabolic and stress states. Accelerated surgery may improve outcomes by reducing the duration of these states and immobility. We undertook a pilot trial to determine the feasibility of a trial comparing accelerated care (i.e., rapid medical clearance and surgery) and standard care among patients with a hip fracture. Methods: Patients aged 45 years or older who, during weekday, daytime working hours, received a diagnosis of a hip fracture requiring surgery were randomly assigned to receive accelerated or standard care. Our feasibility outcomes included the proportion of eligible patients randomly assigned, completeness of follow-up and timelines of accelerated surgery. The main clinical outcome, assessed by data collectors and adjudicators who were unaware of study group allocations, was a major perioperative complication (i.e., a composite of death, preoperative myocardial infarction, myocardial injury after noncardiac surgery, pulmonary embolism, pneumonia, stroke, and life-threatening or major bleeding) within 30 days of randomization. Results: Of patients eligible for inclusion, 80% consented and were randomly assigned to groups (30 to accelerated care and 30 to standard care) at 2 centres in Canada and 1 centre in India. All patients completed 30-day follow-up. The median time from diagnosis to surgery was 6.0 hours in the accelerated care group and 24.2 hours in the standard care group (p < 0.001). A major perioperative complication occurred in 9 (30%) of the patients in the accelerated care group and 14 (47%) of the patients in the standard care group (hazard ratio 0.60, 95% confidence interval 0.26–1.39). Interpretation: These results show the feasibility of a trial comparing accelerated and standard care among patients with hip fracture and support a definitive trial. Trial registration: ClinicalTrials.gov, no. NCT01344343.

Early versus delayed operative management of closed tibial fractures

Fractures of the tibial shaft are the most common long bone fractures. Operative treatment of isolated closed tibial shaft fractures frequently is delayed in favor of treatment of life threatening injuries. A retrospective chart review of 200 tibial fractures was performed. These injuries were managed by two surgeons at a Level 1 trauma center between 1989 and 1996. Strict inclusion criteria identified 54 patients with an isolated closed tibial fracture. Postoperative hospital stay and complication rates were recorded. At a mean followup of 3.6 years, a quality of life questionnaire was administered via telephone calls to these patients. Two patient groups were identified: Group 1, 21 patients (< 12-hour surgical delay); and Group 2, 33 patients (> 12-hour surgical delay). Both groups were similar for baseline characteristics. Group 2 patients remained an extra 4.6 days in the hospital. A Kaplan-Meier analysis revealed that by the eighth postoperative day, all Group 1 patients were discharged from the hospital, whereas 47.8% of Group 2 patients remained in the hospital. Plate fixation was associated with a greater incidence of complications when compared with intramedullary nail internal fixation. Complication rates were significantly greater in the delayed surgical group. A multiple regression analysis revealed that surgical delay and postoperative complications accounted for 35% of the total variance in postoperative hospital stay. Time to surgical treatment was not prognostic of long term quality of life. Surgical delay results in longer postoperative hospital stays, greater complication rates, and increased total cost to the health care system.