Paul Appleton

Distal femoral fractures treated by hinged total knee replacement in elderly patients

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures.

INTRODUCTION Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. PATIENTS AND METHODS A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. RESULTS 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI>30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P<0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. DISCUSSION Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.

Pilot Randomized Trial of Donepezil Hydrochloride for Delirium After Hip Fracture

To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair.

The treatment of unstable fractures of the ankle using the Acumed fibular nail: Development of a technique

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Does late night hip surgery affect outcome

BACKGROUND There is a perception that after-hours hip surgery may result in increased complication rates. Surgeon fatigue, decreased availability of support staff, and other logistical factors may play an adverse role. However, there are little data supporting this perception in the hip fracture literature. We present a retrospective study comparing outcomes of hip fracture surgeries performed after hours versus regular daytime hours and outcomes before and after implementation of a dedicated orthopedic trauma room staffed by a fellowship trained traumatologist. METHODS A retrospective study of 767 consecutive patients with intertrochanteric, subtrochanteric, or femoral neck fractures was performed for the years 2000 to 2006. Surgeries were stratified by time of incision into two groups: day (07:00 AM-05:59 PM) and night (06:00 PM-06:59 PM). Each group was further divided into a period before the implementation of a trauma room and the period after (August 2004). Records were examined for procedure length, intraoperative blood loss, complications (nonunion, implant failure, infection, deep vein thrombosis, pulmonary embolus, and refracture), reoperation, and mortality. RESULTS Four hundred ninety-nine patients were included the day group and 268 in the night group. There were no differences in terms of age, ethnicity, American Society of Anesthesiologists status, total number of comorbidities, and fracture type between groups. There were significantly more females in the night group than the day group. Intertrochanteric fractures were 64% of all fractures, femoral neck fractures were 34%, and subtrochanteric fractures were 2%. Duration of surgery for Dynamic Hip System procedures was significantly longer in the night group and also before the trauma room became available. These differences in duration of surgery also correlate with blood loss differences between the groups. Intramedullary nails also took longer to do at night. Hemiarthroplasties demonstrated no significant differences. The 1-year and 2-year mortalities of hip fracture patients operated during daytime hours in a trauma room (13 and 15%, respectively) were significantly less than they were before the implementation of the trauma room (25 and 37%, respectively). When the effect of the trauma room was eliminated, there were no significant differences between overall daytime and nighttime mortalities at 1 month, 1 year, and 2 years. There were no significant differences in other complications noted between the different groups. CONCLUSIONS We recommend that nighttime surgery should not be dismissed in hip fracture patients that would otherwise benefit from an early operation. However, there seems to be a decreasing trend in mortality when hip fractures are operated in a dedicated daytime trauma room staffed by a dedicated traumatologist.

Driving after musculoskeletal injury. Addressing patient and surgeon concerns in an urban orthopaedic practice

Patient and public safety concerns make the timing of return to driving after musculoskeletal injury or orthopaedic surgery an important decision that is made by orthopaedic surgeons on a daily basis. Neither the American Academy of Orthopaedic Surgeons nor any other orthopaedic specialty society has endorsed recommendations, policies, or practice guidelines that address when a patient is able to return to driving after a musculoskeletal injury. To our knowledge, there are no specific guidelines available on how the decision should be made, who should be involved, or to what extent retesting of driving abilities after an injury should be required. The only and most recent guidelines available were developed in 2003 by the National Highway Traffic Safety Administration (NHTSA) in cooperation with the American Medical Association specifically to assess the ability to return to driving in older patients1. While these guidelines address to a limited degree musculoskeletal disability in older individuals, they are not specific to musculoskeletal injury or orthopaedic surgery and they are not entirely applicable to younger age groups. They also fail to incorporate a substantial part of the already limited orthopaedic literature on the topic2-10. The American Occupational Therapy Association (AOTA) is the only organization that has addressed the issue and actually offers Driving and Community Mobility Specialty Certification for occupational therapists who seek the training (www.aota.org). Comprehensive evaluation of driving abilities, as recommended by the AOTA, involves both an office evaluation and a behind-the-wheel assessment administered in a properly equipped test vehicle. Unfortunately, such specialized programs are not standard in conventional occupational therapy practices and are not always geographically or financially accessible to all patients recovering from musculoskeletal injury or orthopaedic surgery. To address the issue of return to driving in our practice, we formulated a return-to-driving policy that takes …

Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years.

Objectives: To compare failure rates between short and long cephalomedullary nails used for the treatment of intertrochanteric hip fractures in patients over 65 years of age. Design: Retrospective cohort study. Data were collected from medical records and radiographs. Setting: Three level 1 trauma centers. Patients/Participants: Patients aged 65 years or older who underwent treatment of an intertrochanteric hip fracture with a cephalomedullary nail between January 2004 and December 2010. Intervention: Open reduction and internal fixation of intertrochanteric hip fracture with either short or long cephalomedullary nail. Main Outcome Measurement: Postoperative treatment failure rate, defined as periprosthetic fracture or reoperation requiring removal or revision of nail, including conversion to arthroplasty. Results: Incidence of treatment failure (periprosthetic fracture and reoperation requiring removal of nail) was 30 of 559 (5.4%) for the entire cohort; 13 of 219 (5.9%) occurred after placement of a short nail compared with 17 of 340 (5.0%) after placement of a long nail (P = 0.70). There were 11 of 559 (2.0%) patients who sustained a periprosthetic fracture after nailing, 6 of 219 (2.7%) after short nails and 5 of 340 (1.5%) after long nails (P = 0.35). The remaining 19 treatment failures were major reoperations requiring removal of nail, 7 of 219 (3.2%) after short nails and 12 of 340 (3.5%) after long nails (P = 0.81). The reasons for these 19 revision procedures were: screw/helical blade cutout (16), progressive arthritis with conversion to arthroplasty (1), avascular necrosis of femoral head with conversion to arthroplasty (1), and symptomatic leg length discrepancy with conversion to arthroplasty (1). Median follow-up period for patients living at least 1 year postoperatively was 30 months (range, 12–85 months). Overall, 175 of 698 (25%) patients died within 1 year after index surgery. Conclusions: When using contemporary cephalomedullary implants, short and long nails exhibit similar treatment failure rates. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnosis and treatment of acute extremity compartment syndrome

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

A novel methodology for the study of injury mechanism: ankle fracture analysis using injury videos posted on YouTube.com

Purpose: An inherent deficiency in the understanding of the biomechanics of fractures is the reliance on cadaveric or other nonphysiological injury models resulting from the prohibitive ethical and practical considerations of conducting injury studies in live participants. We describe a novel methodology for studying injury mechanisms using in vivo injury videos obtained from Youtube.com demonstrating injuries as they occur in real time and correlating them with the resulting injury radiographs. Methods: Over 1000 video clips of potential ankle fractures were assessed for clear visualization of the mechanism of injury, including the foot position and deforming force. Candidate videos were selected if the mechanism of injury was classifiable by those described by Lauge-Hansen and there appeared to be a significant mechanism to likely cause fracture. X-rays were then requested from the individuals posting the video clips. Videos and x-rays were reviewed and classified using the Lauge-Hansen system in a blinded manner. The deforming mechanism in the video clips was classified as supination external rotation, supination adduction (SAD), pronation external rotation (PER), or pronation abduction. X-ray fracture patterns were similarly classified. Results: Two hundred forty videos were selected and individuals posting the videos were contacted. Of 96 initial positive responses, we collected 15 videos with their corresponding radiographs. Eight had SAD-deforming trauma and seven had PER-deforming trauma as appreciated in the videos. There were 12 true ankle fractures. All five fractures judged by video to be SAD injuries resulted in a corresponding SAD pattern radiographic ankle fractures. Of the seven fractures judged by video to be PER injuries, only two resulted in PER pattern radiographic ankle fractures. Five PER injuries resulted in supination external rotation ankle fracture patterns. Conclusion: Our series shows that when in vivo injury videos are matched to their corresponding x-rays, the Lauge-Hansen system is only 58% overall accurate in predicting fracture patterns from deforming injury mechanism as pertaining to SAD and PER injury mechanisms. All SAD injuries correlated but only 29% of PER injuries resulted in a PER fracture pattern. This study illustrates the ethical and practical difficulties of using public access Internet YouTube videos for the study of injury dynamics. The current case series illustrates the methods potential and may lead to future research analyzing the validity of the Lauge-Hansen classification system as applied to in vivo injuries.

A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients

AIMS The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems. PATIENTS AND METHODS A total of 100 patients (25 men, 75 women) over the age of 65 years with unstable ankle fractures were randomised to undergo standard ORIF or fibular nailing (11 men and 39 women in the ORIF group, 14 men and 36 women in the fibular nail group). The mean age was 74 years (65 to 93) and all patients had at least one medical comorbidity. Complications, patient related outcome measures and cost-effectiveness were assessed over 12 months. RESULTS Significantly fewer wound infections occurred in the fibular nail group (p = 0.002). At one year, there was no evidence of difference in mean functional scores (Olerud and Molander Scores 63; 30 to 85, versus 61; 10 to 35, p = 0.61) or scar satisfaction. The overall cost of treatment in the fibular nail group was £91 less than in the ORIF group despite the higher initial cost of the implant. CONCLUSION We conclude that the fibular nail allows accurate reduction and secure fixation of ankle fractures, with a significantly lower rate of soft-tissue complications, and is more cost-effective than ORIF. Cite this article: Bone Joint J 2016;98-B:1248-52.