Fracture Fixation Surgery Research Articles

Hardware removal rates after surgical treatment of proximal femur fractures

BackgroundVarious internal fixation methods have been used to treat proximal femur fractures and occasionally the fixation material is removed. However, nationwide trends of hardware removals are not known. Thus, this study investigated the hardware removal rates after proximal femur fractures in Finland during 1997–2016.Materials and methodsFinnish adults aged 18 years or older in 1997–2016 formed the basic study population. From the National Hospital Discharge Register patients with trochanteric femur fracture treated with an intramedullary nail (IMN) or dynamic hip screw (DHS), and patients with femoral neck fracture treated with screw fixation, were included. Hardware removal and secondary prosthesis rates were assessed.ResultsAltogether 41,253 patients underwent proximal femoral fracture fixation surgery in Finland in 1997–2016. Of these, 16,152 were DHS surgery and 15,724 IMN surgery and 8491 underwent screw operation of femoral neck fracture. The total removal rates of DHS and IMN were 5.5% and 5.4%. The total removal rate of screw fixations of the femoral neck was higher, 18.5%. The total removal rates during the first 3 years after the IMN more than halved in 1997–2013, from 7.6% to 3.7%, whereas the removal rate of the DHS or screw fixation of femoral neck fractures did not show consistent trend. The rate of secondary prosthesis operations following DHS and IMN was low (1.8% for both). This was in clear contrast to the prosthesis rate following screw fixations of the femoral neck (7.2%).ConclusionsIMN operations largely replaced DHS operations in trochanteric fractures of the proximal femur in Finland in 1997–2016. The removal and secondary prosthesis rates of the DHS and IMN were clearly lower than the corresponding rates after screw fixations of the femoral neck fracture.Level of evidenceIII, Epidemiologic study.

Sciatic obturator femoral technique versus spinal anaesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator. A randomised trial

BackgroundPeripheral nerve block is preferable for lower extremity surgery because it sufficiently blocks pain pathways at different levels providing excellent anaesthesia at the site of surgery. We designed this study to compare the efficacy and safety of SOFT block (sciatic-obturator-femoral technique) compared with spinal anaesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator.MethodsOne hundred and seven patients ASA I, II scheduled for fixation of open tibial fractures using Ilizarov external fixator. The patients were randomly allocated to receive either spinal anaesthesia or SOFT block. In spinal anaesthesia group, patients received spinal anaesthesia with hyperbaric bupivacaine 0.5% (7. 5-10mg). In SOFT group, patients received SOFT block with bupivacaine 0.25%. Primary endpoint included the duration of analgesia. The secondary endpoints included patient satisfaction scores, visual analogue scores, incidence of adverse events as vomiting, systemic toxicity from local anaesthetic drug and time to first effect of the techniques.ResultsThe duration of SOFT block and time to first analgesic dose in SOFT group was significantly longer (p < 0.001). There was no significant difference between the study groups regarding satisfaction scores, the incidence of cardiovascular collapse, seizures and paraesthesia. Pain scores were significantly lower in SOFT group at 3,6,12 h postoperative (p < 0.001). The time to the first effect was significantly longer in SOFT group (p < 0.001).ConclusionSOFT is a feasible technique of local anaesthesia for control of postoperative pain with unremarkable adverse events compared with spinal anaesthesia, in patients undergoing fixation of tibial fractures using Ilizarov external fixator.Trial registrationThis trial was retrospectively registered at ClinicalTrials.gov. registry number: NCT03450798 on February 20, 2018.

Rehabilitation protocols in unstable trochanteric fractures treated with cephalomedullary nails in elderly: current practices and outcome.

Optimal rehabilitation treatment after surgery for fixation of unstable trochanteric fractures is challenging in elderly patients. The objective of this study is to analyse the existing literature on available rehabilitation protocols with regards to permitting or restricting early weight bearing following fixation of unstable trochanteric fractures treated by the use of cephalomedullary nails in patients at least 65years of age. A systematic review was performed based on the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies published between 1948 and 2018 on elderly patients with unstable trochanteric fractures treated with cephalomedullary nails that offered information on the postoperative rehabilitation protocol have been selected. Subsequently, the results and complications have been analysed according to the protocols. Fifteen of the 7056 initial articles have been selected for analysis. Authors who did not restrict weight bearing to their patients reported a shorter hospitalization time and a lower orthopaedic complication rate but a greater systemic complication rate, worse functional scores, and a higher reoperation and mortality rates. Those results should be taken with caution because of the heterogeneity of provided clinical information and the fact that none of the included studies considered the different rehabilitation protocols as study variables to analyse its influence on the results. With evidence available to date, there is no clear agreement on the postoperative rehabilitation protocol following fixation of an unstable trochanteric fracture by cephalomedullary nail in the elderly.

A Multidisciplinary Approach to Expedite Surgical Hip Fracture Care.

Introduction:In 2014, we implemented a geriatric hip fracture patient care pathway at our institution which was designed to improve outcomes and decrease time to surgery.Materials and Methods:We analyzed retrospective data from 463 patients, aged greater than 50, who had surgical treatment for a closed hip fracture due to a low-energy injury between 2013 and 2016 at an academic institution. Objective outcome measures included time to surgery, mortality rate, and total hospital length of stay. Our primary goal was to decrease the time to surgery for definitive fracture fixation to within 24 hours of admission to the hospital for patients who were medically fit for surgery.Results:We implemented a multidisciplinary, collaborative approach to address the needs of this specific patient population. Prior to implementing the pathway in 2013, our baseline time to surgery within 24 hours was 74.67%. After implementation, we had incremental yearly increases in the percentage of patients operated on within 24 hours, 82.31% in 2014 (P = .10) and 84.14% in 2015 (P = .04). During the study period, our overall time to surgery was reduced by 27% with an initial average of 20.22 hours in 2013, decreasing to 15.33 hours in 2014, and 14.63 hours in 2015. Our mortality rate at 1 year was 16% in 2013, 17% in 2014, and 15% in 2015.Conclusion:With implementation of the pathway, we were able to expedite surgical care for our patients and demonstrate a 10% improvement in the percentage of patients able to have surgery within 24 hours over a 3-year period. Our mortality and hospital length of stay, however, remained the same. Through this collaborative process and system standardization, we believe we have significantly improved not only direct patient care but their overall hospital experience. We continue to make improvements in our pathway.

Morphometric Variations of Scaphoid and Safety of Screw Fixation for Its Waist Zone Fractures in Indian Population: A Preliminary Report

Purpose Surgeons fixing scaphoid fractures need to be familiar with their morphological variations and their implications for safe screw placement during fixation. The purpose of this computed tomography (CT)-based study was to analyze the anatomical limits of safe screw placement for scaphoid waist fractures in the Indian population. Methods We measured the coronal and sagittal dimensions of the scaphoid in 3 zones: proximal, waist, and distal, in CT scans of wrists with intact scaphoids obtained from 50 live subjects. In addition, we studied the curvature of the scaphoid, its longitudinal extent, and the safe placement of trajectories for different screw diameters. Results The proximal segment had the narrowest mean coronal width of 6.39 mm, whereas the waist region had the narrowest mean sagittal width of 9.02 mm. Mean scaphoid curvature was 132.23°. Maximal bony extent of the scaphoid was significantly higher than the mean length of screw placed centrally in the mid-waist region. Conclusions This study showed that there is a considerable amount of variation in scaphoid morphometry in Indian patients. All scaphoids capable of safely containing a single 4-mm screw or 2 parallel 1.7-mm screws coplanar in the sagittal plane. Surgeons treating these fractures should consider a CT-based analysis to plan the screw direction and length and need to be familiar with the morphometric variations of the scaphoid. Clinical relevance The measurements and techniques in this study may be helpful in understanding morphometric variations of the scaphoid and in planning surgery for fixation of fractures around its waist region.

A comparative study of postoperative effects of two doses of preemptive pregabalin after tibial fracture fixation under spinal anesthesia

Background Orthopedic patients experience severe immediate postoperative pain, and they require more analgesia. Effective management of perioperative and postoperative pain after lower extremity orthopedic surgery represents an important component of early postoperative recovery. It is essential to facilitate rehabilitation and accelerate functional recovery, enabling patients to return to their normal activity more quickly. Moreover, treating patient’s preoperative anxiety improves postoperative pain. Pregabalin was found to be useful in decreasing postoperative pain and analgesic requirements as well as anxiolytic and sleep-modulating effects. Objective This study compares analgesic, anxiolytic, and sedative effects of pregabalin 75 and 150 mg versus placebo in patients undergoing surgery for fixation of traumatic tibial fractures under spinal anesthesia. Patients and methods This blind study contained 45 patients scheduled for fixation of tibial fractures under spinal anesthesia using a closed envelope technique. The patients were divided into three groups (15 patients each). Group P75 received 75 mg pregabalin capsule, group P150 received 150 mg pregabalin capsule, and group P0 received matching placebo capsule. In the preoperative holding area, patients were randomly divided into three groups. Then, an intravenous line was secured. Then, an hour before the surgery, all patients underwent assessment of level of anxiety using visual analog scale and assessment of degree of sedation using Ramsay Sedation Scale. Thereafter, the drug selected for the study was given with a sip of water by a staff nurse who was not involved in the study. Before anesthesia, anxiety and sedation were reassessed for the second time for all patients using visual analog scale for anxiety and Ramsay Sedation Scale, respectively. Spinal anesthesia was instituted at L3–L4 interspace, and a volume of 2.5–3.5 ml (according to the patient’s height and weight) of 0.5% heavy bupivacaine was injected over 30 s through a 25-G spinal needle. In the postoperative period, all patients received ketorolac 30 mg/kg, and they were observed for pain score and level of sedation for 24 h postoperatively. Results The use of pregabalin 150 mg preoperatively succeeded in significantly decreasing the postoperative pain and analgesic requirements and increasing the sedation score in comparison with 75 mg dose. Both doses succeeded in significantly decreasing the preoperative anxiety. Conclusion The use of pregabalin before surgery for fixation of traumatic tibial fractures could achieve good postoperative analgesia, preoperative anxiolysis, and perioperative sedation.

Additive manufactured metallic implants for orthopaedic applications

Metallic implants are commonly used in various orthopaedic surgeries, like fracture fixation, spinal instrumentation, joint replacement and bone tumour surgery. Patients may need to adapt to the fixed dimensions of the standard implants. It may result in suboptimal fit to the host bones and possible adverse clinical results. The standard traditional implants may not address the reconstructive challenges such as severe bone deformity or bone loss after implant loosening and bone tumour resection. With the advent of digital technologies in medical imaging, computer programming in three-dimensional (3D) modelling and computer-assisted tools in precise placement of implants, patient-specific implants (PSI) have gained more attention in complex orthopaedic reconstruction. Additive manufacturing technology, in contrast to the conventional subtractive manufacturing, is a flexible process that can fabricate anatomically conforming implants that match the patients’ anatomy and surgical requirements. Complex internal structures with porous scaffold can also be built to enhance osseointegration for better implant longevity. Although basic studies have suggested that additive manufactured (AM) metal structures are good engineered biomaterials for bone replacement, not much peer-reviewed literature is available on the clinical results of the new types of implants. The article gives an overview of the metallic materials commonly used for fabricating orthopaedic implants, describes the metal-based additive manufacturing technology and the processing chain in metallic implants; discusses the features of AM implants; reports the current status in orthopaedic surgical applications and comments on the challenges of AM implants in orthopaedic practice.

Iatrogenic Injuries of the Palmar Branch of the Median Nerve Following Volar Plate Fixation of the Distal Radius.

Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management. Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified. Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2. Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.

Activation of cannabinoid receptor type 2 attenuates surgery-induced cognitive impairment in mice through anti-inflammatory activity

BackgroundNeuroinflammation plays a major role in postoperative cognitive dysfunction (POCD). Accumulated evidence indicates that cannabinoid receptor type 2 (CB2R) can mediate anti-inflammatory and immunomodulatory effects in part by controlling microglial activity. However, the impact of CB2R on postoperative cognition has not been investigated. We hypothesized that CB2R is involved in surgery-induced cognitive impairment in adult mice.MethodsAdult C57BL/6 mice were subjected to intramedullary fixation surgery for tibial fracture under isoflurane anesthesia and CB2R agonist (JWH133) or CB2R antagonist (AM630) treatment. The mice were trained 24 h prior to surgery using a fear conditioning protocol and assessed in a novel context on postoperative days 1, 3, and 7 to evaluate cognitive function. Open-field testing was performed to evaluate the locomotor activity of the mice. The expression levels of IL-1β, TNF-α, MCP-1, and CB2R in the hippocampus and prefrontal cortex were assessed by Western blotting; the expression of microglial marker CD11b in the CA1 area of the hippocampus and medial prefrontal cortex was assessed by immunostaining.ResultsThe mice displayed no changes in locomotor activity after surgery and drug treatments. The mice exhibited impaired hippocampal-dependent memory accompanied by an increased expression of proinflammatory factors in the hippocampus and prefrontal cortex 1, 3, and 7 days after surgery, while hippocampal-independent memory remained unaffected at the same time points. JWH133 treatment attenuated surgery-induced memory loss, while AM630 treatment aggravated surgery-induced memory loss, paralleled by a decreased or increased expression of proinflammatory factors in the hippocampus and prefrontal cortex. The expression of CB2R in the hippocampus and prefrontal cortex was upregulated following surgery; however, it was downregulated by postoperative treatment with JWH133. Similarly, the expression of CD11b in the CA1 area of the hippocampus and medial prefrontal cortex was upregulated following surgery and downregulated by postoperative treatment with JWH133.ConclusionsThese findings indicate that CB2R may modulate the neuroinflammatory and cognitive impairment in a mouse model of orthopedic surgery, and the activation of CB2R may effectively ameliorate the hippocampal-dependent memory loss of mice in the early postoperative stage.

Smart-Draping-A Validated Novice Technique to Prevent Drapes Peeling off During Hip Fracture Fixation Surgery: A Prospective Randomized Controlled Study

The contamination of the surgical field can be a potential risk of infection that can be devastating to patients undergoing hip fracture fixation surgery. Drapes peeling off during such operation is a recognized challenge that can lead to such a contamination. We describe and validate a simple technique to prevent drapes peeling off the operative field during hip fracture fixation surgery using the smart-draping technique. The smart-draping entails applying a sterile disposable single large adhesive op-sheet to the inferior aspect of the thigh, just under the proposed surgical incision, followed by applying the usual plastic vertical isolation drape. Fourteen neck-of-femur fracture patients undergoing dynamic hip screw (DHS) fixation were recruited and randomized into a study and control groups to measure fluid leakage, as an indirect measurement of the vertical drapes peeling off the surgical site. Incontinence pads were placed on the floor to collect all leaked fluid in all patients. The average weight of the fluid collected in the study groups was 11.4 gm (SD ± 12.1) while that of the control group was 354.3 gm (SD ± 175). There was a statistical significant difference between the two methods favoring the smart-draping method over the control one. (P<0.001) We conclude that smart-draping technique will make it harder for the drapes to peel off thus, avoiding the potential contamination of the surgical field and ultimately avoiding potential infection of the surgical site in hip fracture fixation surgery.

Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study

IntroductionFibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes. Patients and methodsData on all major trauma patients (January 2007–July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression. ResultsOf 4773 patients identified, 114 (2.4%) had fibrinogen less than 1g/L, 283 (5.9%) 1.0–1.5g/L, 617 (12.9%) 1.6–1.9g/L, 3024 (63.4%) 2–4g/L and 735 (15%) >4g/L. Median fibrinogen was 2.6g/L (interquartile range 2.1–3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1g/L 3.28 [95% CI 1.71–6.28, p<0.01], 1–1.5g/L adjusted OR 2.08 [95% CI 1.36–3.16, p<0.01] and 1.6–1.9g/L adjusted OR 1.39 [95% CI 0.97–2.00, p=0.08]). Predictors of initial fibrinogen <1.5g/L were younger age, lower GCS, systolic blood pressure <90mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature. ConclusionsInitial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.

Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures—a randomized trial

Study objectivePain arising from femur fractures is of severe nature. Surgery for fixation of femoral fractures may be done under spinal anesthesia. We conducted this study to compare the analgesic efficacy of fascia iliaca compartment block (FICB) and intravenous fentanyl (IVF) before positioning for spinal anesthesia. DesignRandomized controlled trial. SettingOperating room. Patients and interventionsSixty patients aged 25 to 75 years, with American Society of Anesthesiologists status I to III, undergoing surgery for femur fracture were chosen for the study and randomized into 2 groups. Patients in group FICB received the block with 30 mL of 0.375% ropivacaine 15 minutes before the subarachnoid block. Patients in group IVF received intravenous fentanyl at 0.5 μg/kg body weight repeated up to a maximum of 3 doses. Spinal was administered using 12 to 15 mg of 0.5% hyperbaric bupivacaine with glucose 80 mg/mL in patients of both groups. MeasurementsPreprocedural and postprocedural parameters such as visual analog scale (VAS) scores, sitting angle, quality of positioning, and time to perform the spinal were recorded. Patients were also assessed in the first 24 hours for analgesic requests. Main resultsPreprocedural VAS scores were similar in both groups. The “VAS after” was 24.72±15.70 mm in group FICB vs 61.22±18.18 mm in group IVF (P=.01). The drop in VAS scores was significantly more in the FICB group. Sitting angle improved significantly in the FICB group. (56.17°±16.54° vs 21.38°±23.90°; P=.01). Patients in group FICB also needed less time for spinal and had better quality of positioning. Postoperative analgesic requirement was lesser in group FICB. ConclusionFascia iliaca block offers superior analgesia compared to IVF in patients with femur fracture before positioning for spinal anesthesia.

The biomechanical cost of variable angle locking screws

IntroductionVariable angle (VA) locking plates in fracture fixation surgery allow screws to be fastened to the plate within a conical “locus of vectors” in order to avoid existing prostheses, joint surfaces, or poor quality bone. Clinical failures of VA constructs in which screws have rotated at the plate/screw interface have been reported raising the concern that there may be a biomechanical cost for the increased flexibility that VA provides. The objective of this study was to test the mechanical properties of one commonly used VA locking mechanism with screws placed in both nominal and off–axis trajectories and compare these against the standard locking mechanism. MethodsVA locking screws were inserted into plates for distal femur fractures (VA Curved Condylar) at various angles (0° to 15° away from perpendicular). A control group of standard locking screws/plates was also tested. Maximum moment at the screw/plate interface and moment at two reference displacements were determined. ResultsVA screws locked perpendicular to the plate provided the greatest maximum moment and moment at the reference displacements when using the VA system, and demonstrated lower moments compared to standard locking screws/plates (p<0.001). Based on linear regression, there was an average decrease of approximately 0.4 Nm screw-plate interface strength for every 1° increase in screw-plate angle (p<0.001). Decreases (p<0.05) were discovered in both maximum moment and moment at the reference displacements for screws locked at 5° relative to those locked at 0°, 10° relative to 0°, and 15° relative to 10°. DiscussionStandard locking systems provided greater resistance to rotational failure at the screw/plate interface than variable angle locking systems. Variable angle systems provided the greatest resistance to rotation when the screw was inserted perpendicular to the plate. As the off-axis angle increased, the resistance to rotation at the screw/plate interface decreased almost linearly. It is unknown if these differences are clinically significant in an actual fracture construct, but recent reported failures in the distal femur suggest that they might be. ConclusionSurgeons should weigh the risks and benefits of VA systems and attempt to minimize the off-axis angle magnitude when VA systems are selected.

Accurate determination of screw position in treating fifth metatarsal base fractures to shorten radiation exposure time.

Anatomical markers can help to guide lag screw placement during surgery for internal fixation of fifth metatarsal base fractures. This study aimed to identify the optimal anatomical markers and thus reduce radiation exposure. A total of 50 patients in Huashan Hospital, Shanghai, China, who underwent oblique foot radiography in the lateral position were randomly selected. The angles between the fifth metatarsal axis and cuboid articular surface were measured to determine the optimal lag screw placement relative to anatomical markers. The line connecting the styloid process of the fifth metatarsal base with the second metatarsophalangeal (MTP) joint intersected with the fifth metatarsal base fracture line at an angle of 86.85° ± 5.44°. The line connecting the fifth metatarsal base styloid with the third and fourth MTP joints intersected with the fracture line at angles of 93.28° ± 5.24° and 100.95° ± 5.00°, respectively. The proximal articular surface of the fifth metatarsal base intersected with the line connecting the styloid process of the fifth metatarsal base with the second, third and fourth MTP joints at angles of 24.02° ± 4.77°, 30.79° ± 4.53° and 38.08° ± 4.54°, respectively. The fifth metatarsal base styloid and third MTP joint can be used as anatomical markers for lag screw placement in fractures involving the fifth tarsometatarsal joint. The connection line, which is normally perpendicular to the fracture line, provides sufficient mechanical stability to facilitate accurate screw placement. The use of these anatomical markers could help to reduce unnecessary radiation exposure for patients and medical staff.

Profunda femoris artery injury following internal fixation with cannulated hip screws for a femoral neck fracture

Profunda femoris artery (PFA) injury is a rare complication following fracture of the femoral neck. Here, we present a case of a patient with an injured branch of the PFA following internal fixation with cannulated hip screws for a femoral neck fracture. Computed tomography angiography revealed active bleeding from the ascending and descending branches of lateral femoral circumflex artery. We suspected that the cause of the vessel laceration was the sharp tip of the guidewire used during surgery or the closed reduction performed during surgery. The patient was successfully treated with coil embolization. With early recognition and prompt radiological intervention, this rare complication following fracture fixation surgery can be treated without the need for additional surgery.

Factors Associated With Reoperation After Fixation of Displaced Olecranon Fractures.

Surgery for fixation of olecranon fractures is associated with reoperation, mostly for implant removal. A study of a large cohort of patients treated by many different surgeons allows us to determine if specific techniques or implants are associated with a higher rate of reoperation. After open reduction and internal fixation of isolated olecranon fractures, what factors are associated with (1) reoperation and (2) implant removal? Three hundred ninety-two adult patients who had operative treatment of a displaced olecranon fracture not associated with other fractures, dislocation, or subluxation at two area hospitals between January 2002 and May 2014 were analyzed to determine factors associated with reoperation. One hundred thirty-eight (35%) patients had plate and screw fixation and 254 (65%) tension band wiring. Nearly 100% of patients with displaced olecranon fractures are currently treated operatively at our hospitals. All patients were followed for at least four months. Two hundred three of the 392 (52%) patients were followed for one year or more. Ninety-nine patients (25%) had a second operation, 92 (93%) at least in part for implant removal (12 for wire migration [3% of all fractures, 12% of reoperations]). We considered patient-related, fracture-related, and implant-related endpoints as possible factors associated with reoperation. With a total sample size of 99 reoperations, an α of 0.05, and an effect size of 0.3, we had 87% power. Reoperation was less common in men (36 [36%], women: 63 [64%]; adjusted odds ratio, 0.32; 95% confidence interval, 0.18-0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87; p < 0.001). Similarly, request for implant removal was less in men (33 [36%], women: 59 [64%], adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87; p < 0.001). Patients who have operative fixation of a fracture of the olecranon can be counseled that most patients keep their implants, that only 3% experience implant migration, and that technical factors such as the type or configuration of an implant seem less important than personal factors in determining who requests a second surgery for implant removal. Level III, prognostic study.

The dangers of hemilithotomy positioning on traction tables: case report of a well-leg drop foot after contralateral femoral nailing

BackgroundPostoperative contralateral morbidities after fracture fixation surgery by hemilithotomy positioning on traction table is uncommon. We’d report a case of unexpected common peroneal nerve palsy developed on the contralateral side manifesting with drop foot after a common orthopedic femoral nailing.Case reportA 28-year-old female sustained an unusual common peroneal nerve palsy manifesting contralateral drop foot after prolonged femoral nailing. Although the initial presentations were similar to the notorious well-leg compartment syndrome, a benign course with complete recovery in functions was observed 3 months later. After neurophysiologic exam and review of pertinent literature, this iatrogenic and transient dysfunction was delineated to be position-related neuropraxia.ConclusionPosition adjustment at intervals or complete avoidance of prolonged knee hyperflexion is recommended to prevent contralateral common peroneal nerve morbidity.

(371) Pain over the dorsum of third metacarpophalangeal joint: which nerve to block, radial or ulnar?

The distribution of radial and ulnar nerve on the dorsum of hand seems pretty demarcated in textbooks. However overlap or crossover of nerve distribution might happen especially after injury or surgery. In this case report, a 42 year old male suffered right third metacarpophalageal (MCP) joint fracture with a traumatic degloving type laceration over the dorsal aspect of the right hand over a year ago. He had open reduction and internal fixation of right middle metacarpal fracture and wrist external fixation surgery on the same day of injury. Six months after surgery, patient was referred to our pain clinic for persistent pain over the right third MCP joint which completely resolved after scar injection. However, the pain relief only lasted for couple days. Patient subsequently had right superficial radial nerve block which only provided 20-25% instant pain relief. Scar injection with Botox provided complete pain relief which unfortunately only lasted for about a month. Patient subsequently went through a second hand surgery for excision of an osteophyte at the radial side of the right third MCP joint. Also a radial sensory neuroma was identified during the surgery which was buried into distal right radius. However three months later, patient returned to the clinic with persistent pain over the same location--dorsal third MCP joint. Diagnostic nerve block of right dorsal antebrachial cutaneous nerve and right common radial nerve failed to relieve the pain. Eventually dorsal branch of the ulnar nerve was identified (as a small fascicular bundle separating from the distal ulnar nerve then passing dorsally around the ulna deep to the flexor carpi ulnaris) and specifically blocked with a small volume of local anesthetic resulting in complete resolution of pain. Lack of ulnar nerve block was confirmed by spared sensation over ventral hand.

Day case surgery for open reduction and internal fixation of clavicle fractures and acromio-clavicular joint stabilisation. Is this a reasonable alternative?

Day case surgery for open reduction and internal fixation of clavicle fractures and acromio-clavicular joint stabilisation. Is this a reasonable alternative?

Do bisphosphonates affect bone healing? A meta-analysis of randomized controlled trials.

BackgroundWhether bisphosphonates affect indirect bone healing is still unclear.MethodWe carried out a comprehensive search strategy. Only randomized controlled trials were included. Two reviewers independently assessed methodological qualities and extracted outcome data. Analysis was performed with RevMan 5.2.ResultsEight eligible randomized controlled trials with 2,508 patients were included. Meta-analysis results showed that no statistically significant differences were founded in indirect bone healing in short time (within 3 months) (relative risk (RR) 1.40, relative the control group; 95% CI 0.36 to 5.49) and in long-term (more than 12 months) postoperation (RR 1.0; 95% CI 0.98 to 1.02) between bisphosphonates infusion groups and control groups. There were no statistically significant differences of indirect bone healing between early and delay bisphosphonates administration groups. Bisphosphonates infusion after lumbar infusion surgery could promote bone healing and shorten fusion time in 6 months postoperation (RR 1.35; 95% CI 1.11 to 1.66).ConclusionThere was no clinically detectable delay to fracture healing via external callus formation following bisphosphonates treatment. Considering the benefit aspects of bisphosphonates for osteoporosis treatment, we recommend bisphosphonates infusion after fracture fixation surgery and lumbar fusion surgery.