Fracture Fixation Surgery Research Articles

Evaluation of the Patient-Specific Functional Scale in hand fractures and dislocations.

Generic upper extremity disability questionnaires utilize standardized items. The Patient-Specific Functional Scale (PSFS) allows the patient to identify specific self-reported items. This study evaluated the validity of the PSFS to assess outcome in patients with hand fractures or dislocations. Adults with hand fractures or dislocations, who completed hand therapy between January 2012 and January 2013, were eligible for inclusion. At the initial and final assessment, each patient was asked to complete the PSFS. Each patient identified three items that were difficult or they were unable to perform, and the degree of difficulty was ranked from 0 to 10 (able to perform at pre-injury level). We excluded patients with an incomplete PSFS. Statistical analyses evaluated the relationships between the PSFS and the independent variables. There were 63 patients (37 men, 26 women); 21 of the 63 patients underwent surgery for fracture fixation. The mean duration of hand therapy treatment was 2.2 ± 1.4months. The mean PSFS scores were as follows: initial 3.2 ± 2.2; final 8.1 ± 2.2. There was a significant improvement in PSFS scores from initial to final assessment (p < 0.001) and a moderate correlation (r = 0.3, p = 0.02). There was no statistical difference in PSFS scores between men and women or surgery and no surgery. In these patients with hand fractures or dislocations, the PSFS indicated significant improvement in function. Using items identified by the patient, the PSFS provides a valuable perspective of outcome and may be used in conjunction with generic disease-specific questionnaire for assessment of the upper extremity.

Metal Hypersensitivity in Patients with Conventional Orthopaedic Implants.

Metal implants are widely used in orthopaedic surgery for elective joint arthroplasty or fracture fixation. Metal alloys also are widely used in other medical specialties for devices such as dental implants, cardiovascular stents, and gastrointestinal wire mesh stents. Metal hypersensitivity, as detected with skin patch testing, is common, with a prevalence of between 10% to 17% in the general population1-5. This raises the concern that hypersensitivity reactions may occur in patients with metallic orthopaedic implants and the possibility that metal hypersensitivity reactions may account for ongoing pain or aseptic loosening following joint arthroplasty6,7. The purpose of the present review is to examine the current understanding of metal hypersensitivity and its potential clinical importance in orthopaedic surgery. The methods of testing for metal hypersensitivity and the limitations of such tests are also discussed. In this article, we consider conventional arthroplasty implants (metal-polyethylene and metal-ceramic articulations) and fracture-fixation devices. Coverage of the localized reactions reported in association with metal-on-metal arthroplasty is beyond …

The Use of Blood Cell Salvage in Acetabular Fracture Internal Fixation Surgery

To determine if the routine use of intraoperative blood cell salvage in acetabular fracture internal fixation reduces the need for allogenic blood transfusion, is cost effective, and whether it is influenced by the acetabular fracture pattern. A retrospective study. Tertiary pelvic and acetabular reconstructive center. Patients undergoing internal fixation for acetabular fractures. Eighty consecutive patients were reviewed, comprising 26 elementary fracture (EF) and 54 associated fracture (AF) types. The mean volume of autologous blood transfused was 484 mL. The mean volume of 561 mL of autologous blood transfused in patients with AF types was significantly greater than the mean volume of 325 mL transfused in the EF group (P = 0.007). Additional allogenic blood transfusion was required in 5 (19%) patients with EFs and 15 (28%) patients with AFs (P = 0.418). The mean cost of the blood cell salvage and additional blood products in our study was $223 (£135) for all fracture types ($174/£105 for EF and $246/£149 for AF).When treating AF types, the mean cost of using blood cell salvage was $246 (£149) as compared with the mean predicted cost of not using blood cell salvage and transfusing the equivalent of 1.7 units of allogenic blood instead, which was $463 (£281). These distributions are significantly different (P = 0.01). The use of blood cell salvage for internal fixation surgery for acetabular fracture is cost effective, particularly when treating AF types, and its routine use is advocated to limit the need for allogenic blood transfusion.

Tip to apex distance in femoral intertrochanteric fractures: a systematic review

BackgroundHip fractures are associated with high morbidity, mortality, and cost. Implants used for hip fracture fixation can fail for many reasons including lag screw cut-out. Tip–apex distance (TAD) is indicative of the position and depth of a screw in the femoral head and has been shown to be associated with cut-out failure. We conducted a systematic review of the published literature to quantify the association between TAD and cut-out failure for patients undergoing hip fracture fixation surgery. MethodsWe performed a search of the Medline, Embase, and Cochrane databases. We performed abstract and full text reviews independently and in duplicate. We used a random effects model to combine, in duplicate, the incidence of cut-out for patients who had TAD <25mm and TAD >25mm. We also combined mean TAD values for patients who had cut-out failure and those who did not. ResultsSeventeen studies were eligible for this review, four of which were included in combined analysis of dichotomous outcomes and seven in combined analysis of continuous outcomes. Patients with TAD >25mm had a significantly greater risk of cut-out than patients with TAD <25mm (RR=12.71). Patients who experienced implant cut-out had significantly higher TAD scores than those who did not (mean difference=6.54mm). ConclusionTip–apex distance is an important concept in relation to cut-out failure of hip fracture fixation surgery. Surgeons should understand and apply the concept of TAD to improve outcomes for their patients.

Breakage and Migration of Metal Wires in Operated Patella Fractures: Does it Correlate with Time?

BackgroundTension-band wiring with metal wires is a commonly used technique to treat transverse patella fractures. Wire breakage and migration may potentially cause complications or morbidities such as nerve irritation or skin impingement. The need of extra wound or surgery for implant removal may be required. We hypothesize that the breakage of patellar tension-band wires is related to the patient's age and the length of time after fracture fixation. MethodsWe retrieved and analysed our 11 years records (from January 1, 2000, to May 31, 2011). The inclusion criteria were: (1) patients with transverse patella fracture treated with tension-band plus cerclage wiring technique, (2) with their metal wires removed in our hospital, (3) unilateral patella fracture, (4) wire removal not due to infection, (5) wire removal after complete fracture union, (6) no fracture distal pole or partial patellectomy with protective wire loop, and (7) known exact date of the initial fracture fixation surgery. We reviewed the reasons of wire removal, the presence of broken or migrated wires upon implant removal, and the time lapse from fracture fixation to removal of wire. ResultsA total of 59 cases were recruited and studied. A total of 28 patients had intact wires and 31 patients had broken wires upon implant removal. For the age of patients at fracture fixation, there was no statistically significant difference between the intact wire group and the broken wire group. However, for the length of time from fracture fixation to implant removal, the difference was statistically significant between the two groups of patients. It suggested that the risk of wire breakage increases with time after patellar tension-band wiring. If 12 months was used as a cut-off time, there was a statistically significant association between the duration from fracture fixation to implant removal and the presence of broken wire. There were seven cases of wire migration among the 31 patients with broken wires, and two of them needed an extra open wound at popliteal fossa for implant removal. ConclusionsThe risk of patellar tension-band wire breakage was associated with increase time lapse from fracture fixation, but not the patients' age upon fracture fixation. The risk of wire breakage significantly increases after 12 months from the fracture fixation. Wire breakage can lead to further morbidities or complications. Routine removal of wire loops may be indicated. Future prospective longitudinal long-term studies may be required.

Modified miniplates for orthopaedic skeletal anchorage

The use of temporary anchorage devices (TADs) in orthodontics has increased over recent years. One type of TAD, a modification of the titanium miniplate frequently used in orthognathic surgery for osteotomy or fracture fixation, has been used successfully as a skeletal anchorage device for various orthodontic applications. Most of these applications have focused on achieving dental movements, but recent case reports have demonstrated the use of TADs as an adjunct to orthopaedic treatment. Young patients with maxillary hypoplasia are usually treated with a facemask: heavy anterior traction is applied on the maxilla to stimulate its growth and to restrain or redirect mandibular growth. Titanium miniplates used for anchorage now offer the possibility to apply pure bone-borne orthopaedic forces between the maxilla and the mandible for 24 h per day, avoiding dentoalveolar compensation. As a result, they eliminate the need for a means of extraoral anchorage such as headgear, which has been considered an effective means of orthodontic anchorage but requires good patient cooperation to achieve results. The difficulty of using an extraoral appliance and the aesthetic concerns related to its unusual appearance make patient cooperation difficult to maintain throughout the treatment.

Hip Arthroplasty After Intramedullary Hip Screw Fixation

Although literature exists regarding surgery after hip screw/side plate devices, we are unaware of any reports of hip arthroplasty after intramedullary devices. This is a retrospectively reviewed case series. Tertiary care medical center. A consecutive unselected series. Hip arthroplasty surgery after failed hip fracture fixation surgery using an intramedullary nail device. Twenty cases of conversion surgery after intramedullary fixation for hip fractures were retrospectively reviewed. The indications for hip arthroplasty were nonunion with failed fixation in 15, avascular necrosis with secondary hip arthritis in three, and progression of hip arthritis in four. Average operative time and blood loss were 166 minutes and 621 mL, respectively. Of note, nine of 20 patients ultimately developed a nonunion of the greater trochanter after hip arthroplasty. In only one of these cases of nonunion was the greater trochanter refractured intraoperatively and this as part of a trochanteric osteotomy. Patients undergoing hip arthroplasty after failed hip fracture fixation using an intramedullary nail device are at high risk for greater trochanteric fracture and nonunion. The average operative time and blood loss for these procedures were greater than reported for primary but less than for revision arthroplasty. We now consider treating these cases with a trochanteric plate with or without a trochanteric slide osteotomy to minimize fracture of the remaining, damaged trochanteric bone. Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Orbitozygomatic Fractures With Enophthalmos: Analysis of 64 Cases Treated Late

To present our treatment experience in delayed orbitozygomatic fracture with enophthalmos and compare the results of traditional surgery, navigation-guided surgery, and 3-dimensional (3D) model-guided surgery in the Departments of Oral and Maxillofacial Surgery and Ophthalmology, Shanghai Ninth People's Hospital, Shanghai, China. This is a retrospective review of a consecutive clinical case series. From 2008 to 2010, 64 patients diagnosed with delayed orbitozygomatic fractures with enophthalmos were treated in the departments. Computed tomography (CT) scan and ophthalmologic examination were performed before surgery. Traditional surgery and computer-assisted treatment (navigation and 3D model) were used for zygoma reduction. Three materials were applied for orbital reconstruction: hydroxyapatite (HA), porous polyethylene (Medpor; Porex Surgical Inc, Newnan, GA), and titanium mesh. Zygomatic reduction and globe projection of different treatment methods were evaluated by postoperative CT scan and clinical follow-up visits. Thirty-nine cases with enophthalmos (mean, 4.96 mm) had traditional surgery for fracture reduction and orbital reconstruction, whereas the other twenty-five cases with enophthalmos (mean, 5.71 mm) had computer-assisted surgery consisting of 3D models to pre-bend the titanium mesh for orbital reconstruction and plates for fracture fixation (n = 25) and navigation-guided surgery (n = 11). Postoperative CT with 3D reconstruction showed good zygomatic reduction in 74.3% of the cases with traditional surgery, 85.7% with computer-assisted 3D models only, and 100% with navigation-guided surgery. In the traditional surgery group, 74.2% of the cases had good postoperative globe projection (≤2 mm), 19.4% had mild enophthalmos (≤3 mm), and 6.5% had moderate enophthalmos (≤4 mm). In the group undergoing computer-assisted 3D model surgery, 75% of the cases had good globe projection and 25% had mild enophthalmos. In the navigation-guided surgery group, 90.9% of the cases had good globe projection and 9.1% had mild enophthalmos. Titanium mesh was used for orbital reconstruction in 47 cases (among which, 12 combined with Medpor or HA), whereas 12 had Medpor only and 5 had HA only. Good globe projection was acquired in 74% of the cases with titanium mesh only, 83% with combined materials, 67% with Medpor only, and 20% with HA only. Computer-assisted surgery can improve the treatment results of delayed orbitozygomatic fracture with enophthalmos. Navigation-guided surgery with a 3D model and titanium mesh with Medpor are the best ways to treat delayed orbitozygomatic fractures with severe enophthalmos.

THA After Acetabular Fracture Fixation: Is Frozen Section Necessary?

Infection is uncommon after THA performed for failed acetabular fracture repair, despite a high reported incidence of culture-positive fixation implants. The use of frozen section analysis at the time of THA after acetabular fracture fixation surgery is unknown. We asked whether frozen section analysis predicted occult infection after THA performed after acetabular fracture repair. We retrospectively reviewed the charts of 43 of 49 patients with prior acetabular fracture fixation who had intraoperative frozen section and culture data from a conversion THA between 2002 and 2010. The average age of patients at fracture was 53 years; conversion was performed after an average of 553 days (median, 369 days; range, 51-2951 days). Five patients had an infection after acetabular fracture surgery (three deep, two superficial). At conversion we obtained an average of three frozen section specimens per patient; 10 specimens in eight patients contained greater than 10 polymorphonuclear cells/high-power field. The minimum followup was 51 days (median, 256 days; range, 51-2085 days). Five patients had positive intraoperative cultures, three of whom had a positive frozen section. All patients who had prior deep infection developed positive intraoperative cultures. The sensitivity, specificity, positive predictive value, and negative predictive value of frozen section analysis were 0.60, 0.87, 0.38, and 0.94, respectively. Infection complicating THA after acetabular fracture repair is uncommon. A history of deep infection complicating the acetabular fracture surgery was the strongest predictor of infection. Frozen section analysis has a high specificity and negative predictive value. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Sclerostin and the regulation of bone formation: Effects in hip osteoarthritis and femoral neck fracture

Remodeling imbalance in the elderly femoral neck can result in thin cortices and porosity predisposing to hip fracture. Hip osteoarthritis protects against intracapsular hip fracture. By secreting sclerostin, osteocytes may inhibit Wnt signaling and reduce bone formation by osteoblasts. We hypothesised that differences in osteocytic sclerostin expression might account for differences in osteonal bone-formation activity between controls and subjects with hip fracture or hip osteoarthritis. Using specific antibody staining, we determined the osteocytic expression of sclerostin within osteons of the femoral neck cortex in bone removed from subjects undergoing surgery for hip osteoarthritis (hOA: 5 males, 5 females, 49 to 92 years of age) or hip fracture fixation (FNF: 5 males, 5 females, 73 to 87 years of age) and controls (C: 5 males, 6 females, 61 to 90 years of age). Sclerostin expression and distances of each osteocyte to the canal surface and cement line were assessed for all osteonal osteocytes in 636 unremodeled osteons chosen from fields ( approximately 0.5 mm in diameter) with at least one canal staining for alkaline phosphatase (ALP), a marker of bone formation. In adjacent sections, ALP staining was used to classify basic multicellular unit (BMUs) as quiescent or actively forming bone (ALP(+)). The areal densities of scl(-) and scl(+) osteocytes (number of cells per unit area) in the BMU were inversely correlated and were strong determinants of ALP status in the BMU. In controls and hip fracture patients only, sclerostin-negative osteocytes were closer to osteonal surfaces than positively stained cells. Osteon maturity (progress to closure) was strongly associated with the proportion of osteonal osteocytes expressing sclerostin, and sclerostin expression was the chief determinant of ALP status. hOA patients had 18% fewer osteocytes per unit bone area than controls, fewer osteocytes expressed sclerostin on average than in controls, but wide variation was seen between subjects. Thus, in most hOA patients, there was increased osteonal ALP staining and reduced sclerostin staining of osteocytes. In FNF patients, newly forming osteons were similar in this respect to hOA osteons, but with closure, there was a much sharper reduction in ALP staining that was only partly accounted for by the increased proportions of osteonal osteocytes staining positive for sclerostin. There was no evidence for a greater effect on ALP expression by osteocytes near the osteonal canal. In line with data from blocking antibody experiments, osteonal sclerostin appears to be a strong determinant of whether osteoblasts actively produce bone. In hOA, reduced sclerostin expression likely mediates increased osteoblastic activity in the intracapsular cortex. In FNF, full osteonal closure is postponed, with increased porosity, in part because the proportion of osteocytes expressing sclerostin increases sharply with osteonal maturation.

Piezoelectric inkjet printing of medical adhesives and sealants

Piezoelectric inkjet printing is a noncontact process that enables microscale processing of biological materials. In this research summary, the use of piezoelectric inkjet printing for patterning medical adhesives and sealants, including a two-component polyethylene glycol hydrogel-based medical sealant, an N-butyl cyanoacrylate tissue adhesive, and a mussel adhesive protein biological adhesive, is described The effect of Fe(III) on mussel adhesive protein structure was evaluated by means of atomic force microscopy. The ability to process microscale patterns of medical sealants and adhesives will provide an improvement in tissue joining, including enhanced tissue integrity, reduced bond lines, and decreased adhesive toxicity. Piezoelectric inkjet deposition of medical adhesives and sealants may be used in wound closure, fracture fixation, and microscale vascular surgery.

Different reimbursement influences surviving of hip fracture in elderly patients

Objectives Research has shown that early surgical intervention for hip fractures serves to decrease mortality. In 2004 the Ministry of Health decided to condition the reimbursement regime at the time of operation. The objectives of this study were to examine whether the reform succeeded to decrease inpatient mortality of hip fracture casualties. Method The study utilised data drawn from the Israeli Trauma Registry (ITR) for the years 1999–2006. The study population included patients aged 65 and older with an isolated diagnosis of hip fracture following trauma. Results Two years after the reform, the inpatient mortality decreased by 34% amongst patients undergoing fixation surgery, and by 30% amongst all operated patients. Median LOS decreased by 2 days. The proportion of patients undergoing hip fracture fixation surgery within 48 h increased by 35%. Conclusions The implementation of a payment limited by time for hip fracture fixation surgery increased the number of patients being operated within 48 h, shortened patient LOS, and decreased inpatient mortality.

Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes?

Treatment of fractures is sometimes performed after normal daytime operating hours and in such instances may be performed under less than ideal conditions. The consequence of performing operations under such conditions is largely unknown and was therefore studied in the context of intramedullary nail fixation of tibial and femoral shaft fractures. Two hundred and three consecutive patients with either a femoral or tibial shaft fracture (Orthopaedic Trauma Association classification 32 or 42) treated with intramedullary nail fixation were included in a prospective, multicenter, nonrandomized study. Patients were divided into an after-hours group defined as an operation beginning from 4:00 P.M. to 6:00 A.M. or a daytime group defined as an operation beginning from 6:00 A.M. to 4:00 P.M. These groups were further divided on the basis of the injured bone into the following subgroups: after-hours femoral fracture (fifty-five patients), daytime femoral fracture (forty-four patients), after-hours tibial fracture (forty-eight patients), and daytime tibial fracture (fifty-six patients). The demographic and fracture characteristics were similar among the subgroups. All patients were treated with the same type of femoral antegrade, femoral retrograde, or tibial nail fixation with reaming. Data for fracture-healing, complications, operative time, and fluoroscopy time were collected prospectively. The healing rates were similar between daytime and after-hours surgery groups for both the tibial and femoral nailing. On the basis of univariate analysis, operative times were shorter in the after-hours group compared with the daytime group for both the tibial and femoral nail fixation groups (p < 0.02), but regression analysis failed to identify time of surgery as an independent variable associated with operative time. Radiation exposure was similar for the after-hours group and the daytime group for both tibial and femoral nail fixation (p > 0.05). The after-hours group had more unplanned reoperations than the daytime group (p < 0.02). Removal of painful hardware was more frequent in the after-hours femoral fracture group (27%) than in the daytime femoral fracture group (3%) (p < 0.02), and after-hours surgery was an independent variable associated with the need for removal of painful femoral fracture hardware (p < 0.05). Rates of nonunion, infectious complications, and radiation exposure are similar for after-hours and daytime surgery for intramedullary nail fixation of both femoral and tibial fractures. After-hours femoral nail fixation was associated with an increased frequency for removal of painful hardware, which may be related to technical errors associated with nonideal conditions and shorter operative times. An increase in the allocated amount of daytime operative time for orthopaedic trauma surgery has the potential to reduce minor complication rates for intramedullary nail fixation.

Delayed presentation of lateral femoral circumflex artery injury post cannulated hip screw surgery – a case report

An elderly patient underwent cannulated hip screw surgery for a subcapital neck of femur fracture. Nine days post surgery, she was noted to have collapsed with a falling haemoglobin level. Computed tomography revealed a large haematoma to the thigh. Further angiography showed active bleeding from one of the branches of the lateral femoral circumflex artery (LFCA), which we postulate was caused by the sharp tip of a version guidewire used during fracture fixation surgery. Iatrogenic injury during hip fracture fixation is a rare event, particularly to the circumflex branches of the profunda femoris artery (PFA), and may occur from hard wire use intra-operatively or from the fracture itself. The LFCA branches laterally from the PFA, runs anterior to the femoral neck, where we suspect it was injured in our case. Whilst a version wire is a useful radiological guide intra-operatively, manually clearing a passage for its insertion into the femoral head/neck junction and using the blunt end is recommended. A combination of acute swelling in the operated region and falling haemoglobin post surgery should alert the clinician to possible vascular injury. Compared to duplex ultrasonography, CT angiography remains the gold standard in its specificity and sensitivity for diagnosing arterial injuries. With early recognition and prompt radiological intervention, this rare complication of fracture fixation surgery can be treated without the need for further surgery.

Late Salvage of Failed Open Reduction and Internal Fixation of Posterior Wall Fractures of the Acetabulum

The purpose of this study was to review the outcome of late revision surgery in a series of patients with posterior wall fractures having recurrent hip instability after failed initial open reduction and internal fixation. Retrospective analysis of consecutive patients. Level 1 trauma center. A retrospective analysis of consecutive acetabulum patients treated by a single surgeon between 1989 and 2005 identified 4 patients referred for recurrent hip instability subsequently treated by revision open reduction and internal fixation performed 3 weeks or more (range 3 weeks to 9 months) after the original injury. Revision open reduction and internal fixation through a Kocher-Langenbeck approach. Final radiographic appearance and modified Merle d'Aubigne Score. Three of the 4 patients eventually required total hip arthroplasty. Two of these 3 patients required total hip arthroplasty within 18 months of revision surgery. Both, older than 50 years, had experienced catastrophic early hip redislocation associated with femoral head pathology after the original surgery. Despite progression of traumatic arthrosis, 1 patient continues to ambulate without assistance or pain on her native hip, 18 years after the revision open reduction and internal fixation surgery. Patients are likely to experience poor clinical outcome, ultimately requiring total hip arthroplasty, when salvage procedures are delayed by more than 3 weeks. In older patients, failure occurs rapidly; in younger patients, total hip replacement surgery may be delayed. Therefore, in older patients, particularly if there is concomitant damage to the femoral head, late revision fracture fixation surgery is ill advised and total hip arthroplasty seems to be the most appropriate secondary surgery. However, late revision fracture fixation surgery may provide young, active patients a limited number of years of satisfactory function before total hip arthroplasty is required.

The anatomy of the deltoid insertion

The deltoid muscle is in continuity with the distal arm fascia and musculature. Ten fresh-frozen upper extremity cadaveric specimens were dissected to determine the insertional anatomy of the deltoid muscle. Measurements were made with micro-calipers and acetate grid sheets. The deltoid tendon and fibrous aponeurosis was in continuity with the lateral intermuscular septum posteriorly and the lateral aspect of the brachialis and deep brachial fascia anteriorly in all ten specimens. This interconnection remained in continuity following complete release of the deltoid insertion. The width of the insertion of the anterior head of the deltoid was a mean of 7.3 mm, the middle averaged 4.7 mm, and the posterior averaged 7.8 mm. The mean length of the anterior insertion was 70 mm, the middle was 48.4 mm, and the posterior was 63.4 mm. The mean width of the deltoid tendon and the investing fascia at the superior margin of the insertion was 21.9 mm and at the inferior margin 13.1 mm. Deltoid muscle integrity is critical to shoulder function. The deltoid insertion, however, is often partially released during surgical approaches for internal fixation of proximal humerus fractures and shoulder arthroplasty. Partial detachment without repair as performed during surgical approaches should not result in complete loss of continuity of the deltoid insertion. Knowledge of the distal insertion and interconnections of the deltoid allows for more anatomic repair following extended releases during complex fracture fixation or revision surgery.

Hip fracture fixation in a patient with below-knee amputation presents a surgical dilemma: a case report

IntroductionHip fracture fixation surgery in patients with below-knee amputations poses a challenging problem to the surgeon in terms of obtaining traction for reduction of the fracture. The absence of the foot and part of the leg in these patients makes positioning on the fracture table difficult. We highlight this difficult problem and suggest techniques to overcome it.Case presentationA 73-year-old man with bilateral below-knee amputations presented with a history of fall. Radiographs revealed an inter-trochanteric fracture of the femur. A dynamic hip screw fixation was planned for the fracture but the dilemma was on how to position the patient on the fracture table for the surgery. Special attention was needed in positioning the patient and in surgical fixation of the fracture.ConclusionHip fracture fixation in patients with below-knee amputations poses a special problem in positioning for fracture reduction and fixation. In this case report, we share our experience and suggest techniques to use when encountering this difficult problem.

Cerebral Microemboli During Hip Fracture Fixation: A Prospective Study

Recent studies have shown that cerebral fat microembolism takes place during surgery for hip or knee replacement. In this study, we examined the occurrence of cerebral microembolism, solid or gas, during a standard procedure of hip fracture fixation. This was a prospective study of patients who underwent urgent surgery with a dynamic hip screw for hip fracture fixation. During surgery, patients were monitored with transcranial Doppler for detection of microemboli from right and left middle cerebral arteries. Twenty-two patients were included in the study; their median age was 82 yr (range, 51-97 yr). In nine (41%) patients, high intensity transient signals were recorded, indicating microemboli passage in the middle cerebral arteries. All nine patients had signals of both solid and gas emboli. One of these nine patients had a postoperative cerebrovascular accident. The incidence of cerebral microemboli during urgent surgery for hip fracture fixation is considerable. This phenomenon is not confined to hip or knee replacement surgery. The clinical implications of this finding require further investigation.

Closed suction surgical wound drainage after orthopaedic surgery

Closed suction drainage systems are frequently used to drain fluids, particularly blood, from surgical wounds. The aim of these systems is to reduce the occurrence of wound haematomas and infection. To evaluate the effectiveness of closed suction drainage systems for orthopaedic surgery. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), and contacted the Cochrane Wounds Group. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), and MEDLINE (1966 to March 2006). Articles of all languages were considered. All randomised or quasi-randomised trials comparing the use of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery. Two authors independently assessed trial quality, using a nine item scale, and extracted data. Where appropriate, results of comparable studies were pooled. Thirty-six studies involving 5464 participants with 5697 surgical wounds were identified. The types of surgery involved were hip and knee replacement, shoulder surgery, hip fracture surgery, spinal surgery, cruciate ligament reconstruction, open meniscectomy and fracture fixation surgery. Pooling of results indicated no statistically significant difference in the incidence of wound infection, haematoma, dehiscence or re-operations between those allocated to drains and the un-drained wounds. Blood transfusion was required more frequently in those who received drains. The need for reinforcement of wound dressings and the occurrence of bruising were more common in the group without drains. There is insufficient evidence from randomised trials to support the routine use of closed suction drainage in orthopaedic surgery. Further randomised trials with larger patient numbers are required for different operations before definite conclusions can be made for all types of orthopaedic operations.

Intracapsular hip fractures in end-stage renal failure

Patients with end-stage renal failure (ESRF) have metabolic bone disease. This increases the risk of femoral neck fracture and increases the risk of complications associated with fracture fixation such as non-union and avascular necrosis (AVN). We report the results of treatment in a consecutive series of 15 intracapsular fractures of the hip occurring in 13 patients with ESRF over a 5-year period. Six intracapsular hip fractures (of which five were undisplaced) were treated by internal fixation. Five out of these six (mean=83.3%) required conversion to total hip arthroplasty because of non-union or AVN. In all six of these patients, internal fixation was considered adequate post operatively. Of the remaining nine intracapsular hip fractures treated by hemiarthroplasty, only one required conversion to total hip arthroplasty because of stem subsidence (mean=11%). The difference in the revision rate for the two groups i.e. primary fixation versus primary hemiarthroplasty was statistically significant (p-value=0.01). The six patients with undisplaced intracapsular fractures treated by internal fixation required a total of 14 major operations, at an average rate (including initial fracture fixation and revision surgery) of 2.3 per patient. The 9 displaced fractures treated by hemiarthroplasty required just 10 operations in total, at an average rate of 1.1 per patient. (The difference was significant; p-value=0.006.) The 1-year mortality in the whole group (13 patients with 15 fractures) was 44.4%. We suggest that patients with ESRF with an intracapsular fracture of the neck of femur should be treated by replacement arthroplasty irrespective of femoral head displacement because of the high risk of revision surgery associated with internal fixation.