Secondary Operative Treatment Research Articles

The Clinical Outcomes of Operative Treatment Versus Conservative Treatment for Dancer's Fractures: Protocol for a Retrospective Cohort Study.

BackgroundFifth metatarsal fractures are one of the most common foot fractures, and 11% to 25% of such fractures are Dancer’s fractures (distal spiral fractures). Conservative therapy while wearing a cast and operative treatment have been used as preferred modes of treatment in the limited literature available. However, we often see healing problems, such as delayed union and nonunion, when Dancer’s fractures are treated nonoperatively, resulting in a need for secondary intervention. In our institution, treatment has changed over the years from predominantly conservative treatment to mostly operative treatment. To investigate whether our hypothesis holds true that primary surgical treatment is beneficial, a retrospective study was designed.ObjectiveThe objective of the study is to compare differences between outcomes (delayed union and nonunion) of conservative and operative treatments for Dancer’s fractures.MethodsA retrospective comparative cohort study will be conducted in a level II trauma center (Zaandam Medical Center). Patients who experienced a Dancer’s fracture in the period of 2012 to 2021 will be included and divided into 2 cohorts—the conservative (2012-2015) and operative (2016-2021) treatment cohorts. The primary outcome will be the differences in percentages of delayed union and nonunion between the two groups. The secondary outcomes will be the percentage of primary conservative treatment failure, the need for secondary operative treatment, complications (infection and hardware failure), and functional outcomes. If 118 patients are included in each group, sufficient power is expected to be reached, depending on the age distribution of patients. The percentages of delayed union and nonunion among the two groups will be calculated and statistically compared via chi-square statistics. A logistic regression analysis will be used to investigate possible associations between patient characteristics and failed conservative treatment. A Mann-Whitney U test will be used to compare functional outcomes between groups. An independent, 2-tailed t test will be used to compare mean 12-Item Short Form Survey scores if they are normally distributed, and a Wilcoxon rank sum test will be used if they are nonnormally distributed.ResultsIn total, 2134 potentially relevant health insurance codes have been extracted from the hospital’s register. We expect to find a total of 236 Dancer’s fractures in this data set.ConclusionsOur study has limitations due to it being a single-center study and data collection being performed retrospectively. However, it covers a large time period and may provide the possibility to show treatment outcome differences (delayed union and nonunion, complications, and functional outcomes) in 2 reasonably large cohorts (conservative and operative treatment cohorts), which has not been done before in literature on Dancer’s fractures. If our hypothesis that surgery is beneficial for Dancer’s fractures is proven true by our study, we plan to further corroborate it by conducting a prospective randomized controlled trial.International Registered Report Identifier (IRRID)PRR1-10.2196/37171

Pipkin fractures: epidemiology and outcome

PurposeTo describe the epidemiology of Pipkin fractures including detailed fracture classification and outcome for joint preservation and death.MethodsWe extracted data on all Pipkin fractures in the Swedish Fracture Register from 2013 to 2020 in patients ≥ 18 years. The cohort was cross-matched with the Swedish Hip Arthroplasty Register to obtain data on primary or secondary treatment with arthroplasty. We analysed data on age, sex, injury mechanism, fracture classification, treatment including secondary operative treatment with arthroplasty and mortality. Primary outcome was joint preservation.ResultsIn total 47 Pipkin fractures with a median age of 48 years were included. 74% of the fractures were in males. The median follow-up time was 3.5 years. The most common primary treatment was internal fixation (45%), followed by primary arthroplasty (28%), and excision of fragment (15%). Three of the 34 patients with primary non arthroplasty treatment received secondary treatment with arthroplasty. Two patients died within 30 days, and no further deaths occurred up to 1 year after injury.ConclusionThree of four fractures occurred in males and more than half of the fractures were due to high energetic injuries. Half of the patients received internal fixation (predominantly younger patients) and 28% were treated with primary arthroplasty (predominantly older patients). The revision rate was low, and after secondary treatment with arthroplasty two thirds of the patients still had a preserved joint.

Current practice in the management of acromioclavicular joint dislocations; a national survey in the Netherlands

PurposeThe aim of this study was to investigate current practice in the management of acromioclavicular joint dislocations in the Netherlands.MethodsA 36-item literature-based and expert consensus survey was developed. If available, one orthopaedic and one trauma surgeon for every hospital (n = 82) in the Netherlands was asked to complete the online questionnaire. Only complete data sets were included in the analysis. Descriptive analysis was performed using SPSS.ResultsOf 149 invited surgeons, 106 (71%) fully completed the survey. The diagnosis of ACJ injury was mainly based on physical examination (91%) and radiographs (95%). The vast majority of patients with ACJ injuries was treated non-operatively. The decision for operative treatment was mainly based on the surgeon’s experience and available literature. Patient-related factors that contributed most to the decision to operate or not, were mainly functional needs and age. Cosmesis and gender contributed less to this decision. Rockwood II and III ACJ injuries were usually treated non-operatively, whereas Rockwood IV and V ACJ injuries were usually treated operatively. For primary and secondary operative treatment, a flexible implant was preferred over rigid fixation techniques. All respondents agreed that nonoperative treatment of Rockwood II ACJ injuries leads to satisfactory results and that secondary operative treatment is only rarely required. Also the majority of patients with Rockwood III ACJ injuries is treated non-operatively, although failure rates are considered higher.ConclusionThis survey showed a significant individual variation on diagnosis and treatment strategies among surgeons in the Netherlands. The majority of the Dutch surgeons concern a flexible implant the best available technique for patients who require operative treatment.

Pseudarthrosis after bony avulsion fracture of the posterior cruciate ligament

Tibial bony avulsion fractures of the posterior cruciate ligament (PCL) are rare injuries and in certain cases adelayed healing or non-union can occur under conservative treatment. Presentation of the clinical result of patients with pseudarthrosis who were secondarily operated on after bony avulsion of the PCL. The study included all patients who were operated on since 2010 for reasons of delayed or non-union PCL avulsion fracture in this clinic. Standardized questionnaires and follow-up documentation, e.g. visual analog scale (VAS), International Knee Documentation Committee (IKDC), Lysholm and Tegner scores were used and a magnetic resonance imaging (MRI) monitoring of the injured knee was carried out. A total of 5patients aged from 30 to 63 years (3male, 2female) were identified with mainly persisting flexion pain and instability under conservative treatment and secondary surgery of the knee. In the follow-up of 4patients good results could be achieved (IKDC health condition 81/subjective assessment76) after minimally invasive direct screw reduction with consolidation of the fracture zone; however, there was a slight residual dorsal instability. The secondary operative treatment of pseudarthrosis of bony PCL injuries led to good clinical results. Due to the detectable residual instability the authors are of the opinion that the indications for primary osteosynthesis in the acute phase should be generously considered. This must still be corroborated in studies with larger case numbers. The indications for MRI diagnostics should be generously considered, Smoking appears to be associated with an increased risk of pseudarthrosis. Good results can be achieved with aminimally invasive posterior screw approach, even after a delay.

Comparison of flexible intramedullary nailing with external fixation in compound tibial shaft fractures

Aim: This study compared the results of flexible intramedullary nailingusing Ender nails (EN) with those of external fixation (EF) in compound tibial shaft fractures. Materials and Methods: Twenty-eight patient with tibial shaft fractures were evaluated in thestudy. The patient ages ranged from12 to 40 years, and the average period of follow-up was 24 months. Fifteen patients underwent flexible intramedullary nailing using Ender nails and thirteen patients underwent external fixation. The outcomes were assessed based on the clinical and radiology findings. Result: Bone union was achieved in all cases, and no patients sustained a complication that was expected to cause disability. For EN union occurred at an average of 12 weeks (10-14 weeks). For EF, union was observed at an average of 16 weeks (14-18 weeks). EN group, one patient suffered proximal pin migration. In the EF group, three patients had a pin site infection and loosening. Conclusion: The EN and EF groups showed similar results at the last follow up. However, in the EF group, refracture, pin site infection, and angular deformity were some of the possible complications during the healing process. EN is recommended for grade I & II tibia fractures, not require secondary operative treatment, stable as it is intramedullary implant.

Femoral shaft fractures in young children (

Femoral shaft fractures comprise around 4% of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN). This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications. We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1m or 1-3m, the most frequent result (>40%) being a long spiral fracture. All 19 children below 1year of age were treated by casting or traction. Between the ages of 12 and 24months (n=56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36months, operative and non-operative therapies were equally distributed. In children older than 36months (n=64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections). Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3years of age.

Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland

Although currently there are many different recommendations and strategies in the therapy of odontoid fractures in the elderly, there are still no generally accepted guidelines for a structured and standardised treatment. Moreover, the current opinion of spine surgeons regarding the optimal treatment of odontoid fractures Type II of the elderly is unknown. In order to have an objective insight into the diverging strategies for the management of Anderson Type II odontoid fractures and form a basis for future comparisons, this study investigated the current concepts and preferences of orthopaedic, neuro- and trauma surgeons. Spine surgeons from 34 medical schools and 8 hospitals in Germany, 4 university hospitals in Austria and 5 in Switzerland were invited to participate in an online survey using a 12-item 1-sided questionnaire. A total of 44 interviewees from 34 medical institutions participated in the survey, consisting of trauma (50%), orthopaedic (20.5%) and neurosurgeons (27.3%). Out of these, 70.5% treated 1–20 fractures per year; 63.6% favoured the anterior screw fixation as therapy for Type II odontoid fractures, the open posterior Magerl transarticular C1/C2 fusion, the posterior Harms C1/C2 fusion, and conservative immobilisation by cervical orthosis was preferred by 9.1% in each case. 59.1% preferred the anterior odontoid screw fixation as an appropriate treatment of Anderson Type II odontoid fractures in the elderly. 79.5% chose cervical orthosis for postsurgical treatment. Following operative treatment, nonunion rates were reported to be <10% and <20% by 40.9% and 70% of the surgeons, respectively. 56.8% reported changing from primary conservative to secondary operative treatment in <10% of cases. The most favoured technique in revision surgery of nonunions was the open posterior Magerl transarticular fusion technique, chosen by 38.6% of respondents. 18.2% preferred the posterior Harms C1/C2 fusion technique, 11.4% the percutaneous posterior Magerl technique and the anterior odontoid screw fixation in each case. This study discovered major variations in the treatment of Anderson Type II odontoid fractures in the elderly in terms of indication for conservative and operative treatment between several treatment centres in 3 European countries. Difficulty and complexity in formulating general guidelines based on multicenter studies is conceivable.

Management of long bone fractures and associated injuries from gunshots at a nigerian tertiary hospital

Globally, management of gunshot injuries (GSI) encompasses resuscitation, evaluation and treatment. Wound debridement is mandatory, while definitive treatment of any associated fracture varies from one part of the world to another. In developed countries aggressive modalities of early operative fixation of such fractures have produced good results. In the Nigerian environment, the approach to such fractures is controversial and cautious, with secondary operative and even non-operative methods still being predominant. To compare operative versus non-operative methods of treatment of long bone fractures and associated injuries from gunshots in our centre. This is a prospective study of long bone fractures and associated injuries from civilian gunshots presenting at Lagos University Teaching Hospital (LUTH), Lagos, Nigeria between 1st January 2000 and 31st December 2003. LUTH, one of the tertiary hospitals in Nigeria receives most of the multi-system trauma referrals in Lagos State, Nigeria. Three hundred and sixty patients with GSI were studied, 322 (89.4%) were males while 38 (10.6%) were females, giving a male: female ratio of 8.5:1. One hundred and thirty-six patients (37.8%) had long bone fractures, 94 (69.1%) on the lower limbs. All wounds were debrided and 198 (55.0%) had serial debridement. Eighty-two (60.3%) of 136 patients with fractures from G.S.I had operative treatment done secondarily and 87.5% of them achieved union. Also 42 (77.8%) of 54 patients treated non-operatively achieved union. Two hundred and thirty-four (65.0%) of the gunshot wounds healed by secondary intention, 81 (22.5%) had split thickness skin grafting and 18 (5.0%) had flap cover. This study showed that secondary operative treatment of long bone fractures in GSI produces good outcome.

THE NASAL DEFORMITY IN UNILATERAL CLEFT LIP Some Notes on Its Anatomic Bases and Secondary Operative Treatment

Plastic and Reconstructive Surgery and the Transplantation Bulletin: September 1961 - Volume 28 - Issue 3 - p 295-305