Femoral Fracture Surgery Research Articles

Incidence of nonunion after surgery of distal femoral fractures using contemporary fixation device: a meta-analysis.

Nonunion is the most frequent cause of reoperation and is associated with high morbidity after distal femur fracture (DFF). We examined the rates of nonunion requiring reoperation after fixation for DFF using a locking compression plate (LCP) or retrograde intramedullary nail (RIMN). We included four studies comparing LCP and RIMN and 38 single-cohort studies reporting LCP or RIMN. In total, 2156 femurs were included and 166 non-unions were detected. We conducted a pair-wise meta-analysis (with a fixed-effects model) on the four comparative studies and a proportional meta-analysis on the 38 articles to estimate the nonunion rate. We performed sensitivity analysis by comparing studies using LCP with less invasive surgical systems (LISS) with those that used RIMN. The pairwise meta-analysis showed a similar nonunion rate between the groups [odds ratio: 1.02; 95% confidence interval (CI) 0.94-1.11, p = 0.633]. According to proportional meta-analysis, the pooled prevalence of nonunion was 5% (95% CI 4-7) totally, 6% (95% CI 4-8) in the LCP group, and 4% (95% CI 2-6) in the RIMN group (heterogeneity: p = 0.105). According to the sensitivity analysis, there was no difference in the union rate. The pooled prevalence of nonunion from sensitivity analysis was 4 % (95% CI, 3-5); it was 4% (95% CI, 3-6) in LCP with LISS and was 4% (95% CI, 2-6) in RIMN group (heterogeneity: p = 0.941). Approximately 5% of patients who underwent LCP or RIMN fixation developed nonunion. Therefore, LCP and RIMN are effective DFF techniques and mastering one of them is essential.

Effect of Wound Closure Technique in Proximal Femoral Fractures: A Prospective Cohort Study.

To compare the effect of different wound closure techniques on wound drainage, postoperative length of stay, and complications in patients with proximal femoral fractures, including femoral neck fractures (31A fractures) and peritrochanteric fractures (31B fractures). Prospective cohort study. Footscray Hospital, Western Health, Victoria, Australia; an acute teaching hospital. All inpatients receiving surgery for proximal femoral fractures at our facility between May 2016 and August 2017. A total of 486 consecutive patients who presented during the study period were included in the study. Three cohorts of consecutive patients were assigned to use either skin staples, monofilament absorbable subcuticular sutures (Monocryl), or, sutures with the addition of 2-octylcyanoacrylate (OCA) (Monocryl and Dermabond), respectively, for skin closure according to when the patients entered the study. The primary outcome of interest was prolonged wound drainage measured using a standardized technique after postoperative day 3. Secondary outcomes included inpatient length of stay and overall complications. We found a statistically significant increase in prolonged wound drainage in the staples cohort compared with the subcuticular sutures cohort and the sutures and OCA cohort (21.1% vs. 8.5% vs. 4.4%, P < 0.001). Inpatient length of stay was also significantly increased in the staples cohort (5.83 days vs. 4.78 days vs. 5.5 days, P = 0.005). There were no statistically significant differences between the 3 cohorts when comparing incidence of any medical complications, withholding of thromboprophylactic agents, or usage of topical negative pressure dressings. In patients with proximal femoral fractures, closure with staples has the highest rate of prolonged wound drainage and length of stay. Subcuticular sutures in combination with OCA result in the lowest incidence of prolonged wound drainage. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Safety and efficacy of tranexamic acid with epinephrine for prevention of blood loss following surgery for trochanteric femoral fractures.

This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures. Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications. The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05). Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures. Level III, Therapeutic study.

Relationship between skin and urine colonization and surgical site infection in the proximal femur fracture: a prospective study.

Antibiotic prophylaxis is routinely used in the surgical management of proximal femur fractures. The role of bacterial colonization of the skin and urine in the development of deep surgical site infections (SSI) is yet to be elucidated. This study aimed to evaluate the role of previous skin and urine colonization in the development of deep SSI after a proximal femoral fracture surgery. We conducted a prospective observational study in 326 patients > 64years old, who were scheduled to surgery. Cultures from skin samples of the surgical site and from urine were performed prior to the procedure, and cefazoline was administered as prophylaxis. Skin microbiota was isolated in 233 (71.5%) cases; 8 (2.5%) samples were positive for other bacteria, and 85 (26%) were negative. Of 236 urine samples, 168 were negative or contaminated (71.2%), and 68 (28.8%) were positive, being 58/236 for Enterobacterales (24.6%). Acute deep SSI were diagnosed in nine out of 326 patients (2.7%), and two (22%) were infected by Gram-negative bacilli. Of the 9 cases, normal skin microbiota was isolated in 7 (78%), and the remaining twowere negative. Seven cases had negative or contaminated urine cultures, and the one with E. coli did not correlate with SSI bacteria. In our elderly hip fracture population, most patients harbored normal skin microbiota, and Enterobacterales urine cultures were positive in one-quarter of cases. There was no relationship between skin colonization, urine culture, and deep SSI. We therefore do not believe that our patients would benefit from modifying the current antibiotic prophylaxis.

Travel barriers, unemployment, and external fixation predict loss to follow-up after surgical management of lower extremity fractures in Dar es Salaam, Tanzania.

Objective:Predict loss to follow-up in prospective clinical investigations of lower extremity fracture surgery.Design:Secondary analysis of 2 prospective clinical trials.Setting:National public orthopaedic and neurologic trauma tertiary referral hospital in Dar es Salaam, Tanzania, a low-income country in sub-Saharan Africa.Patients/Participants:Three hundred twenty-nine femoral shaft and 240 open tibial shaft fracture patients prospectively enrolled in prospective controlled trials of surgical fracture management by external fixation, plating, or intramedullary nailing between June 2015 and March 2017.Intervention:Telephone contact for failure to attend scheduled 1-year clinic visit.Main Outcome Measurements:Ascertainment of primary trial outcome at 1-year from surgery; post-hoc telephone questionnaire for reasons patient did not attend the 1-year clinic visit.Results:One hundred twenty-seven femur fracture (39%) and 68 open tibia fracture (28%) patients did not attend the 1-year clinic visit. Telephone contact significantly improved ascertainment of the primary study outcome by 20% between 6-month and 1-year clinic visits to 82% and 92% respectively at study completion. Multivariable analysis associated unemployment (OR = 2.5 [1.7–3.9], P < .001), treatment with an external fixator (OR = 1.7 [1.0–2.8], P = .033), and each additional 20 km between residence and clinic (OR = 1.03 [1.00–1.06], P = .047] with clinic nonattendance. One hundred eight (55%) nonattending patients completed the telephone questionnaire, reporting travel distance to the hospital (49%), and travel costs to the hospital (46%) as the most prevalent reasons for nonattendance. Sixty-five percent of patients with open tibia fractures cited relocation after surgery as a contributing factor.Conclusions:Relocation during recovery, travel distance, travel cost, unemployment, and use of an external fixator are associated with loss to clinical follow-up in prospective investigations of femur and open tibia fracture surgery in this population. Telephone contact is an effective means to assess outcome.

Elixhauser comorbidity measures-based risk factors associated with 30-day mortality in elderly population after femur fracture surgery: a propensity scorematched retrospective case-control study.

Background:As the average life expectancy increases, anesthesiologists confront unique challenges in the perioperative care of elderly patients who have significant comorbidities. In this study, we evaluated Elixhauser comorbidity measures-based risk factors associated with 30-day mortality in patients aged 66 years and older who underwent femur fracture surgery. Methods:We used the Medical Information Mart for Intensive Care III which contains the medical records of patients admitted to the intensive care unit (ICU) at Beth Israel Deaconess Medical Center in the United States between 2001 and 2012 to identify patients admitted to the ICU after femur fracture surgery (n=209). Patients who died within 30 days of admission (case group, n=49) were propensity score-matched to patients who did not (control group, n=98). The variables for matching were age, sex, race, anemia (hemoglobin ≤10 g/dl), and malignancy. We attempted to explain mortality via nine independent factors: hypertension, uncomplicated diabetes, complicated diabetes, congestive heart failure (CHF), cardiac arrhythmias, chronic pulmonary disease, renal failure, neurological disorders other than paralysis, and peripheral vascular disease. Results:Logistic regression identified three significant risk factors: CHF, arrhythmias, and neurological disorders other than paralysis. The odds ratio (OR) for the 30-day mortality of CHF was 4.99 (95% confidence interval [CI], 2.18 to 12.06). The equivalent ORs for cardiac arrhythmias and neurological disorders other than paralysis were 2.61 (95% CI, 1.14 to 6.21) and 2.40 (95% CI, 0.95 to 6.48), respectively. Conclusions:Identifying patients with these risk factors (CHF, arrhythmias, and neurological disorders other than paralysis) will assist clinicians with perioperative planning and provide caregivers with valuable information for decision-making.

Mechanical and anatomical axis of the lower limb in total ankle arthroplasty

IntroductionInadequate correction of mechanical alignment may lead to failure of Total Ankle Replacements (TAR). The mechanical axis of the lower limb (MAL), the mechanical axis of the tibia (MAT) and the anatomical axis of the tibia (AAT) are three well described coronal plane measurements using plain radiography. The assumption is that the MAL, MAT and AAT are equivalent. The relationship between these axes can vary in the presence of proximal deformity. The purpose of this study was to assess the relationship between MAL, MAT and AAT in a cohort of patients considered for TAR. Methods75 consecutive standardised preoperative long leg radiographs of patients with end stage ankle osteoarthritis, between 2016 and 2017 at a specialist tertiary center for elective orthopedic surgery were analysed. Patients were split into 2 groups. The first group had a clinically and radiologically detectable deformity proximal to the ankle (such as previous tibial or femoral fracture, severe arthritis, or previous reconstructive surgery), whereas the second (normal) group did not. The MAL, MAT and AAT were measured and the difference between these values were calculated. ResultsThere were 54 patients in the normal group, and 21 patients in the deformity group. The mean difference between the MAL and AAT was 1.7 ± 1.3° (range, 0.1–5.4°). In the normal group, 15 patients (27%) had a difference of >2° between the MAL and AAT, compared with 52% in the deformity group. The mean difference between the MAL and MAT was 0.9 ± 1.7° (range, −4 to −3.5°). In the deformity group, 42% of patients had a difference between MAT and MAL of >2°, compared with 20% in the normal group. ConclusionMAT, MAL and AAT should not be assumed to be the same in all patients. The authors recommend considering the use of full-length weightbearing lower limb radiographs to plan TAR.

TO COMPARE THE EFFICACY OF FEMORAL NERVE BLOCK vs IV FENTANYL FOR POSITIONING OF SUBARACHNOID BLOCK DURING FEMUR FRACTURE SURGERY.

Introduction: Most dreaded fear associated with any fracture is pain which has got wide psychological, behavioral, and clinical ramifications. Aims and Objectives: To compare the efficacy of femoral nerve block with iv fentanyl for positioning of patient during subarachnoid block in femur fracture surgery in terms of time of onset of analgesia (VAS score upto 4), pain score during positioning and quality of patient’s position. Material and Methods: The patients in FNB GROUP (n=35) were given femoral nerve block with nerve stimulator by injecting 30 ml of levobupivacaine (a mixture of 20 ml of 0.5% levobupivacaine and 10 ml of normal saline).In FENT GROUP (n=35),IV fentanyl 1 ug/kg five-minute prior to positioning was given,escalating the dose to 3 µg/kg maximum until pain score decreased to ≤4. Results: The results showed that the heart rate, SpO2, blood pressure and respiratory rate were maintained and comparable in both the groups. Time of onset of analgesia and pain scores during positioning were less in FNB group. Time of onset of analgesia VAS 4 was achieved at 15 min in group FNB(4.29±0.57) and at 20 min in group FENT(4.69±0.58).The pain scores achieved during positioning was 1.54±0.50 in group FNB and in group FENT it was 3.77±0.59. Quality of patient’s position was better in FNB group.

Combined lumbar plexus-sciatic nerve block in the emergency surgery for pertrochanteric fracture: an alternative technique in patients at high risk of anaesthetic complications

Introductionl’anesthésie pour la chirurgie urgente de la fracture pertrochantérienne (FPT) chez les patients à haut risque anesthésique représente souvent un véritable challenge pour les praticiens en vue du risque periopératoire majeur. Nous rapportons notre expérience avec le bibloc ou bloc combiné lombaire et sciatique plexique (BCLS) comme technique anesthésique alternative face à ce type de situation.Méthodesune étude transversale, descriptive, monocentrique, a été menée sur une période de 3 ans, incluant les patients à haut risque anesthésique présentant une FPT récente. Les deux blocs nerveux étaient réalisés au niveau plexique selon la technique classique de neurostimulation. Un mélange de 20ml de lidocaine 2% et de bupivacaine 0,5% (50/50) a été injecté au niveau de chaque bloc. Le critère d’évaluation principal était l’efficacité du BCLS apprécié par l’incidence d’échecs de la technique anesthésique, définie par la nécessité de convertir en anesthésie générale (AG). Les critères d’évaluation secondaires étaient: 1) les données techniques de la procédure anesthésique, 2) les retentissements hémodynamiques, respiratoires et neurologiques periopératoires, et 3) les résultats et les complications éventuelles en postopératoire.Résultatstrente patients ont été colligés. L’âge moyen était de 74 ± 10 ans. Le délai moyen d’admission aux urgences-intervention était de 12(5-36) heures. La durée moyenne pour la réalisation de la procédure était de 15,20 ± 3,45 minutes. Aucune conversion en AG n’a été nécessaire. Il n’y avait pas de différences statistiquement significatives entre les différentes valeurs enregistrées des paramètres hémodynamiques et respiratoires periopératoires (PAM, FC, SpO2) (p > 0,05). La durée de l’intervention était de 46 ± 5 minutes. La satisfaction des chirurgiens était de 9,7 ± 0,1. La première demande en antalgiques postopératoires était après 8(1-24) heures. Tous les patients avaient une récupération sensitivomotrice complète.Conclusionle BCLS est une alternative anesthésique pour les interventions urgentes de FPT chez les patients à haut risque anesthésique: délais opératoires réduits, efficacité anesthésique, stabilité hémodynamique et respiratoire periopératoire, absence de complications inhérentes aux autres techniques anesthésiques, passage rapide en salle de surveillance post-interventionnelle (SSPI), et analgésie postopératoire de qualité.

Comparative evaluation between fascia iliaca compartment block and intravenous fentanyl administration for painless positioning during spinal Anaesthesia in fracture femur surgeries: A randomized controlled study

Background: Pain poses a unique challenge to anaesthesiologist. Femur fracture is one such condition where patient experiences spikes of excruciating pain whenever patient is subjected to move or position for delivering central neuraxial anaesthesia which further increases stress response and results in poly-pharmacy to tackle its consequences. This study is designed to compare the efficacy of ultrasound guided Fascia Iliaca Compartment Block with bupivacaine over intravenous fentanyl for positioning during spinal anaesthesia in femur fracture cases Methodology: A single blinded, randomised study was carried out with 60 patients of ASA grade I and II aged between 18 to 70 years undergoing Femur fracture surgeries under spinal anaesthesia, patients are randomly allocated into two groups Group FICB: will be given ultrasound guided Fascia Iliaca Compartment Block preoperatively with 30ml of 0.25% bupivacaine, the block will be done 15 minutes before the sub arachnoid block. Group FENT: will be administered intravenous fentanyl preoperatively according to their calculated body weight as 2mcg/kg body weight I.V. Results: The VAS scores (P

Impact of Antiplatelet Therapies on Patients Outcome in Osteosynthetic Surgery of Proximal Femoral Fractures.

Background: Proximal femoral fractures should be treated in a timely manner. Affected patients often require antiplatelet therapy (APT) due to cardiovascular diseases. Guidelines recommend 5-7 days APT interruption for elective surgery. Early osteosynthetic surgery of proximal femoral fractures despite of APT should be considered. Aim of the study: To evaluate whether early osteosynthetic surgery despite of APT is associated with increased blood loss, complications and mortality. Methods: Data of patients with proximal femoral fractures, who were treated by osteosynthesis at the Department of Trauma Surgery at the Medical University of Vienna were collected retrospectively. Study groups were formed by time to surgery and APT interruption. The primary endpoint of the study was the perioperative blood loss. Secondary endpoints were complications, 30-day and 1-year mortality, time to surgery, and the total length of hospital stay. Results: The osteosynthetic treatment of proximal femoral fractures despite of APT resulted in a shorter time to surgery (13.8 vs. 66.0 h; p < 0.01). In patients on APT, the TBL (total perioperative blood loss) was higher without need for revision or an increase in the need for packed red blood cells if surgery was performed within 24 h after admission. APT had no significant influence on mortality. Patients who underwent surgery within 24 h after admission had a lower mortality. The complication rate was higher in patients who underwent surgery later than 24 h after admission. Conclusions: Surgery within 24 h after admission, regardless of APT, resulted in a shorter hospitalization length and was associated with less common complications and a lower mortality.

Perioperative complications and mortality in elderly patients following surgery for femoral fracture: prospective observational study

Background and objectivesPerioperative management of femoral fractures in elderly patients has been studied to determine modifiable causes of complications and death. The aim of this study was to evaluate the mortality rate and its causes in the elderly population with FF. We also evaluated perioperative complications and their association with postoperative mortality. MethodIn this prospective and observational study, we evaluated 182 patients, by questionnaire and electronic medical record, from the moment of hospitalization to one year after surgery. Statistical analyzes using the multivariate Cox proportional hazards model and Kaplan-Meier curves were performed to detect independent mortality factors. ResultsFifty-six patients (30.8%) died within one year after surgery, and the main cause of death was infection followed by septic shock. The main complication, both preoperatively and postoperatively, was hydroelectrolytic disorder. For every one-unit (one-year) increase in age, the odds ratio for death increased by 4%. With each new preoperative complication, the odds ratio for death increased by 28%. Patients ASA III or IV had a 95% higher odds ratio for death than patients ASA I or II. ConclusionsIncreasing age and number of preoperative complications, in addition to ASA classification III or IV, were independent factors of increased risk of death in the population studied. The mortality rate was 30.8%, and infection followed by septic shock was the leading cause of death.

Robotic knee replacement surgery- lets challenge a challenging case - A case report

Introduction: Robotic surgery is one of the recent advance in total knee replacement. It aims for accuracy and precision in execution of surgery. This case report shows a patient with osteoarthritis knee with old implants around knee managed with robotic assisted knee surgery to achieve best possible outcome without removal of previous implant. Case Report: We present a case of 70 years old male patient with history of right knee pain, severe deformity and past history of surgery for right femur and tibia fracture 30 years back with previous implants in situ. After investigation and pre-operative planning we did single stage knee replacement surgery using robotic assistance, all deformities corrected and achieved well balanced knee without removal of previous implant and just using primary knee replacement prosthesis. Conclusion: Robotic knee replacement surgery definitely makes surgeons task easy and more précised not only to address difficult cases but also allows to manage severe deformities without using revision implants. Keywords: Robotic knee replacement, Osteoarthritis, Total knee replacement, Deformity correction, Implant around knee.

Quadricepsplasty: A modality for stiff knee

Stiffness of the knee after trauma and/or surgery for femoral fractures is one of the most common complications and is difficult to treat. Stiffness in extension is more common and can be reduced by vigorous physiotherapy. If it does not improve by physiotherapy, then Quadricepsplasty is indicated. Quadricepsplasty is the surgical procedure required to release the quadriceps muscle in order to improve the range of knee flexion. This procedure is indicated mainly for stiffness of the knee in extension. Thompson and Judet type of Quadricepsplasty are the most common surgical procedures described to treat knee stiffness, the former being more popular. We evaluated our results after Thompson’s Quadricepsplasty and physiotherapy. The patient regained satisfactory functional range of motion after Thompson’s Quadricepsplasty.

Trochanteric entry VS piriformis entry in case of antegrade nailing of femoral shaft fracture treatment: A prospective randomised comparative study

Background: Intramedullary nailing is the best modality for femoral shaft fractures as it is biological fixation with good apposition with minimal tissue damage and fxation is bio mechanically superior to plates and fixators with immediate rehabilitation and fewer complications. The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. Since the study by Ricci et al, there have been a number of randomized, controlled trials (RCTs) and cohort studies comparing the efficacy of the 2 entry points on various patient-and procedure-related outcomes. As per our knowledge, there has been very less systematic review of the literature on optimal entry point during antegrade nailing of femoral shaft fracture. Aims and ObjectivesAims: To compare the operative and fluoroscopic time required for IM nail fixation, time taken for taking entry, the amount of blood loss, and other complication in the form of iatrogenic neck femur fracture in surgery of femoral shaft fractures using the GT (greater trochanter) versus PF (Pyriformis fossa) entry point. A secondary objective was to determine whether there were any differences in complications (delayed and non union), fracture alignment and healing and functional outcomes in the form of thorensen score, and HHS (harris hip score) between the 2 entry points. Materials and Methods: The present pilot project was conducted in a time span of 2 year and 4 months. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 30 (n = 30).

Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment.

Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients. Retrospective cohort study. Level-1 trauma center. Individuals 65 years of age and older with fragility hip fractures. Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered. Postoperative SSIs. Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ. Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utility of Pulmonary Echography for Evaluation of Patients Undergoing Orthopedic Surgery for Femur Fracture

Utility of Pulmonary Echography for Evaluation of Patients Undergoing Orthopedic Surgery for Femur Fracture

Effect of Dexmedetomidine on Levobupivacaine and Ropivacaine in Fascia Iliaca Block for Trochanteric Fractures Treated by Proximal Femoral Nail - A Randomized Trial.

Background: Fascia iliaca block (FIB) is an established procedure for postoperative pain relief in femur fracture surgeries. Dexmedetomidine was found to be a useful additive to local anesthetics (LA) for peripheral nerve blocks resulting in a prolonged anesthetic effect. We evaluated the impact of the addition of dexmedetomidine to an equal concentration of levobupivacaine and ropivacaine for FIB. Methods: The present study is a double-blind, randomized trial conducted on 60 patients in the age group 18-70 years. The patients were divided into two groups: Group LD received 30 ml of an LA solution (29.5 ml 0.25% levobupivacaine and 0.5 ml dexmedetomidine 50 µg), and group RD received 30 ml of another LA solution (29.5 ml 0.25% ropivacaine and 0.5 ml dexmedetomidine 50 µg). The outcomes observed were the duration of analgesia (DOA) and total analgesic requirement (TAR).Results: The DOA was found to be slightly longer in group LD (955.3 ± 114.5 minutes) than in group RD patients (894.6 ± 91.3) with p = 0.027. The TAR was found to be statistically different though clinically irrelevant (group LD: 112 mg; IQR: 105-122 vs. Group RD: 115 mg; IQR: 104-118, p = 0.034, where IQR stands for interquartile range). There were no signs of neurotoxicity in any of the participating patients.Conclusion: Addition of 50 µg dexmedetomidine to 0.25% levobupivacaine extends DOA slightly as compared to when dexmedetomidine is added to 0.25% ropivacaine. However, TAR remains clinically the same for both cases in fascia iliaca block.

Prediction of early postoperative desaturation in extreme older patients after spinal anesthesia for femur fracture surgery: a retrospective analysis.

BackgroundPostoperative desaturation in older individuals is rarely addressed in the literature. The objective of this retrospective study was to investigate whether a preoperative spirometric test and arterial blood gas analysis (ABGA) might predict postoperative desaturation after spinal anesthesia in extreme older patients.MethodsThe medical records of 399 patients (age ≥ 80 yrs) who were administered spinal anesthesia for a femur neck fracture surgery were retrospectively reviewed. Early postoperative desaturation was defined as a reduction of oxygen saturation (SpO2) below 90% within 3 days of surgery, despite O2 supply via a nasal prong. Binary logistic regression analysis was used to identify predictors of early postoperative desaturation.ResultsThe incidence of postoperative desaturation was 12.5%. Major morbidity rate was significantly higher in the desaturation group (n = 50) than that in the non-desaturation group (n = 349) (14% vs. 3.2%, P = 0.001) with more frequent postoperative stays in the intensive care unit (22% vs. 12%, P = 0.004). In a binary logistic regression analysis, preoperative ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) (OR, 0.972; 95% CI 0.952–0.993; P = 0.010) and history of cardiovascular disease (OR, 2.127; 95% CI 1.004–4.507; P = 0.049) predicted postoperative desaturation.ConclusionsPreoperative PaO2/FiO2 ratio, but not preoperative spirometry, was predictive of the postoperative desaturation in older patients after being administered spinal anesthesia for femur fracture surgery. Based on our results, preoperative ABGA may be helpful in predicting early postoperative desaturation in these patients.

Healing physiology following delayed surgery for femoral midshaft fracture caused by high-energy injury: an in vivo study in dogs.

ObjectiveAn experimental model of severe soft tissue damage was designed to simulate high-energy fracture and observe the fracture healing process following early surgery and surgery delayed by 1 week.MethodsForty dogs were randomized to Group A (immediate surgery) and B (delayed surgery). The femur was broken, and the two ends were forcefully stabbed to damage the surrounding soft tissues. The fracture was repaired using a custom six-hole steel plate. Four dogs were killed on day 3 and weeks 1, 2, 4, and 8 following bone fracture. Soft tissue and bone were examined by light and electron microscopy.ResultsIn Group A, no callus was present at 1, 2, 4, and 8 weeks following fracture, resulting in atrophic nonunion. In Group B, visible weak external callus was present 1 week following fracture, and good external callus growth was present at 2, 4, and 8 weeks, leading to callus healing.ConclusionThese findings suggest that the first week is critical for fracture healing. Absence of callus in the early stage is indicative of absence of callus growth throughout the entire healing process, while the presence of callus in the early stage is indicative of vigorous callus growth thereafter.