Time to surgical management of distal radius fractures: effects on health care utilization and functional outcomes.

BACKGROUND: Distal radius fractures are common injuries. Open reduction and internal fixation with volar locking plates is the most common approach for surgical fixation. This study investigated the association between time to surgery and health care utilization, income, and functional outcomes among patients undergoing open reduction and internal fixation for distal radius fracture. METHODS: We conducted a retrospective review of patients who underwent open reduction and internal fixation for isolated acute distal radius fracture between 2009 and 2019. Time to surgery was grouped as early (≤ 14 d) and delayed (> 14 d). We performed χ2 (or Fisher exact) and Wilcoxon rank sum (or Kruskal-Wallis) tests to provide statistical comparison of time to surgery by health care utilization and functional outcomes. Univariable and multivariable logistic regression analyses were performed to identify factors significantly associated with time to surgery. We included all significant univariables in the multivariable logistic regression model, which identified factors based on significant adjusted odds ratios (95% confidence intervals excluding the null) after we adjusted for confounding variables. RESULTS: We included 106 patients, with 36 (34.0%) in the group receiving early treatment and 70 (66.0%) in the group receiving delayed treatment. Patients in the delayed-treatment group attended significantly more clinic visits and postoperative hand therapy sessions. The group with delayed treatment demonstrated significantly lower degrees of wrist flexion at the first follow-up, but this difference did not persist. Patients with higher estimated income (> $39 405 per annum) had lower odds of delayed surgery than those with lower estimated income (≤ $39 405). CONCLUSION: Delayed time to surgery was associated with greater health care utilization and lower degrees of early wrist flexion. Access to care for lower-income patients warrants further evaluation.

Fixation or Revision for Periprosthetic Fractures: Epidemiology, New Trends, and Projections in the United States.

BACKGROUND: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States. METHODS: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons. RESULTS: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures. CONCLUSIONS: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures.

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

Complications After Ankle Fracture Surgery in Finland Between 1998 and 2020.

BACKGROUND: Ankle fracture is a common injury and often requires operative treatment. This study investigated short-term (≤4 months) and long-term (>4 months) complications after ankle fracture surgery in a 23-year period with use of data from a comprehensive, nationwide, individual-level register. METHODS: Data regarding patients who underwent operative treatment for ankle fracture were collected from the Finnish Care Register for Health Care and analyzed with use of logistic and Cox regression. RESULTS: A total of 83,666 ankle fractures were operatively treated between 1998 and 2020. Of these, 36% were lateral malleolar fractures, 7% were medial malleolar fractures, 52% were bimalleolar or trimalleolar fractures, and 5% were other types of fractures. Fifty-one percent of the fractures were in female patients. The overall rate of short-term complications was 7.2%. Specifically, infection occurred in 4.4% of cases; thromboembolic complications,1.6% of cases; mechanical complications, 0.4% of cases; and other complications, 0.9% of cases. An age of >75 years was associated with a higher rate of short-term complications than an age of 51 to 75 years, with an odds ratio of 1.53 in the multivariable analysis (95% confidence interval, 1.39 to 1.67; p < 0.001). Short-term complications were also more prevalent in patients with diabetes (with or without associated complications); chronic pulmonary, kidney, or liver disease; or peripheral vascular disease. Mortality during the first 4 months after the ankle fracture operation was 0.6%. The most common reason for reoperation in the long term (>4 months after the index procedure) was fixation device removal, with a cumulative incidence of 17% within the first 3 years postoperatively. The risk of implant removal increased in younger patients and patients with bimalleolar or trimalleolar fractures. The cumulative incidence of ankle arthrodesis and arthroplasty was low. CONCLUSIONS: Although postoperative complications are relatively rare, their treatment can lead to considerable morbidity. The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Mechanical Analysis and Clinical Application of Butterfly-Shaped Patellar Claw.

Memory alloy patella claws for treating patella fractures have been used for more than 30 years with many desirable features including fast healing, quick recovery, and avoidance of top abrasion of Kirschner wires and other complications. However, there are many models and it is difficult to choose the accurate claw for the patient. In this study, a finite element model of the butterfly-shaped patellar claw made of shape memory alloy was established, its mechanical structure was analyzed, and its clinical application was monitored. We used Solidworks Simulation software for modeling and mainly analyzed the force of the compression ring of the butterfly-shaped patellar claw. Clinically, we chose a closed fresh patella fracture case. After finite element analysis, the maximum stress that the compression ring of the butterfly-shaped patellar claw can withstand is 568.1 MPa. In this range, it always has elastic deformation resistance. The butterfly-shaped patella claw is fixed on the patella and will not break when subjected to a maximum force of 150 N on the encircling arm, and at the same time, there will be no pressure failure due to plastic deformation. A total of 27 cases were clinically used for the assessment of the clinical efficacy of the newly designed butterfly-shaped patella claws. The average follow-up time was 15.5 months, and the average fracture healing time was 8-12 weeks. All patients can get out of bed with crutches within 2 to 3 days after surgery. Among them, there were 15 cases with excellent functional ratings, 10 cases with good ratings, 2 cases with acceptable ratings, and no cases with poor ratings. The designed butterfly-shaped patella claws can provide an effective method for the treatment of patella fractures.

Fracture Prevention Clinic Targeting Patients with Fragility Fracture of the Distal Radius: A Pilot Study.

BACKGROUND: Identifying and treating patients with fragility fractures may be effective in prevention of subsequent fractures because a first fragility fracture often predicts a second fracture. OBJECTIVES: To evaluate a multidisciplinary anti-osteoporotic clinic for patients with prior distal radius fragility fractures (DRFF). To assess whether addressing this early fracture may prevent a second fracture. METHODS: A retrospective case-control study was performed. Cases included patients treated surgically for DRFF who were assessed at a tertiary, multidisciplinary, fracture-prevention clinic. Controls were a series of similarly treated patients who did not attend the clinic. The primary outcome measure was a second fracture. RESULTS: Average follow-up was 42 months for the treated group and 85 months for the untreated group. The treated group received more treatment for osteoporosis than controls; however, despite one new fracture in the treated group and six new fractures in the control group, there was no significant difference in fracture occurrence. CONCLUSIONS: This pilot study supports the effectiveness of our multidisciplinary anti-osteoporotic clinic in treating osteoporosis but not in reducing subsequent fractures. Further study with larger cohorts and longer follow-up is needed to improve our ability to implement effective prevention of fragility fractures.

Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture.

BACKGROUND: Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture. METHODS: This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups. RESULTS: Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5). CONCLUSION: The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.

[Retrospective study of 50 cases of tibial pilon fractures in adults at the Department of Orthopedics of the University Hospital Center Habib Bourguiba, Sfax, Tunisia]. / Etude rétrospective de 50 cas de fractures du pilon tibial chez l'adulte dans le Département d'Orthopédie, Centre Hospitalier Universitaire Habib Bourguiba de Sfax, Tunisie.

Tibial pilon fractures are polymorphic fractures posing therapeutic and prognostic challenges. The purpose of this study is to examine the epidemiological profile of these fractures and to assess our findings from an anatomical and functional point of view. We collected data fom 50 medical records of patients treated for tibial pilon fractures and monitored over the period 2004-2013 at the Orthopedic-Trauma Department of the Habib Bourguiba University Hospital in Sfax. Functional outcomes were assessed using the Ankle-Hindfoot score. Radiological findings were used to determine fracture healing. Treatment was based on internal osteosynthesis in 30 cases, external fixation in 11 cases and on a combination of both techniques in 9 cases. At the end of this study, functional outcomes were good and very good in 36 cases. Thirty cases of fracture healing were reported, with 18 cases of vicious callus and two cases of pseudosteoarthritis. Therapeutic management of tibial pilon fractures is difficult in some cases. Solid osteosynthesis with anatomical reduction is the only therapeutic option to secure a satisfactory functional outcome.

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach.

ABSTRACT: To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ±â€Š3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ±â€Š3.92°, a mean PA of 7.43 ±â€Š2.68°, and a mean Rasmussen radiological score of 16.00 ±â€Š2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ±â€Š3.51°, a mean PA of 9.68 ±â€Š4.01°, and a mean Rasmussen radiological score of 15.33 ±â€Š2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ±â€Š10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ±â€Š10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment.

BACKGROUND: Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures. METHODS: Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded. RESULTS: Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases. CONCLUSION: For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Bone healing of distal radius nonunion treated with bridge plating with bone graft substitutes in combination with systemic romosozumab administration: A case report.

Romosozumab is a humanized, anti-sclerostin monoclonal antibody used to treat osteoporosis, which increases bone formation and decreases bone resorption. It enhances fracture healing and systemic romosozumab administration may have therapeutic potentials for accelerating bone healing of even nonunion. Herein, a 61-year-old heavy smoker male with distal radius nonunion who achieved successful bone union by combination therapy of romosozumab and spanning distraction plate fixation with bone graft substitutes was presented. Through the dorsal approach, atrophic comminuted nonunion of the distal radius was sufficiently debrided. Reduction of the distal radius was performed using indirect ligamentotaxis, and a 14-hole locking plate was fixed from the third metacarpal to the radial shaft. A beta (ß) tricalcium phosphate block was mainly packed into the substantial metaphyseal bone defect with additional bone graft from the resected ulnar head. Postoperatively, systemic administration of monthly romosozumab was continued for six months. Complete bone union was achieved 20 weeks postoperatively and the plate was, then, removed. Wrist extension and flexion improved to 75o and 55o, respectively, without pain, and grip strength increased 52 weeks postoperatively from 5.5 kg to 22.4 kg. During romosozumab treatment, bone formation marker levels increased rapidly and finally returned to baseline, and bone resorption marker levels remained low. In conclusion, combination of systemic romosozumab administration and grafting ß-tricalcium phosphate with bridge plating provides an effective treatment option for difficult cases of comminuted distal radius nonunion with risk factors such as smoking, diabetes, and fragility.

What Are the Tradeoffs in Outcomes after Casting Versus Surgery for Closed Extraarticular Distal Radius Fractures in Older Patients? A Statistical Learning Model.

BACKGROUND: Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown. QUESTIONS/PURPOSES: (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting? METHOD: This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score). RESULTS: Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment. CONCLUSION: There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Predictors of wound leakage in patients undergoing surgery for neck of femur fractures.

AIMS: Persistent wound leakage following joint arthroplasty is a known risk for periprosthetic joint infection. Little is known of the predictors of wound leakage, particularly in patients with a fractured neck of femur. We aimed to determine patient and surgical risk factors for wound leakage in this cohort. MATERIALS AND METHODS: All patients undergoing surgery for a fractured neck of femur at Leicester Royal Infirmary between May and August 2017 were included. Patients were identified from a prospective database and placed into two groups: those with wound leakage later than three days postoperatively and those without leakage. All previously reported potential risk factors for wound leakage were compared between groups using a chi-square test and logistic regression. A Kattan-style nomogram was also created to allow probabilities output for the regression predictive models in a visual representation. RESULTS: Two hundred patients underwent surgery for a fractured neck of femur. Overall, 17% of patients (33/200) developed a persistent leaky wound. A multivariable model highlighted increased age (p = 0.01), raised body mass index (BMI; > 25 kg/m2; p = 0.047), diabetes (p = 0.03) and intramedullary hip screw fixation (p = 0.03) as significant risk factors for wound leakage. Patients with persistent wound leakage had significantly longer hospital admission than those without (p = 0.001). DISCUSSION: Our analysis identified four perioperative risk factors for wound leakage following fractured neck of femur surgery. We also developed a novel tool to identify those patients at highest risk of leakage. Once identified, the aggressive management of certain medical comorbidities in these patients may help to reduce their incidence of wound issues and the prolonged admissions that result.

Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective.

BACKGROUND: Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature. MATERIALS AND METHODS: A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed. RESULTS: Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables. CONCLUSION: Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.

Comparison of two different proximal femoral nails in instabil intertrochanteric fractures concerning radiological parameters.

BACKGROUND: The aim of this study was to compare two different nail types (i.e., Intertan (IT) and Talon Distal Fix Nail / Lag Screw (TDFN)) used in the treatment of unstable intertrochanteric fractures in mobile patients over 65 years of age in terms of radiological parameters. METHODS: Between June 2013 and August 2018, 106 patients over 65 years old who were operated with closed reduction and internal fixation for intertrochanteric fractures were included in this single-center study. Patients were divided into two groups based on the proximal femoral nail used: IT group and TDFN group. These two groups were compared in terms of age, sex, complication rates and radiological parameters (i.e., reduction quality, tip apex distance (TAD), Parker index, union time, cut-out rate, and varus collapse). RESULTS: There were no differences between the groups in terms of age, sex, fracture union time as well as reduction quality measured on the first postoperative radiograph, Parker index, and collodiaphysial angle. In the first postoperative radiographs, TAD was higher than 25 mm in 12 patients in the IT group and in 5 patients in the TDFN group. Although the number of patients with high TAD was more than that of the IT group, varus collapse and the cut-out complications were higher in TDFN nail. In the IT group, nail-dependent complications emerged in 4 patients (trochanter major fracture in 3 cases, femoral fracture in distal screw in 1 case) while there was no complication in the TDFN group. CONCLUSION: Intertan nail is superior to TDFN in preventing varus collapse and the cut-out complications as well as in maintaining of radiological parameters until fracture union. On the other hand, the higher complication rate is a disadvantage of this nail.

Comparison of treatment results between surgical and conservative treatment of distal radius fractures in adults: A meta-analysis of randomized controlled trials.

OBJECTIVE: This meta-analysis study aims to determine the efficacy and safety of surgical and conservative treatments for distal radius fractures (DRFs) in adults. METHODS: Reports of randomized controlled trials were retrieved from the Web of Science, Pubmed, Google Scholar, EMBASE, Cochrane Library, Medline, Ovid, and BIOSIS for studies that met the eligibility criteria. The search was limited to human subjects and had no language limits. The search strategy was check by two independent reviewers. If there was any dispute, a third reviewer was consulted. Primary outcomes were: (1) the active wrist range of motion including flexion, extension, pronation, supination, radial, and ulnar deviation; (2) the Disabilities of the Arm, Shoulder, and Hand (DASH) score; and (3) radiological outcomes including radial inclination and ulnar variance. Secondary outcomes were the number of complications including non-infectious and infectious. Quality assessment was performed using the Cochrane Risk of Bias Tool provided by the Cochrane Review Manager 5.3. RESULTS: A total of 10 randomized controlled trials were included. The meta-analysis detected no statistically significant difference in pooled data for complications not included infection (MD 0.64, CI: 0.33 to 1.23, Z=1.34, p=0.18). Surgical treatment achieved a better range of motion (MD 3.76, CI: 1.58 to 5.95, Z=3.37, p=0.0007), DASH score (MD -6.57, CI: -9.08 to -4.06, Z=5.12, p<0.00001), and radiographic outcomes (MD 3.75, CI: 2.75 to 4.74, Z=7.37, p<0.00001) compared with conservative treatment. In contrast, the conservative treatment achieved less infection rate compared with surgical treatment (MD 4.09, CI: 1.18 to 14.21, Z=2.21, p=0.03). CONCLUSION: Findings of this study reveal that when compared with conservative treatment, surgical treatment can ensure better clinical and radiological results for the treatment of DRFs in adults. Although similar complication rates can be encountered with both treatment modalities, it should be taken into account that the rate of infection may be higher in surgical treatment. LEVEL OF EVIDENCE: Level I, Therapeutic Study.

Treatment and outcomes of basicervical femoral neck fractures: A systematic review.

PURPOSE: This study aims to systematically review the literature comparing surgical treatments options and respective failure rates for basicervical hip fractures. METHODS: A comprehensive search of databases, including MEDLINE, Embase, Web of Science, and Cochrane Central for studies published in English on or before June 21, 2019 was performed. Selected search terms included "basicervical," "basi cervical," "AO/OTA type 31-B," "femoral neck fracture" AND "bone nails," "bone screws," "fracture fixation," "internal fixation," "arthroplasty," "cephalomedullary," "sliding hip screw," "ORIF," and "treatment outcome." We included studies that assessed outcomes of basicervical fracture fixation using open reduction internal fixation or arthroplasty. Two authors extracted the following data from each paper: study design, country, cohort year, definition of basicervical, intervention type, sample size, patient demographics, follow-up length, percent of fractures that required revision, and the percent of implants that failed. RESULTS: Sixteen articles encompassing 910 patients were included. The main outcome was the percent of implants that required revision. The total revision rates were 8% (8 studies, 157 patients, range 0%-55%) for cephalomedullary nails, 7% (10 studies, 584 patients, range 0%-18%) for sliding hip screws, 23% (3 studies, 40 patients, range 16%-50%) for cannulated screws, 0% (1 study, 6 patients) for total hip arthroplasty, and 8% (2 studies, 13 patients, range 0%-11%) for hemiarthroplasty. CONCLUSION: Management of basicervical fractures with SHS and CMN produces similar failure and re-operation rates. Limited evidence is available on the use of cannulated screws and arthroplasty, but available studies suggest that cannulated screws have an unacceptable revision rate (23%) while arthroplasty may be acceptable. Future studies examining the comparative efficacy of various fixation methods would benefit from strict definition of fracture type as well as consistent reporting of functional outcomes, re-operation rates, and mortality.

Dynamic Hip Screw Fixation Vs. Proximal Femur Nail For Unstable Per-Trochanteric Fractures: A Comparative Analysis Of Outcomes And Complications.

BACKGROUND: There are various implant choices to fix unstable per- trochanteric fractures. The aim of this study was to compare the outcomes of dynamic hip screw and proximal femur nail for unstable per-trochanteric fractures including complications associated with both fixations. METHODS: A retrospective analysis done on pertrochanteric fractures of femur who were treated with Dynamic hip Screw (DHS) and Proximal Femur Nail (PFN). The data was taken from our hospital hip data base for the past two years from January 2017 to January 2019. Data of 174 patients was analysed, divided in to Group A with DHS (n=122) and Group B with PFN (n=52). Follow up included X-ray (anteroposterior and lateral) views for fracture union and collapse, femur neck shortening, implant position and identification of mode of failure or collapse (cut out risk) by using tip-apex distance. The Harris hip score used to evaluate mobility status and other functional outcomes. RESULTS: The mean age in years of patients treated with PFN and DHS were 55.9 and 59.8, ranging from 39-83 years. The mean of Harris hip score at 2 year was 69.28±9.99 in DHS group and 72.12±9.71 in PFN group with the p-value 0.31. The mean of limb shortening was 12mm in DHS and 9 mm in PFN group. In DHS group, four cases had tip-apex distance of 39 mm and reported implant cut out that needs revision of surgery. CONCLUSIONS: Proximal Femur Nail group demonstrated no implant cut out and less mean limb length shortening where as other parameter like functional outcomes, fracture union, rate of infection, hospital stay and postoperative pain are not significantly different in two groups.

Comparison of clinical outcomes with hip replacement versus PFNA in the treatment of intertrochanteric fractures in the elderly: A systematic review and meta-analysis (PRISMA).

BACKGROUND: The purpose of this meta-analysis was to evaluate the clinical efficacy and safety of HR and PFNA in the treatment of intertrochanteric fractures in the elderly. METHODS: We carried out this review according to the principle of preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline. The clinical randomized controlled trials (RCTs), prospective cohort studies, retrospective cohort studies (RCSs), and case-control studies involving HR and PFNA in the treatment of intertrochanteric fractures in the elderly from 2000 to 2020 were compared by searching Web of Science, Pubmed, the Cochrane Library, and Embase. The quality of the included cohort study (CS) lines was evaluated using the Newcastle-Ottawa Scale (NOS). The quality of the included RCT lines was evaluated using Jadad. Forest plots were drawn by RevMan5.4 software based on the results and the data were analyzed. RESULTS: After screening, a total of 9 articles were included, of which one was a clinical RCT and eight were RCSs with 1374 patients. The operative time of the PFNA group was shorter [WMD = 15.20; 95% CI (13.17, 17.23), P < .05] and the intraoperative blood loss was less [WMD = 178.81; 95% CI (97.24, 260.38), P < .05] than the HR group, while the first weight-bearing time of the HR group was shorter [WMD = -7.70; 95% CI (-10.54, -4.86), P  < .05] than the PFNA group. There was no significant difference in the length of hospital stay, HHS, postoperative orthopedic complications, and postoperative medical complications between the 2 groups. CONCLUSION: With the development of HR technology and minimally invasive technology, the trauma caused by surgery is decreasing. Under the premise of improving perioperative management, such as optimizing the preoperative preparation and postoperative management, shortening the operative time, reducing intraoperative blood loss, and actively managing co-existing diseases, HR has more advantages than PFNA in the treatment of senile intertrochanteric fractures.