Orthopedic trauma surgeon in Sierra Leone: how to keep one's head over water.

PURPOSE: Developing a guideline for orthopedic trauma surgeons working in civilian trauma hospitals in low-income countries. METHODS: This is a retrospective data analysis in a non-governmental organizational trauma hospital in Sierra Leone, Africa. Trauma victims (282), with 349 fractures, were admitted to the hospital 10/2015-01/2016. The incidence of open and closed fractures and the use of implants were evaluated. RESULTS: The most common fractures were open and closed tibial shaft fractures and closed femoral shaft fractures in adults, and closed supracondylar humerus fractures in children. The most used implants were external fixators, K-wires, and intramedullary nails. External fixators were used for open fractures, K-wires for closed fractures in children, hand and foot, and nails for closed fractures of the lower extremity in adults. Plates were used the least and mostly for fractures of the upper extremity, the proximal tibia and malleolar region in adults. The complication rate was 5.67%. CONCLUSION: Surgeons in low-income country trauma hospitals should treat conservatively on outpatient basis only, to reduce the amount of stationary patients. Open fractures should be treated with external fixators, and closed fractures in children, hand and foot, with K-wires. Closed fractures in adults of the lower extremity should be nailed, and closed fractures in adults of the upper extremity can be treated with plates.

Alterations in structure of the muscle-tendon unit and gait pattern after percutaneous repair of Achilles tendon rupture with the Dresden instrument.

BACKGROUND: Functional deficits after Achilles tendon (AT) ruptures are observed. The relationship between musculotendinous structural alterations and functional outcome is not clear. METHODS: Kinematic analyses (level walking, stair climbing), patient-reported outcome measures (PROMs), calf atrophy (maximum calf circumference (MCC)), and AT length were evaluated in patients after percutaneous AT repair with the Dresden instrument (n=20min. FOLLOW-UP: 24 months). RESULTS: Patients achieved good results in PROMs. However, MCC decreased significantly and AT length increased significantly postoperatively. Side-to-side MCC differences over 2cm resulted in significantly lower PROMs. AT lengthening correlated with increased dorsiflexion and decreased plantarflexion. CONCLUSION: Calf atrophy and AT lengthening after minimally invasive AT repair resulted in inferior ankle kinematics and PROMs.

Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument.

BACKGROUND: The aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors. MATERIALS AND METHODS: 118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined. RESULTS: Hannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations. CONCLUSIONS: Percutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome.

Heterotopic ossification after total ankle replacement: The role of prosthesis alignment.

BACKGROUND: The aetiology of heterotopic ossifications (HO) after total ankle arthroplasty (TAR) remains controversial. The aim of the study was to evaluate the prevalence and localisation of HO and the effect of alignment. METHODS: 88 TARs with a series of radiological controls and follow-up of 36 months were evaluated. Frontal and sagittal alignment parameters (alfa and beta angle defined by Hintermann) and tibial coverage were evaluated. RESULTS: The prevalence and grading of HO increased over time, mostly in the posterior gutter. Varus alignment correlated with HO increase in the ventral and lateral gutters the first year. A dorsally located rotational centre correlated with total HO growth and HO in the posterior gutter. These correlations were not detected after 3 years, as HO were seen in all prostheses, regardless of alignment. CONCLUSIONS: HO grow over time with a prevalence up to 100% after 3 years. TAR alignment correlates with gutter-specific HO formation within the first year.

Long-term functional outcome and quality of life after successful surgical treatment of tibial nonunions.

PURPOSE: Our aim was to evaluate quality of life (QoL) and functional outcome of patients with tibial nonunions after completion of surgical treatment with an average follow-up of five years. METHODS: The following data of 64 patients were retrospectively evaluated: fracture type, type and duration of surgical therapy, range of motion of the knee and ankle and American Orthopaedic Foot and Ankle Society (AOFAS) score. QoL was evaluated with the Short-Form Health Survey (SF-36) questionnaire; pain intensity, patient satisfaction and impairments of daily, professional and sport activities with a ten point visual analogue scale. RESULTS: QoL, even in cases with successfully completed treatment, was significantly reduced compared with the normal general population. Pain intensity and limited ankle dorsal extension, despite the absence of intra-articular fractures, were significantly correlated with inferior QoL. CONCLUSIONS: This study emphasises the long-term negative impact of tibial nonunions on patient QoL, even after successful surgical treatment.

Anabolic androgenic steroids reverse the beneficial effect of exercise on tendon biomechanics: an experimental study.

BACKGROUND: The effect of anabolic androgenic steroids on tendons has not yet been fully elucidated. Aim of the present study was the evaluation of the impact of anabolic androgenic steroids on the biomechanical and histological characteristics of Achilles tendons. METHODS: Twenty-four male Wistar rats were randomized into four groups with exercise and anabolic steroids (nandrolone decanoate) serving as variables. Protocol duration was 12 weeks. Following euthanasia, tendons' biomechanical properties were tested with the use of a modified clamping configuration. Histological examination with light and electron microscopy were also performed. RESULTS: In the group of anabolic steroids and exercise the lowest fracture stress values were observed, while in the exercise group the highest ones. Histological examination by light and electron microscopy revealed areas of collagen dysplasia and an increased epitendon in the groups receiving anabolic steroids and exercise. CONCLUSIONS: These findings suggest that anabolic androgenic steroids reverse the beneficial effect of exercise, thus resulting in inferior maximal stress values.

Necrotizing fasciitis: is the bacterial spectrum changing?

PURPOSE: Necrotizing fasciitis (NF) is a rare, but potentially fatal pathology. The aim of the present study was to identify the population characteristics of the NF patients, the responsible bacteria, and the differences between survivors and nonsurvivors. METHODS: In this retrospective case-control study, all patients with NF from January 1, 2005, to December 31, 2010, treated in an academic level 1 trauma center, were identified, and their medical records were reviewed. RESULTS: The mortality rate of the 24 identified patients was 20.8 %. The majority of the infections (54.2 %) (13/24) were monomicrobial. Hemolytic Streptococcus of group A (25 %) and methicillin-resistant Staphylococcus aureus (20.8 %) were the commonest germs. The mean number of comorbidities was 3.62 (standard deviation (SD) 3.58). Diabetes mellitus, cardiovascular disease, and immunosuppression were the commonest. Mean number of operations was 8.1 (SD 4.7). Five patients (20.8 %) developed a disseminated intravascular coagulation (DIC); all of them died. Nonsurvivors, who presented with deteriorated coagulation factors, developed a DIC (p < 0.001) and received more often antibiotic monotherapy (ampicillin/sulbactam) as initial empirical therapy (p < 0.001). CONCLUSIONS: The present study suggests a shift of the bacterial spectrum towards monomicrobial infections with multiresistant bacteria. The early recognition of high-risk patients and the aggressive surgical treatment with at least double-schema antibiotic therapy are of outmost importance.

Closed reduction of distal radius fractures: does instability mean irreducibility?

INTRODUCTION: The belief that not all distal radius fractures can be initially anatomically reduced with conservative means is rising. The aim of this study was to examine whether adequate reduction with a closed reduction technique is possible and to assess the importance of each step. MATERIALS AND METHODS: We prospectively enrolled 63 distal radius fractures (62 patients). A standardized reduction technique was implemented. Reduction was radiologically evaluated in hanging traction, after reduction, and in plaster. Subgroup analysis was performed for fracture-dependent and fracture-independent factors on their influence on reduction. RESULTS: The mean radiological values (radial inclination, dorsal tilt, ulnar variance) showed near anatomic reduction of all fractures in plaster. Fracture severity according to AO classification, initial displacement, number of instability criteria and patient age did not affect the reduction outcome. CONCLUSIONS: All types of enrolled fractures were nearly anatomically reduced. This contradicts the opinion that some "severe" fractures are too unstable to be initially reduced by closed means.

Signal-inducing bone cements for MRI-guided spinal cementoplasty: evaluation of contrast-agent-based polymethylmethacrylate cements.

OBJECTIVE: The purpose of this work is to evaluate two signal-inducing bone cements for MRI-guided spinal cementoplasty. MATERIALS AND METHODS: The bone cements were made of polymethylmethacrylate (PMMA, 5 ml monomeric, 12 g polymeric) and gadoterate meglumine as a contrast agent (CA, 0-40 µl) with either saline solution (NaCl, 2-4 ml) or hydroxyapatite bone substitute (HA, 2-4 ml). The cement's signal was assessed in an open 1-Tesla MR scanner, with T1W TSE and fast interventional T1W TSE pulse sequences, and the ideal amount of each component was determined. The compressive and bending strength for different amounts of NaCl and HA were evaluated. RESULTS: The cement's MRI signal depended on the concentration of CA, the amount of NaCl or HA, and the pulse sequence. The signal peaks were recorded between 1 and 10 µl CA per ml NaCl or HA, and were higher in fast T1W TSE than in T1W TSE images. The NaCl-PMMA-CA cements had a greater MRI signal intensity and compressive strength; the HA-PMMA-CA cements had a superior bending strength. CONCLUSIONS: Concerning the MR signal and biomechanical properties, these cements would permit MRI-guided cementoplasty. Due to its higher signal and greater compressive strength, the NaCl-PMMA-CA compound appears to be superior to the HA-PMMA-CA compound.

A formula for the stratified selection of patients with paroxysmal atrial fibrillation in the emergency setting: a retrospective pilot study.

BACKGROUND: Amiodarone is a commonly used medication in the treatment of atrial fibrillation (AF) of recent onset. STUDY OBJECTIVES: The aim of the study was to identify a possible formula for selecting Emergency Department (ED) patients with paroxysmal AF who will spontaneously restore sinus rhythm (SR), successfully restore SR with the use of loading intravenous (i.v.) amiodarone, or require 24-h maintenance amiodarone infusion. METHODS: This retrospective pilot study included 141 patients with recent-onset AF. Patients who did not restore SR spontaneously received i.v. amiodarone (5 mg/kg) within a period of 30 min. In case of no response, an additional dosage of 1000 mg of i.v. amiodarone was administered over a period of 24 h. Binary logistic regression models were used to determine the predictors of spontaneous conversion and the response to amiodarone administration. RESULTS: The formula ([heart rate/systolic blood pressure] + 0.1 × number of past AF incidences) was chosen as the one with the highest combined sensitivity and specificity. This index identified the patients who spontaneously restored SR (cutoff point 1.31 with 78.6% sensitivity and 77.9% specificity), whereas for patients who responded to the loading i.v. amiodarone dose, the use of the index (cutoff point 1.24) exhibited 84.1% sensitivity and 75.3% specificity. CONCLUSIONS: This formula may be a useful and reliable bedside diagnostic tool to identify AF patients most likely to spontaneously convert, or respond to loading amiodarone administration in the emergency setting. The use of this index also can assist in patient risk stratification.

Sonographic measurements of subcutaneous fat in obese individuals may correlate better with peripheral artery disease indices.

PURPOSE: The purpose of this study was to investigate the association of various methods for body fat assessment with indices of peripheral artery disease in the deep and superficial femoral arteries. METHODS: The intima-media thickness (IMT), maximal IMT (max IMT), femoral wall thickness (FWT), maximal FWT (max FWT), cross-sectional intima media area (CIMA), and atherosclerotic burden score (ABS) were measured sonographically in 26 subjects. The minimum thickness of the abdominal subcutaneous fat layer (Smin) was measured sonographically close to the xyphoid process, and body fat percentage was calculated using various formulas. RESULTS: Smin correlated significantly with body fat percentage calculated with all formulas and was the sole parameter that was associated significantly with all the femoral artery atherosclerotic indices IMT: r = 0.74, p < 0.001; max IMT: r = 0.53, p < 0.05; FWT: r = 0.78, p < 0.001; max FWT: r = 0.57, p < 0.005; ABS: r = 0.52, p < 0.05; CIMA: r = 0.86, p < 0.001; Smin was the major independent predictor of femoral IMT on a multiple stepwise regression analysis (beta = 0.02; SE = 0.008, R(2) = 0.35, p < 0.05). CONCLUSIONS: Smin correlates better than indirect indices and formulas of body fat estimation with markers of extracoronary atherosclerosis. Sonographic measurement of Smin may serve in the future as a useful tool in everyday clinical practice.

A prognostic index for the successful use of adenosine in patients with paroxysmal supraventricular tachycardia in emergency settings: a retrospective study.

STUDY OBJECTIVES: The use of adenosine on failure of vagal maneuvers in patients with paroxysmal supraventricular tachycardia (PSVT) is recommended. The aim of the present study was to identify a possible prognostic index for the efficacy of adenosine in PSVT. METHODS: This retrospective study included 321 patients with PSVT, in whom vagal maneuvers failed to restore normal sinus rhythm and who received 6 mg adenosine, followed by 12 mg adenosine (repeated if necessary). A 2-step clustering algorithm was used to reveal nonapparent groupings. Various patients' characteristics were inserted into the model. RESULTS: A straightforward index has been chosen that would aid the distinction of patients failing to respond to adenosine. The formula, (age / heart rate at admission) + number of past PSVT episodes, was chosen as the one that combined the highest sensitivity (96.2%) and specificity (71.2%). CONCLUSIONS: This prognostic index constitutes a useful and reliable bedside diagnostic tool to identify patients with PSVT who were less likely to respond to adenosine administration in the emergency setting.

Effect of statins on serum apolipoprotein j and paraoxonase-1 levels in patients with ischemic heart disease undergoing coronary angiography.

It has been proposed that apolipoprotein J (apo J) and paraoxonase-1 (PON1) correlate with the extent and severity of ischemic heart disease (IHD). This article compares apo J and PON1 serum concentrations, PON1 activity, and the apo J/PON1 ratio in 138 IHD patients (64 statins users and 74 statin nonusers) referred for angiography and possible percutaneous coronary intervention. The effect of statin treatment on apo J and PON1 concentrations, PON1 activity, and the degree of coronary artery stenosis were evaluated. In both groups, apo J levels were increased, whereas PON1 concentration and activity decreased. IHD patients on statins had significantly lower apo J concentration and higher PON1 concentration and activity. Patients on statins had less coronary artery stenosis. High apo J levels, low PON1 levels, low PON1 activity, and a high apo J/PON1 ratio were associated with IHD. Statin treatment reverses these changes, probably by multiple beneficial actions.

Fracture heuristics: surgical decision for approaches to distal radius fractures. A surgeon's perspective.

Introduction: The aim of the present study is to develop a heuristic that could replace the surgeon's analysis for the decision on the operative approach of distal radius fractures based on simple fracture characteristics. Patients and methods: Five hundred distal radius fractures operated between 2011 and 2014 were analyzed for the surgeon's decision on the approach used. The 500 distal radius fractures were treated with open reduction and internal fixation through palmar, dorsal, and dorsopalmar approaches with 2.4 mm locking plates or underwent percutaneous fixation. The parameters that should replace the surgeon's analysis were the fractured palmar cortex, and the frontal and the sagittal split of the articular surface of the distal radius. Results: The palmar approach was used for 422 (84.4%) fractures, the dorsal approach for 39 (7.8%), and the combined dorsopalmar approach for 30 (6.0%). Nine (1.8%) fractures were treated percutaneously. The correlation between the fractured palmar cortex and the used palmar approach was moderate (r=0.464; p<0.0001). The correlation between the frontal split and the dorsal approach, including the dorsopalmar approach, was strong (r=0.715; p<0.0001). The sagittal split had only a weak correlation for the dorsal and dorsopalmar approach (r=0.300; p<0.0001). Discussion: The study shows that the surgical decision on the preferred approach is dictated through two simple factors, even in the case of complex fractures. Conclusion: When the palmar cortex is displaced in distal radius fractures, a palmar approach should be used. When there is a displaced frontal split of the articular surface, a dorsal approach should be used. When both are present, a dorsopalmar approach should be used. These two simple parameters could replace the surgeon's analysis for the surgical approach.

Fracture severity of distal radius fractures treated with locking plating correlates with limitations in ulnar abduction and inferior health-related quality of life.

INTRODUCTION/BACKGROUND: The operative treatment of distal radius fractures has significantly increased after the introduction of locking plates. The aim of the present study was the evaluation of health-related quality of life, functional and radiological outcome of patients with distal radius fractures treated with the locking compression plate (LCP). MATERIALS AND METHODS: In the present study 128 patients (130 fractures) that were operatively treated with the LCP (2.4 mm/3.5 mm, Synthes(®)) were retrospectively evaluated. Mean follow-up was 22.7 months (SD 10.6). The fractures were radiographically evaluated (radial inclination, palmar tilt, ulnar variance) pre-, postoperatively and at the last follow-up visit. Range of motion (ROM) was documented. Grip strength was assessed with the use of a JAMAR dynamometer. The score for disabilities of the arm, shoulder and hand (DASH) and the Gartland-Werley score (GWS) were evaluated. Health-associated quality of life was assessed with use of SF-36 Health Survey. RESULTS: Postoperative reduction was excellent; at the last follow-up visit only minimal reduction loss was observed. Except for pronation, a statistically significant decrease of ROM was present; in most cases that was not disturbing for the patients. The injured side achieved 83.9% of grip strength of the intact side. Mean DASH was 18.9 and mean GWS was 3.5. Health-associated quality of life was generally not compromised. However, limitations in ulnar abduction correlated with inferior quality of life. Fracture severity correlated with inferior quality of life, despite the absence of correlation with the functional and radiological outcome. Complication rate was low. CONCLUSIONS: Fracture severity seems to affect ulnar abduction and therefore patient quality of life, despite almost anatomical reduction; the objective and subjective scores were in most cases excellent. Modern everyday activities, such as keyboard typing, could be associated with the present results.

Diagnosing fractures: pain intensity and subjective functional impairment are unreliable markers for initial assessment of possible extremity fractures.

OBJECTIVES: The triage of trauma patients is based on patient-given information. The aim of the study was the accuracy of pain intensity, subjective functional impairment, trauma history, and clinical examination in identifying patients with fractures. METHODS: We prospectively asked 436 patients with an extremity trauma whether they believed they had a fracture. Pain intensity and subjective functional impairment were also assessed. The physicians were also asked, based on trauma history and clinical examination. RESULTS: The sensitivity and specificity of patient opinion and of the functional questions for fracture detection were low. The combination of history and clinical examination delivered the best results. There was only a slight difference in pain intensity between patients with and those without fractures. CONCLUSION: Fracture diagnosis based only on patient opinion or subjective functional impairment can be misleading. Pain intensity needs further investigation for its role in fracture detection.

Biomechanical behavior of MRI-signal-inducing bone cements after vertebroplasty in osteoporotic vertebral bodies: An experimental cadaver study.

BACKGROUND: Conventional water-free polymethylmethacrylate cements are not MRI visible due to the lack of free protons. A new MRI-visible bone cement was developed through the addition of a contrast agent and either a saline solution or a hydroxyapatite (Wichlas et al., 2010). The purposes of the study were to examine the influence of the two MRI-signal-inducing cements on the biomechanical behavior of cadaveric osteoporotic vertebral bodies after vertebroplasty and to compare the performance of the cements with conventional polymethylmethacrylate cement. METHODS: Three different cements were used: standard polymethylmethacrylate cement and two modified MRI-signal-inducing cements that were mixed with either a 0.9% saline solution or a hydroxyapatite. The modulus of elasticity for the standard polymethylmethacrylate cement was 2040MPa, and the moduli for the MRI-signal-inducing cements that were mixed with a 0.9% saline solution and a hydroxyapatite were 1477 and 1225MPa, respectively. The lumbar vertebral bodies from nine osteoporotic spines (mean age=87 years, range=78-99 years) of female cadavers were examined. Three groups were formed: polymethylmethacrylate cement with saline solution (n=14), polymethylmethacrylate cement with hydroxyapatite (n=12) and polymethylmethacrylate cement (n=13). The vertebral bodies were biomechanically tested before and after vertebroplasty. Stiffness was chosen as the primary biomechanical parameter. FINDINGS: The vertebral body stiffness was nearly two-fold greater after vertebroplasty, and this increase was statistically significant for every group. All the groups had similar vertebral body stiffness value before and after the vertebroplasty. The UNIANOVA test for multivariate analysis of variance showed no influence of lumbar level, injected cement volume and initial vertebral body stiffness. INTERPRETATION: The elastic moduli of the cements appear to exert little influence on the biomechanical values when the cement is in the vertebral body. Based on the direct comparison with the classic polymethylmethacrylate cement, we believe that the implementation of such cements for MRI-guided vertebroplasties is feasible.

Periprosthetic fractures in total ankle replacement: classification system and treatment algorithm.

BACKGROUND: Despite progress in implant design and surgical technique, the reported number of periprosthetic ankle fractures following total ankle joint replacement continues to increase. A treatment-oriented classification of these fractures has not yet been reported. The purpose of this study was to evaluate the prevalence, cause, and location of periprosthetic fractures and the stability of the associated prosthetic components after total ankle replacement and to develop a method of classification. METHODS: Data regarding 503 total ankle replacements with a mean follow-up of 14.7 months were reviewed. The prevalence, location, and possible cause of the fractures as well as prosthesis stability were analyzed and a systematic method of classification based on these factors was developed. RESULTS: Twenty-one patients (4.2%) with a periprosthetic fracture were identified. The fracture was intraoperative (Type 1) in eleven patients (2.2%) and postoperative in the remaining ten (2.0%). Two of the latter fractures were traumatic (Type 2) and eight were stress fractures (Type 3). Two-thirds (fourteen) of the twenty-one fractures occurred in the medial malleolus. CONCLUSIONS: The prevalence of periprosthetic fractures following primary total ankle replacement was relatively low. We propose a classification system for these fractures that is based on more than 500 cases. We believe that this classification can facilitate therapeutic decision-making, as it allows for differential analysis of the cause and guides the choice among operative and nonoperative treatment options.