Hydrocephalus in prematurity: does valve choice make a difference?

PURPOSE: Extremely premature neonates diagnosed with post-haemorrhagic hydrocephalus (PHH) are recognised to have particularly poor outcomes. This study assessed the impact of a number of variables on outcomes in this cohort, in particular the choice of shunt valve mechanism. METHODS: Electronic case notes were retrospectively reviewed of all premature neonates admitted to our centre for management of hydrocephalus between 2012 and 2021. Data included (i) gestational age, (ii) birth weight, (iii) hydrocephalus aetiology, (iv) surgical intervention, (v) shunt system, (vi) 'surgical burden' and (vii) wound failure and infection rate. Data was handled in Microsoft Excel and statistical analysis performed in SPSS v27.0 RESULTS: N = 53 premature hydrocephalic patients were identified (n = 28 (52.8%) female). Median gestational age at birth was 27 weeks (range: 23-36 + 6 weeks), with n = 35 extremely preterm patients and median birth weight of 1.9 kg (range: 0.8-3.6 kg). Total n = 99 programmable valves were implanted (n = 28 (28.3%) de novo, n = 71 (71.2%) revisions); n = 28 (28.3%) underwent n ≥ 1 pressure alterations, after which n = 21 (75%) patients had symptoms improve. In n = 8 patients exchanged from fixed to programmable valves, a mean reduction of 1.9 revisions per patient after exchange was observed (95%CI: 0.36-3.39, p = 0.02). Mean overall shunt survival was 39.5 weeks (95%CI: 30.6-48.5); 33.2 weeks (95%CI: 25.2-41.1) in programmable valves and 35.1 weeks (95%CI: 19.5-50.6) in fixed pressure (p = 0.22) with 12-month survival rates of 25.7% and 24.7%, respectively (p = 0.22). Shorter de novo shunt survival was associated with higher operation count overall (Pearson's R: - 0.54, 95%CI: - 0.72 to - 0.29, p < 0.01). Wound failure, gestational age and birth weight were significantly associated with shorter de novo shunt survival in a Cox regression proportional hazards model; gestational age had the greatest impact on shunt survival (Exp(B): 0.71, 95%CI: 0.63-0.81, p < 0.01). CONCLUSION: Hydrocephalus is especially challenging in extreme prematurity, with a shorter de novo shunt survival associated with higher number of future revisions. Programmable valves provide flexibility with regard to pressure setting, with the potential for fewer shunt revisions in this complex cohort.

Patient-reported outcomes in Primary Spinal Intradural Tumours: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: Primary Spinal Intradural Tumours (PSITs) are rare pathologies that can significantly impact quality of life. This study aimed to review patient reported outcomes (PROs) in PSITs. METHODS: A systematic search of Pubmed and Embase was performed to identify studies measuring PROs in adults with PSITs. PRO results were categorised as relating to Global, Physical, Social, or Mental health. Outcomes were summarised descriptively. RESULTS: Following review of 2382 records, 11 studies were eligible for inclusion (737 patients). All studies assessed surgically treated patients. Schwannoma was the commonest pathology (n = 190). 7 studies measured PROs before and after surgery, the remainder assessed only post-operatively. For eight studies, PROs were obtained within 12 months of treatment. 21 PRO measurement tools were used across included studies, of which Euro-Qol-5D (n = 8) and the pain visual/numerical analogue scale (n = 5) were utilised most frequently. Although overall QoL is lower than healthy controls in PSITs, improvements following surgery were found in Extramedullary tumours (EMT) in overall physical, social, and mental health. Similar improvements were not significant across studies of Intramedullary tumours (IMT). Overall QoL and symptom burden was higher in IMT patients than in brain tumour patients. No studies evaluated the effect of chemotherapy or radiotherapy. CONCLUSION: Patients with PSITs suffer impaired PROs before and after surgery. This is particularly true for IMTs. PRO reporting in PSITs is hindered by a heterogeneity of reporting and varied measurement tools. This calls for the establishment of a standard set of PROs as well as the use of registries.

Incidence of diabetic ketoacidosis during COVID-19 pandemic: a meta-analysis of 124,597 children with diabetes.

BACKGROUND: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of type 1 diabetes mellitus (T1DM) that has increased during the COVID-19 pandemic. This study will not only shed light on such life-threatening complications but also be a step to increase the awareness of healthcare providers about such complications in the upcoming pandemic waves and increased dependence on telemedicine. Thus, we aimed to further investigate the increase of DKA in pediatrics. METHODS: PubMed, Web of Science, and Scopus were broadly searched for studies assessing the incidence of DKA in pediatrics during the COVID-19 pandemic. RESULTS: Our study included 24 papers with a total of 124,597 children with diabetes. A statistically significant increase occurred in the risk of DKA among newly diagnosed T1DM patients during the pandemic (RR 1.41; 95% CI 1.19, 1.67; p < 0.01; I2 = 86%), especially in the severe form of DKA (RR 1.66: 95% CI 1.3, 2.11) when compared to before. CONCLUSION: DKA in newly diagnosed children with T1DM has increased during the pandemic and presented with a severe form. This may reflect that COVID-19 may have contributed not only to the development but also the severity of DKA. IMPACT: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM) that has increased during the COVID-19 pandemic. Our study included 25 papers with a total of 124,597 children with diabetes. A statistically significant increase occurred in the risk of DKA among newly diagnosed T1DM patients during the pandemic. Our findings reflect that COVID-19 may have an altered presentation in T1DM and can be related to DKA severity.

Cow's Milk-related Symptom Score for cow's milk allergy assessment: a meta-analysis for test accuracy.

BACKGROUND: We aimed to assess the ability of Cow's Milk-related Symptom Score (CoMiss) in screening cow's milk protein allergy (CMPA) and assess validation of its sensitivity and specificity. METHODS: We searched the PubMed, WOS, Embase, and Ovid databases using broad terms and keywords for the concepts of the symptom-based score (CoMiss) and cow's milk allergy. We performed the meta-analyses using a meta-package of R software and Meta-DiSc software. RESULTS: Fourteen studies were included with a total of 1238 children. At cut-off value 12, CoMiss had a pooled sensitivity of 0.64 and a pooled specificity of 0.75. The PLR and NLR were 3.05 and 0.5, respectively. The AUC value of the sROC curve was 0.7866. CoMiss showed a significant difference in CMPA patients at baseline and after milk elimination for 2-4 weeks (MD, 7.18), as well as between the CMPA-positive group compared with the CMPA-negative group, however, the statistical significancy was obtained after leave study of Selbuz et al. out of the analysis (MD, 4.61). CONCLUSIONS: CoMiss may be a promising symptom score in the Awareness of the symptoms related to cow's milk allergy and a useful tool in monitoring the response to a cow's milk-free diet. IMPACT: Cow's milk protein allergy (CMPA) is the most frequent food allergy in children under the age of 3 years. Cow's Milk-related Symptom Score (CoMiss) is a clinical scoring system to assist primary healthcare providers in early detection of CMPA We performed a meta-analysis of CoMiss test accuracy. Our findings reflect that CoMiss may be a promising symptom score in CMPA awareness and a useful tool in monitoring the response to a cow's milk-free diet.

When is a staging scan required for newly diagnosed brain lesions on CT? A multivariate logistic regression analysis.

PURPOSE: For patients with a new lesion on CT head (CTH) suspected to be a brain tumor, a staging chest, abdomen, and pelvis CT (CTCAP) is only warranted if a metastatic lesion is suspected. Unnecessary CTCAPs are often performed too early in a patient's journey due to poor patient selection. We sought to create a protocol to guide the selection of patients for CTCAPs based on their CTH findings. METHODS: Patients with suspected new brain tumors discussed at the neuro-oncology MDT at a tertiary neurosurgical center were reviewed. Patient demographics and CTH features were collected. For protocol creation, data was collected from July to December 2020, and predictor variables were identified using multivariate logistic regression. Candidate protocols were assessed in a protocol testing stage using similar data collected from January to June 2021. Sensitivity, specificity, and area under the curve (AUC) were computed for each protocol. RESULTS: Variables from the protocol creation stage (222 patients) were assessed in the protocol testing stage (216 patients). The most sensitive variables predicting metastatic disease were a previous history of cancer, multiple lesions, lesion < 4 cm, and infratentorial location. A protocol recommending a CTCAP based on the presence of one of these features has a sensitivity of 99.1% (AUC 0.704). CONCLUSIONS: Unnecessary CTCAPs are reduced if performed only if a patient has one of the four identified predictor variables.

Establishing mild, moderate and severe criteria for the myelopathy disability index in cervical spondylotic myelopathy.

AIM: Cervical Spondylotic Myelopathy (CSM) is a disabling condition arising from arthritic compression and consequent injury of the cervical spinal cord. Stratification of CSM severity has been useful to inform clinical practice and research analysis. In the UK the Myelopathy Disability Index (MDI) is a popular assessment tool and has been adopted by the British Spinal Registry. However, no categories of severity exist. Therefore, the aim of this study was to define categories of mild, moderate and severe. METHOD: An anchor-based analysis was carried out on previously collected data from a prospective observational cohort (N = 404) of patients with CSM scheduled for surgery and assessed pre-operatively and at 3, 12, 24 and 60 months post-operatively. Outcomes collected included the SF-36 version-1 quality of life measure, visual analogue scales for neck/arm/hand pain, MDI and Neck Disability Index (NDI). A Receiver Operating Curve (ROC) analysis, using the NDI for an anchor-based approach, was performed to identify MDI thresholds. RESULTS: Complete data was available for 404 patients (219 Men, 185 Women). The majority of patients underwent anterior surgery (284, 70.3%). ROC curves plotted to identify the thresholds from mild to moderate to severe disease, selected optimal thresholds of 4-5 (AUC 0.83) and 8-9 (AUC 0.87). These MDI categories were validated against domains of the SF36 and VAS scores with expected positive linear correlations. CONCLUSION: Categories of mild, moderate and severe CSM according to the MDI of 4-5 and 8-9 were established based on the NDI.

Informing the UK Muslim Community on Organ Donation: Evaluating the Effect of a National Public Health Programme by Health Professionals and Faith Leaders.

There is a significant shortage of transplantable organs in the UK particularly from Black, Asian and Minority Ethnic (BAME) groups, of which Muslims make a large proportion. The British Islamic Medical Association (BIMA) held a nationwide series of community gatherings with the aim of describing the beliefs and attitudes to organ donation amongst British Muslims and evaluate the efficacy of a national public health programme on views and uncertainties regarding religious permissibility and willingness to register. Eight public forums were held across the UK between June 2019 and March 2020 by the British Islamic Medical Association (BIMA). A panel of experts consisting of health professionals and Imams discussed with audiences the procedures, experiences and Islamic ethico-legal rulings on organ donation. Attendees completed a self-administered questionnaire which captured demographic data along with opinions before and after the session regarding religious permissibility and willingness to register given permissibility. A total of 554 respondents across seven UK cities were included with a M:F ratio 1:1.1. Only 45 (8%) respondents were registered as organ donors. Amongst those not registered multiple justifications were detailed, foremost of which was religious uncertainty (73%). Pre-intervention results indicated 50% of respondents were unsure of the permissibility of organ donation in Islam. Of those initially unsure or against permissibility or willingness to register, 72% changed their opinion towards deeming it permissible and 60% towards a willingness to register indicating a significant change in opinion (p < 0.001). The effectiveness of our interventions suggests further education incorporating faith leaders alongside local healthcare professionals to address religious and cultural concerns can reduce uncertainty whilst improving organ donation rates among the Muslim community.

Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review.

PURPOSE: Postoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques. METHODS: Pubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible. RESULTS: 193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity. CONCLUSIONS: Modern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.

Evaluating the utility of quantitative pupillometry in a neuro-critical care setting for the monitoring of intracranial pressure: A prospective cohort study.

INTRODUCTION: Assessment of the pupillary light reflex (PLR) is key in intensive care monitoring of neurosurgical patients, particularly for monitoring intracranial pressure (ICP). Quantitative pupillometry using a handheld pupillometer is a reliable method for PLR assessment. However, many variables are derived from such devices. We therefore aimed to assess the performance of these variables at monitoring ICP. METHODS: Sedated patients admitted to neurocritical care in a tertiary neurosurgical centre with invasive ICP monitoring were included. Hourly measurement of ICP, subjective pupillometry (SP) using a pen torch device, and quantitative pupillometry (QP) using a handheld pupillometer were performed. RESULTS: 561 paired ICP, SP and QP pupillary observations from nine patients were obtained (1122 total pupillary observations). SP and QP had a moderate concordance for pupillary size (κ=0.62). SP performed poorly at detecting pupillary size changes (sensitivity=24%). In 40 (3.6%) observations, SP failed to detect a pupillary response whereas QP did. Moderate correlations with ICP were detected for maximum constriction velocity (MCV), dilation velocity (DV), and percentage change in pupillary diameter (%C). Discriminatory ability at an ICP threshold of >22 mmHg was moderate for MCV (AUC=0.631), DV (AUC=0.616), %C (AUC=0.602), and pupillary maximum size (AUC=0.625). CONCLUSION: QP is superior to SP at monitoring pupillary reactivity and changes to pupillary size. Although effect sizes were moderate to weak across assessed variables, our data indicates MCV and %C as the most sensitive variables for monitoring ICP. Further study is required to validate these findings and to establish normal range cut-offs for clinical use.

Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis.

OBJECTIVE: The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms. METHODS: A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784). RESULTS: A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT. CONCLUSIONS: This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.

The clinical outcomes of imaging modalities for surgical management Cushing's disease - A systematic review and meta-analysis.

Introduction: Cushing's disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing's disease. Methods: Searches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing's disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging. Results: 166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37-0.69]; p<0.0001), previous surgery (OR=0.48 [CI: 0.28-0.81]; p=0.008), and lesions ≥10mm (OR: 0.63 [CI: 0.35-1.14]; p=0.12) were associated with lower remission. Less stringent thresholds for remission was associated with higher reported remission (OR: 1.37 [CI: 1.1-1.72]; p=0.007). After adjusting for this heterogeneity, no imaging modality showed significant differences in remission compared to standard preoperative MRI.The overall recurrence rate was 14.5% [CI: 12.1%-17.1%]. Lesion ≥10mm was associated with greater recurrence (OR: 1.83 [CI: 1.13-2.96]; p=0.015), as was greater duration of follow-up (OR: 1.53 (CI: 1.17-2.01); p=0.002). No imaging modality was associated with significant differences in recurrence.Despite significant improvements in detection rates over four decades, there were no significant changes in the reported remission or recurrence rates. Conclusion: A lack of controlled comparative studies makes it difficult to draw definitive conclusions. Within this limitation, the results suggest that despite improvements in radiological detection rates of Cushing's disease over the last four decades, there were no changes in clinical outcomes. Advances in imaging alone may be insufficient to improve surgical outcomes. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020187751.

High incidence of spring ligament laxity in ankle fractures with complete deltoid ruptures and secondary first ray instability.

AIMS: To assess the incidence of spring ligament failure in patients who have complete deltoid ruptures. PATIENTS AND METHODS: The authors retrospectively analysed ankle fractures in our trauma database from January 2015 to January 2019. 61 patients who sustained ankle fractures with complete deltoid ligament ruptures based on an AP ankle radiographs with increased medial joint space were identified. 25 patients attended clinic for assessment. Of these, 5 were found to have gross planovalgus with pre-existing spring ligament laxity in the uninjured control foot and these were excluded from the analysis. 20 patients were assessed for spring ligament failure /laxity. For each patient, the uninjured foot was used as the control. RESULTS: The TMT instability score and the lateral translation score showed statistically significant increases in the injured compared to the uninjured foot. The ratio of increase in both TMT instability and lateral translation scores (strain) in the injured versus the uninjured foot was assessed. A strong correlation (+0.62 pearson correlation coefficient) was found between the two ratios. CONCLUSION: All 20 patients showed increased spring ligament laxity and 19 patients showed increased TMT instability. Our results show that with complete deltoid rupture, there is likely greater disruption of the medial ligamentous structures of the foot than previously recognised. The degree of increase in the spring ligament strain also correlates with the degree of strain at the plantar TMT joint ligaments, and thus first ray instability. This finding has significant implications for the long-term assessment and management of ankle fractures involving complete deltoid disruption. Early intervention with orthotics in this cohort may prevent progressive destabilisation of the midfoot and the first ray. This evolving understanding may lead to the prospect of earlier surgical intervention to reconstitute the integrity of the spring ligament and protect the foot progressing to stage 2 AAFD.

Influence of bone quality on the strength of internal and external fixation of tibial plateau fractures.

We studied the influence of different parameters of bone quality on the fixation strength of bicondylar tibial plateau fractures and examined the relationship between these parameters. Bone quality was measured in the plateau of 16 cadaveric tibias using three modalities: dual-energy X-ray absorptiometry (DXA), peripheral quantitative computer tomography (pQCT), and spectral analysis of digitized radiographs (SADR). The tibias were divided into two groups by the median bone mineral density (BMD) and randomized to receive either dual plating or external fixator for the stabilization of a standardized bicondylar tibial fracture. The fixed fractures were subjected to axial compression until failure. DXA BMD correlated most significantly with the failure load (r>or=0.79, p<0.001), followed by the pQCT parameters of cancellous bone (0.52>or=r>or=0.73, p<0.01). Similar strong correlations were also evident in both fixation methods. For parameters derived from SADR, only those including both longitudinal and transverse trabecular orientations had modest correlation with the fixation strength (0.53>or=r>or=0.71, p<0.01). The failure loads of the two fixation techniques were not significantly different (mean+/-SD=3522+/-1386 N and 3710+/-1356 N, respectively, p=0.78). However, BMD in the dual-plating group influenced the failure load significantly (p=0.03), whereas in the external fixation group this was less evident (p=0.100). The majority of bone quality parameters that correlated with fixation strength were also strongly correlated with each other, particularly the BMDs measured by DXA and pQCT. This is the first study that relates fixation strength of bicondylar tibial plateau fractures to bone quality assessed at the same anatomical site. BMD around the fracture site had the best correlation with the failure load regardless of the fixation technique. The two fixation methods tested performed equally well, and the choice between them depends on the soft tissue condition and surgeon preference.

Experimental model of tibial plateau fracture for biomechanical testing.

Although adequate reduction and stable fixation have been recognized to be the prime goals in the treatment of displaced tibial plateau fractures, the optimal fixation technique remains controversial. The lack of a reliable model and a standard methodology contribute to this situation. The purpose of this study is to develop an experimental model of a tibial plateau fracture and a testing methodology that reproduces the failure mode commonly seen in the clinical setting. Using solid-foam and composite Sawbones tibiae, three different models of bi-condylar tibial plateau fracture (solid-foam, reinforced solid-foam and composite), six specimens for each model, were created and stabilized with double plating. The specimens were subjected to cyclic axial compression with increasing maximum load until failure. A femoral component of a total knee replacement of similar size and shape to the synthetic tibial surface was used as a load applicator. The experiment was repeated on six specimens of human cadaver tibiae. Among the Sawbones specimens, only the reinforced solid-foam model was found to produce a consistent failure mode (collapse in the medial plateau) comparable to that reported clinically in the literature. This mode of failure was also confirmed by the cadaver experiments. The failure load of the reinforced solid-foam model ranged from 4150 to 4260 N with a mean +/- SD of 4201 +/- 44 N and a coefficient of variance of 0.01, whereas for the cadaver model the failure load ranged from 1675 to 6096 N with a mean +/- SD of 3768 +/- 1482 N and a coefficient of variance of 0.39. We recommend the reinforced-foam model for future mechanical tests to compare different fixation methods for tibial plateau fractures.

Maximizing the safety of glycerol preserved human amniotic membrane as a biological dressing.

INTRODUCTION: Preservation of human amniotic membrane (HAM) in glycerol 85% has been used clinically but the use of glycerol 98% can give the maximum virucidal activity and increases the safety of HAM. OBJECTIVE: To determine the degree of clinical efficacy of HAM preserved in glycerol 98% as a biological dressing in management of donor site of split thickness skin graft (STSG). PATIENTS AND METHODS: 40 subjects were enrolled in this randomized, controlled study conducted in Al-Azhar University Hospitals from August 2013 to June 2014. We compared HAM preserved in glycerol 98% to vaseline gauze. Patients were randomly allocated to STSG donor site dressing with one of these materials. Outcome measures included pain scores at postoperative days 2, 6 and 10, time to re-epithelialization, and incidence of infection. RESULTS: Both groups were homogenous regarding age, gender, cause of burn and size. The HAM group showed significantly less pain on postoperative days 2 and 6 (4 and 2.7 vs. 5.6 and 4.2 respectively with p value <0.05). Shorter time to re-epithelialization was also found in the HAM group (11.7 vs. 15.4 with p value <0.05). No significant difference was found between both groups in the incidence of infection. CONCLUSION: HAM preserved in glycerol 98% is clinically effective as a biological dressing. The higher glycerol concentration increases the safety of HAM with retaining the clinical effect at the same time.

Outcome of complex fractures of the tibial plateau treated with a beam-loading ring fixation system.

Fine-wire external fixation is accepted as a minimally invasive technique, which can provide better outcomes than traditional open methods in the management of complex fractures of the tibial plateau. Available fixators vary in their biomechanical stability, and we believe that a stable beam-loading system is essential for consistently good outcomes. We assessed, prospectively, the clinical, radiological and general health status of 20 of 21 consecutive patients with complex fractures of the tibial plateau who had been treated using a standard protocol, with percutaneous screw fixation and a neutralisation concept with a fine wire beam-loading fixator allowing early weight-bearing. Bony union was achieved in all patients, with 85% having good or excellent results. Full weight-bearing started during the first six weeks in 60% of patients. The general health status assessment correlated well with the knee scores and reflected a satisfactory outcome.

Failure of fixation of tibial plateau fractures.

OBJECTIVE: To define the failure of fixation in tibial plateau fractures, detect its incidence, and determine the contributing factors. DESIGN: Mail survey and literature review were used to define the fixation failure; this definition was applied to a radiologic review of patients who were treated surgically for tibial plateau fracture at a Level 1 trauma unit for a three-year period from 1993 to 1995. PATIENTS AND SETTING: Forty-two consecutive patients treated surgically at our trauma unit for tibial plateau fractures were studied retrospectively, specifically for loss of fixation. Factors that might affect the fracture fixation were reviewed, including age, mechanism of injury, type of fracture, bone quality, severity of fragmentation, severity of displacement, time to surgery, operating time, fixation method, use of bone graft, postoperative bracing, and mobilization. MAIN OUTCOME MEASURES: The main outcome measure was failure of fixation, by using criteria defined by the result of a mail survey of experts and literature review. RESULTS: Using a strict definition of radiologic failure of fixation, we reported an overall 31 percent rate of failure of fixation: 79 percent in patients older than sixty years compared with 7 percent in younger patients. The statistically significant associations with loss of reduction were age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. CONCLUSION: It is logical to define failure of fixation using the same measures considered as indications for reduction and fixation. Using these strict criteria, the incidence of radiologic failure was much higher than previous published series. In the elderly this was unacceptably high, and treatment goals should be limited to restoring stability and alignment.

Treatment of displaced bicondylar tibial plateau fractures (OTA-41C2&3) in patients older than 60 years of age.

OBJECTIVE: To investigate the outcome (clinical, radiographic, and general health status) of the surgical treatment of displaced bicondylar tibial plateau fractures (OTA-41C) in patients >60 years old. DESIGN: Prospective cohort study. SETTING: Limb reconstruction service, university teaching hospital. PATIENTS: Eleven consecutive patients >60 years old with a mean age of 72 years (range 60 to 90 years). The indications for surgery were displaced bicondylar tibial fractures, open fractures, and fractures with severe soft tissue injury. INTERVENTION: All patients were treated according to a standard protocol, which involved limited articular reconstruction and percutaneous intrafragmentary screw fixation, followed by neutralization with a stable beam-loading external fixator and early mobilization. MAIN OUTCOME MEASUREMENTS: The clinical outcome was assessed using Rasmussen's system and the Iowa knee score. For general health assessment, the anglicized SF-36 was used. Radiographic assessment was performed for redisplacement and angulation on digitized radiographs. RESULTS: After a mean follow-up of 38 months (range 18 to 51 months), bony union was achieved in all patients. Seven of 11 patients started full weight bearing 2 to 6 weeks postoperatively. According to Rasmussen's system, 9 of 11 (82%) scored satisfactory results. Radiographic redisplacement was found in three severely comminuted cases resulting in >/=10 degrees of valgus malunion. One patient received a corrective osteotomy while still in the fixator. Another needed TKA. Limited knee flexion was found in three patients with cross knee fixation. Superficial pin site infection occurred in five patients, but there were no cases of deep infections or septic arthritis. CONCLUSIONS: All-ring external fixation, as a beam-loading system applied in a neutralizing mode, is a safe, stable, and reliable technique for the treatment of displaced bicondylar tibial plateau fractures in elderly patients.

The strength of different fixation techniques for bicondylar tibial plateau fractures--a biomechanical study.

OBJECTIVE: To compare the mechanical strength of fixation of bicondylar tibial plateau fractures using internal and external fixation techniques. DESIGN: A randomised laboratory testing of fixation methods currently in clinical use. BACKGROUND: To reduce the high complication rate associated with the double plating, many surgeons have started to use less invasive techniques. However the literature comparing the mechanical performance of these methods is still scarce. METHODS: Bicondylar tibial plateau fractures were simulated on Sawbones tibiae and fixed with one of the five fixation methods: dual plating, a two-ring hybrid fixator with inter-fragmentary screws, a ring-bar hybrid fixator with inter-fragmentary screws, lateral plate and medial monolateral external fixator, lateral plate and medial inter-fragmentary screws. Following statistical power calculations, seven tibiae were used for each fixation method. The specimens were tested in cyclical compression to failure. The vertical subsidence in the medial or lateral plateau was measured using extensometers. RESULTS: In all cases the mode of failure was consistent with collapse occurring in the medial plateau. There was no significant difference in the failure load between dual plating and the two-ring hybrid fixator (4218 N and 4184 N respectively; P=0.28, t-test). Failure was seen at significantly lower loads with the other fixation systems. CONCLUSION: Weight-bearing mobilisation of the patient may be undertaken earlier with more confidence by using the double plating or two-ring hybrid fixator rather than other less strong techniques. The choice on which of these two methods to use may depend on tissue viability and surgeon preference.

The precision and accuracy of templating the size of unicondylar knee arthroplasty.

In trauma and joint arthroplasty, preoperative templating is an important step that can help in the selection of implant size, position and alignment. Although the precision (reproducibility) of templating in unicondylar knee arthroplasty has been assessed previously, the accuracy has never been studied. Our aim is to assess the precision and accuracy of using the templating system for one commonly used unicondylar knee arthroplasty, ALPHANORM design (Alphanorm Medizintechnik, Germany). Eight observers used the templating system to estimate the size of the unicondylar knee prosthesis ALPHANORM in 29 randomly selected patients with osteoarthritis. The observers, who all were orthopaedic surgeons with two different levels of experience, worked independently and repeated their measurements 2 weeks later. All the patients subsequently underwent unicondylar knee replacements, and the actual size of the femur and tibia was assessed intra-operatively without any knowledge of the template sizes. Our results revealed a high level of intra-observer reproducibility. However, the inter-observer reproducibility and the accuracy all were poor.