Does the surgical treatment of concomitant upper limb fractures affect the outcomes of hip fractures in the elderly population?

INTRODUCTION: Elderly patients with concomitant upper limb and hip fractures present a management dilemma because upper limb fractures potentially affect rehabilitation outcomes for the hip fracture. This study aims to evaluate whether the site of upper limb fractures and the decision to surgically treat such fractures affect the functional outcome of surgically treated hip fracture patients. METHODOLOGY: We retrospectively reviewed 1828 hip fracture patients treated at a single trauma centre over 3 years, of whom 42 with surgically treated hip fractures had concomitant upper limb fractures. Outcome measures, such as length of hospital stay, complications, mortality and readmission rates, were assessed, whilst the functional outcomes were evaluated using the Modified Barthel Index (MBI) on admission, post-operatively and at 6 and 12 months of follow-up. RESULTS: Amongst the 42 patients with surgically treated hip fractures, 31.0% had proximal humerus fractures, 50.0% had wrist fractures, 16.7% had elbow fractures and 2.4% had forearm fractures. 50.0% of these upper limb fractures were treated surgically. There was no difference in complications, inpatient morbidity, readmission rates or the length of hospital stay for patients whose upper limb fractures were surgically treated as compared to those non-surgically treated. There was no difference in absolute MBI scores at 6 and 12 months based on the management of upper limb fractures. However, patients with surgically treated wrist fractures had statistically significant higher MBI scores at 6 months as compared to those treated non-surgically. CONCLUSION: Surgical treatment of concomitant upper limb fractures does not appear to change the outcomes of the hip fractures. Hip fracture patients with surgically treated wrist fractures had better functional outcomes at 6 months compared to those treated non-surgically; however, there was no difference at 12 months. Hip fracture patients with concomitant wrist fractures had better functional outcomes compared to hip fracture patients with proximal humerus fractures.

The ideal implant for Mayo 2A olecranon fractures? An economic evaluation.

BACKGROUND: The ideal implant for stable, noncomminuted olecranon fractures is controversial. Tension band wiring (TBW) is associated with lower cost but higher implant removal rates.On the other hand, plate fixation (PF) is purported to be biomechanically superior, with lower failure and implant removal rates, although associated with higher cost. The primary aim of this study is to look at the clinical outcomes for all Mayo 2A olecranon between PF and TBW. The secondary aim is to perform an economic evaluation of PF vs. TBW. MATERIALS AND METHODS: This is a retrospective study of all surgically treated Mayo 2A olecranon fractures in a tertiary hospital from 2005-2016. Demographic data, medical history, range of motion, and complications were collected. All inpatient and outpatient costs in a 1-year period postsurgery including the index surgical procedure were collected via the hospital administrative cost database (normalized to 2014). RESULTS: A total of 147 cases were identified (94 TBW, 53 PF). PF was associated with higher mean age (P < .01), higher American Society of Anesthesiologists score (P < .01), and higher proportion of hypertensives (P = .04). There was no difference in the range of motion achieved at 1 year for both groups. In terms of complications, TBW was associated with more symptomatic hardware (21.6% vs. 13.7%, P = .24) and implant failures (16.5% vs. none, P < .01), whereas the plate group had a higher wound complication (5.9% vs. none, P = .02) and infection rate (9.8% vs. 3.1%, P = .09). TBW had a higher implant removal rate of 30.9% compared with 22.7% for PF (P = .36). PF had a higher cost at all time points, from the index surgery ($10,313.64 vs. $5896.36, P < .01), 1-year cost excluding index surgery ($5069.61 vs. $3850.46, P = .46), and outpatient cost ($1667.80 vs. $1613.49, P = .27). DISCUSSION AND CONCLUSION: Based on our study results, we have demonstrated that TBW is the ideal implant for Mayo 2A olecranon fractures from both a clinical and economic standpoint, with comparable clinical results, potentially similar implant removal rates as PF's, and a lower cost over a 1-year period. In choosing the ideal implant, the surgeon must take into account, first, the local TBW and PF removal rate, which can vary significantly because of the patient's profile and beliefs, and second, the PF implant cost.

The Evolution of Olecranon Fractures and Its Fixation Strategies.

Introduction: Olecranon fractures are a common fracture of the upper extremity. The primary aim was to investigate the evolution of olecranon fractures and fixation method over a period of 12 years. The secondary aim was to compare complication rates of Tension Band Wiring (TBW) and Plate Fixation (PF). Materials and Methods: Retrospective Study for all patients with surgically treated olecranon fractures from 1 January 2005 to 31 December 2016 from a tertiary trauma center. Records review for demographic, injury characteristics, radiographic classification and configuration, implant choices and complications. Results grouped into three 4-year intervals, analyzed comparatively to establish significant trends over 12 years. Results: 262 patients were identified. Demographically, increasing mean age (48.7 to 58.9 years old, p value 0.004) and higher ASA scores (7.1% ASA 3 to 21.0% ASA 3 p value 0.001). Later fractures were more oblique (fracture angle 86.1-100.0 degrees, p value 0.001) and comminuted (Schatzker D type 10.4-30.0%, p value 0.025, single fracture line 94.0-66.0%, p value 0.001). Implant choice, sharp increase in PF compared to TBW (PF 16.0% to PF 80.2%, p value 0.001). Complication-wise, TBW had higher rates of symptomatic implant, implant and bony failures and implant removal. Conclusion: Demographic and fracture characteristic trends suggest that olecranon fractures are exhibiting fragility fracture characteristics (older age, higher ASA scores, more unstable, oblique and comminuted olecranon fractures). Having a high index of suspicion would alert surgeons to consider use of advanced imaging, utilize appropriate fixation techniques and manage the underlying osteoporosis for secondary fracture prevention. Despite this, trends suggest a potential overutilization of PF particularly for stable fracture patterns and the necessary precaution should be exercised.

Co-gasification of sewage sludge and woody biomass in a fixed-bed downdraft gasifier: toxicity assessment of solid residues.

As the demand for fossil fuels and biofuels increases, the volume of ash generated will correspondingly increase. Even though ash disposal is now strictly regulated in many countries, the increasing volume of ash puts pressure on landfill sites with regard to cost, capacity and maintenance. In addition, the probability of environmental pollution from leakage of bottom ash leachate also increases. The main aim of this research is to investigate the toxicity of bottom ash, which is an unavoidable solid residue arising from biomass gasification, on human cells in vitro. Two human cell lines i.e. HepG2 (liver cell) and MRC-5 (lung fibroblast) were used to study the toxicity of the bottom ash as the toxins in the bottom ash may enter blood circulation by drinking the contaminated water or eating the food grown in bottom ash-contaminated water/soil and the toxic compounds may be carried all over the human body including to important organs such as lung, liver, kidney, and heart. It was found that the bottom ash extract has a high basicity (pH = 9.8-12.2) and a high ionic strength, due to the presence of alkali and alkaline earth metals e.g. K, Na, Ca and Mg. Moreover, it also contains concentrations of heavy metals (e.g. Zn, Co, Cu, Fe, Mn, Ni and Mo) and non-toxic organic compounds. Although human beings require these trace elements, excessive levels can be damaging to the body. From the analyses of cell viability (using MTS assay) and morphology (using fluorescence microscope), the high toxicity of the gasification bottom ash extract could be related to effects of high ionic strength, heavy metals or a combination of these two effects. Therefore, our results suggest that the improper disposal of the bottom ash wastes arising from gasification can create potential risks to human health and, thus, it has become a matter of urgency to find alternative options for the disposal of bottom ash wastes.

Performance of a submerged anaerobic membrane bioreactor with forward osmosis membrane for low-strength wastewater treatment.

A submerged anaerobic membrane bioreactor with forward osmosis membrane (FO-AnMBR) was operated at 25 °C for the treatment of synthetic wastewater. As the experiment progressed, the water flux reduced due to the membrane fouling and the increasing salinity in the reactor, and achieved at around 3.5 LMH in one cycle. It was worth noting that the level of salinity in the reactor was not a concern in terms of inhibition or toxic effects on the biological processes. The FO-AnMBR process exhibited greater than 96% removal of organic carbon, nearly 100% of total phosphorus and 62% of ammonia-nitrogen, respectively, suggesting a better removal efficiency than the conventional anaerobic membrane bioreactor. The methane and carbon dioxide compositions achieved concentrations of around 65%-78% and 22%-35%, respectively; and no obvious difference in the biogas composition was observed with the changes of conductivity. With respect to the methane yield, an average value of 0.21 L CH4 g(-1) COD was obtained, exhibiting the feasibility of energy recovery by this FO-AnMBR system. Additionally, an increase in the salinity enhanced the accumulation of soluble microbial products, especially for the proteins with 88.9% increment as the conductivity increased from 1.2 to 17.3 ms cm(-1). In contrast, a relatively stable concentration of extracellular polymer substances (EPS) was observed, indicating that the influence of conductivity on EPS cannot be directly correlated.