Complication rates after proximal femoral nailing: does level of training matter?

BACKGROUND: Surgical treatment of pertrochanteric fractures is one of the most performed surgeries in orthogeriatrics. Proximal femoral nailing, the most performed procedure, is often used as a training surgery for young residents. The objective of this study was to evaluate the relevance of the resident's training level to complication rates. MATERIAL AND METHODS: This study was a retrospective cohort study. Surgeons were divided into four groups according to their training level. Complications included infection, cut-out, and revision surgery. The study was performed at a level 1 trauma center. All patients who were treated with proximal femoral nailing surgery with a radiological follow-up of at least 3 months were included. RESULTS: Of the 955 patients extracted, a total of 564 patients met the inclusion criteria. Second-year residents had significantly higher cut-out rates (p = 0.012). Further analysis indicated a correlation between level of training and surgery duration (p < 0.001) as well as a correlation between surgery duration and infection rate (p < 0.001). The overall complication rate was 11.2%. Analyzing overall complications, no significant difference was found when comparing surgeon groups (p = 0.3). No statistically significant difference was found concerning infection (p = 0.6), cut-out (p = 0.7), and revision surgery (p = 0.3) either. CONCLUSION: Complication rates after proximal femoral nailing are not higher in patients who are treated by residents. Therefore, proximal femoral nailing is an excellent procedure for general orthopedic training. However, we must keep in mind that accurate positioning of the femoral neck screw is essential to keep cut-out rates as low as possible.

[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

Braided polypropylene augmentation device in reconstructive surgery of the anterior cruciate ligament: long-term clinical performance of 594 patients and short-term arthroscopic results, failure analysis by scanning electron microscopy, and synovial histomorphology.

Long-term clinical results and short-term arthroscopic and microscopic findings from two augmented reconstruction procedures for the ruptured anterior cruciate ligament are reported. The braided polypropylene ligament augmentation device (Kennedy model) was used with temporary double-end fixation in 279 patients to augment the attachment of the anterior cruciate ligament after acute proximal rupture and in 315 patients to augment a bone-tendon-bone autograft, mainly after chronic instability. Check arthroscopy was performed and the metal fixation hardware was removed after a mean of 11 months. Of the 569 patients evaluated, 101 partial or total breakages of the ligament augmentation device were found. Together with nine breakages detected late in the follow-up period, 110 (19.3%) failures were found. Most of these failures were accompanied by effusion that was immediately alleviated when the failed device was removed. No generalized synovitis was visible. Scanning electron microscopic analysis of 24 retrieved failed ligament augmentation devices showed fatigue to be the principal failure mode, together with local abrasion at the fracture. Synovial biopsies were taken during arthroscopy in 84 patients with and without ligament augmentation device-failure who had given informed consent, and histological evaluation revealed that in 21 patients, chronic but no acute synovial inflammation was found, and wear particles could be identified in foreign body cells in 17. Statistically, the presence of chronic synovitis was predicted neither by wear particles and foreign body cells nor by abrasion or fatigue failure of the ligament augmentation device. Irrespective of the failures, for which ligament augmentation device removal is recommended, in the final Orthopaedische Arbeitsgemeinschaft Knie evaluation (after a mean of 6.2 years), excellent and good clinical results were found in 83.6% of all 594 patients.

Twisting of patellar tendon grafts does not reduce their mechanical properties.

The purpose of this study was to investigate whether the twisting of a patellar tendon (PT) graft improves or reduces its mechanical properties. Twenty-seven pairs of 10 mm cadaveric PT grafts were tested at a strain rate of 10% min(-1). For each pair, the left specimen served as an unmanipulated control while the right specimen was either left untwisted, twisted + 90 degrees, or twisted - 90 degrees. All avulsion failures were excluded from the data analysis, focusing only on pure in-substance tendon ruptures. Higher ultimate load values than previously reported were obtained for both the twisted and untwisted specimens, without a statistical significant difference between the two. The values obtained for the left and right specimens from Group A were 4014+/-319 and 3973+/-245 N, from Group B 3613+/-207 and 3891+/-14 N, and from Group C 3997+/-278 and 4415+/-507 N, respectively. Stiffness and failure strain were not influenced by the twisting. Neither the presence of a twist, nor the direction of the twist were found to increase the ultimate load of the 10 mm cadaveric patellar tendon graft. Therefore, recommendation for twisting cannot be assessed to its mechanical properties.

[Diagnosis of pelvic fractures: synoptic views of the pelvis versus CT]. / Diagnostik von Beckenfrakturen: Beckenübersichtsaufnahmen versus CT.

An attempt has been made, using 21 patients with pelvic fractures, to determine the circumstances in which plain films provide adequate information and when additional information can be obtained by CT. It was found that in all cases of acetabular fractures the diagnosis could be suspected on plain films, but that it proved impossible to demonstrate accurately the position of fragments, the degree of dislocation or the presence of intra-articular bone fragments. These problems could be solved by using CT. In patients with injury to the sacro-iliac joints or of the sacrum, the extent of the injury and the degree of pelvic instability was better shown by CT. All other bony lesions, such as fractures of the ilium, pubis, ischium or the symphysis could be diagnosed adequately by simple radiographs.

[Long-term results of selective proximal vagotomy]. / Langzeitergebnisse der selektiv-proximalen Vagotomie.

Highly selective vagotomy was performed in 361 patients over the past 10 years. The mortality was 0.3% in uncomplicated, and 1.6% in complicated duodenal ulcer. With a mean follow-up period of 52 months the recurrence rate was 7.4%. The known advantages of this operation, namely low mortality and low postoperative morbidity (dumping 0.8%, diarrhoea 0.8%, unintentional weight loss 0%, food intolerance 1.9% and epigastric fullness after meals 1.9%), were confirmed in our patients. The overall clinical result was excellent or good (Visick I or II) in 87% of patients. Clinical failures were most often caused by recurrent ulceration. Highly selective vagotomy is still the operation of choice in uncomplicated duodenal ulcer. It can also be recommended in selected cases of complicated ulcer disease.

[Differential treatment of post-traumatic carpal tunnel syndrome]. / Differenzierte Behandlung des posttraumatischen Karpaltunnelsyndroms.

The pathogenesis and treatment of posttraumatic compression of the median nerve in the carpal canal are analysed in 36 patients. Nine patients had mal-union of a Colles' fracture. In these patients the symptoms of median nerve compression were completely relieved by correction osteotomy of the radial metaphysis, which also improved radiocarpal joint function. At follow-up examination after four years the results were satisfactory and the median nerve appeared normal in clinical and electro-physiological tests. In the other twenty-seven patients there had been a Colles' fracture in seventeen, healed with a deviation of less than 10 degrees; a carpal bone fracture in three cases; in seven patients no osseous lesion was found. In these patients the flexor retinaculum was split and resected. An anterior callus was removed in three cases. At reexamination after four years four patients still noticed diminished sensibility in the median nerve distribution, and in four cases there was wrist joint pain in relation to exercise.

[Results and analysis of poor results after conservative therapy of distal radius fracture]. / Ergebnisse und Analyse von Misserfolgen der konservativen Therapie bei distaler Radiusfraktur.

The authors report on the results of a follow-up study of 120 conservatively treated distal radius fractures. Follow-up averaged 35 months (25 to 48 months). The quality of initial reduction has a crucial impact on the final outcome. 87 fractures showed nearly perfect anatomical reduction, of these, 48 resulted in excellent, 16 in good, 15 in satisfactory, and 8 in poor final anatomical outcomes. In comparison, in 33 fractures with unsuccessful initial reduction, only two cases gave excellent and 12 cases good results (42%); 11 fractures were considered satisfactory and 8 poor. The necessity of a second reduction was significantly lower in the first group of initially well-reduced fractures when compared to the second group: 8 (9.2%) to 14 (42.4%) respectively. Evaluation of the functional outcome according to the Sarmiento scheme showed a strong correlation between the AO fracture classification and the final outcome. In group A fractures, 78% gave excellent or good, 22% satisfactory or bad results. Type B fractures gave 82% excellent or good and 18% satisfactory or poor results. In group C, only 50% reached excellent or good results, the C 3 fractures having the worst prognosis, achieving excellent or good results in only 20% of the cases. Regression analysis demonstrated a significant correlation between anatomical and functional outcome.

[Risk of injuries in snow boarding]. / Verletzungsrisiken beim Snowboarden.

Survey of a group of injured snowboarders and analysis of their sustained injuries and risk factors in comparison to experience level and equipment. 55% of all injuries occurred within the first 7 days of learning how to ride the snowboard. The affected body region of 36% of all injuries and 53% of the severe injuries was the wrist. The primary mechanism of injury was through low-velocity falls on hard or icy snow, essentially a loss of balance with backward fall onto out-stretched arms leading to hyperextension and trauma to the wrist.

[Value of primary stabilization of femoral shaft fractures in patients with simple and multiple injuries]. / Der Stellenwert der Primärstabilisierung von Oberschenkelschaftfrakturen bei einfach- und mehrfachverletzten Patienten.

There is a variety of opinions about the optimal time when to stabilise femoral shaft fractures. The data of 100 patients were analysed in order to compare primary versus secondary intramedullary stabilisation. The rate of wound infections and of other concomitant complications was significantly lower after primary osteosynthesis which is therefore superior to secondary stabilisation in both kinds of patients--those with single and those with multiple injuries. In the group of 50 patients with immediate surgery four complications altogether were found, including one wound-infection, whereas in the group of 50 patients with delayed surgery there was a total of twelve complications, including five wound-infections and six cases of fat- and pulmonary-embolism. The average duration of stay in hospital was only 17 days after primary but 28 days after secondary surgery.

[Importance of measuring stability and function in knee ligament surgery]. / Bedeutung der Stabilitäts- und Funktionsmessung in der Kniebandchirurgie.

To compare results in knee ligament surgery between different surgeons and between different centers, too, is difficult. We investigated if an improvement can be achieved by using easy to handle methods of measurement. The long-term results of 180 patients who underwent ACL surgery between 1983 and 1986 (n = 191) were evaluated. For international comparing of our results we used the scoring of the OAK (Orthopädische Arbeitsgemeinschaft Knie). In addition stability was measured by use of the KT-1000 arthrometer and function by "one leg hop for distance". Together with different usual functional tests those two methods were investigated for being comparable, practicable, and relevant. We found that both measurements came up to these conditions. We succeeded in rating the patients' result by measuring KT-1000 and one leg hop for distance. Examination after knee ligament surgery has to contain these two parameters for international comparison.

[Results of conservatively treated radius fractures at typical sites]. / Ergebnisse von konservativ behandelten Radiusfrakturen an typischer Stelle.

The results of 78 displaced Colles' fractures treated with reduction and below-elbow plaster were investigated. The follow-up varied from 11 to 24 months (phi 14 months). According to the schema of Sarmiento 66.7% of the patients had a very good or good result; 33.3% had a moderate or poor result. Most of the poor results were intraarticular fractures type C (AO). Primarily anatomical reduction leads to the best results. Every further reduction leads to a poor result, as well as to a higher number of Sudeck's disease.

[The surgical treatment of humeral shaft fractures]. / Die operative Versorgung von Humerusschaftfrakturen.

This is a study of 84 patients with upper arm fractures who were treated by plate osteosynthesis. The indication was mandatory in 9 patients with open fractures, 23 patients with primary radial nerve palsy on admission, 5 patients with radial nerve palsy after the initial treatment, 22 patients with pseudarthrosis and 7 patients who were polytraumatised. The operation was also indicated in 15 patients, because of the form of the fracture, in 3 patients with brachial plexus lesion, in 3 patients because it involved both upper arms and in 3 patients with segmental fractures. The 4.5 DCP was used in all these cases. All the cases of pseudarthrosis progressed to achieve bony union after the operation. There was no incidence of postoperative pseudarthrosis. We did encounter two cases (2.4%) of radial nerve palsy that required exploration. All the preoperative primary and secondary cases of radial nerve palsy recovered postoperatively. After an average follow-up period of 2.4 years (1-10 years) 90% of the patients could be classified as having very good or good results.

[Percutaneous drill wire fixation in treating distal radius fractures at risk of dislocation]. / Die perkutane Bohrdrahtfixation zur Behandlung dislokationsgefährdeter distaler Radiusfrakturen.

We are presenting an investigation of 47 cases treated with Kirschner wire fixation using drill wires for distal radius fractures. The average study period was 18 months after the fixation (13-25 months). Using Sarmiento's ratings we obtained the following results: 21 patients were rated as excellent, 19 as good, 6 as fair and 1 as poor. In contrast to a good reduction with a stepless joint surface, the initial fracture form and displacement does not influence the functional end results.

[Transfixation in treatment of comminuted fractures of the distal end of the radius]. / Die Transfixation zur Behandlung von Trümmerbrüchen am distalen Speichenende.

In comminuted fractures of the distal radius we apply our own method of transfixation. A Kirschner-wire is put through the bases of the metacarpal II-V, in addition an above elbow-plaster is applied. 47 persons (38 female, 9 male, age: phi 69 a) treated by this method have been checked-up after 16 months (26-5 months). In spite of the predominantly negative prognosis of the C3 fracture, according to the scheme of AO, we found out in our check-up considering principles of Sarmiento a good or a very good result in 41 cases (87%).

[Surgical complications following implantation of femur head prostheses in a traumatology patient sample. Prevention and therapy]. / Chirurgische Komplikationen nach Implantation von Hüftkopfprothesen in einem traumatologischen Krankengut. Prophylaxe und Therapie.

At the 1st University-Clinic of Traumatology, Vienna, 420 patients with a medial fracture of the femoral neck received a femoral neck prosthesis (59 male, 361 female, phi age 81.3 years; range: 60-97 years). Severe early complications were fractures of the femoral shaft in 1.19%, that healed without problems after cerclage and plate osteosynthesis, and early infections in 3.1%. The rate of infections can be reduced to 1% prophylactic administration of antibiotics, surgery in an laminar airflow operating theater, and by the use of cement containing antibiotics. Dislocation of the prosthesis was observed in 2 patients (0.47%). the low rate of dislocation appears to be due to the antero-lateral operative approach according to Watson-Jones without osteotomy of the trochanter as well as to the precise technique of implantation of the prosthesis. More frequent late complications were periarticular calcification in 20 cases (4.7%) and protrusion in 18 cases (4.28%). However, only one out of the patients with calcification is restricted in his movements, and only 3 out of the patients with protrusion do complain of symptoms. The low rate of symptomatic protrusions is explained by a correct level of resection, by the implantation of a head prosthesis with appropriate dimensions and by the exclusion of patients with arthrosis of the hip or severe osteoporosis from the implantation of a femoral head prosthesis.

[Biological reaction to alloplastic reinforcement of the anterior cruciate ligament]. / Biologische Reaktion auf alloplastische Verstärkungen des vorderen Kreuzbandes.

Control arthroscopy in usually done 6-12 months after reconstruction of the ACL with ligamentum patellae transplant augmented with LAD using Marshall's technique. During these control arthroscopies the metal implants are removed and a biopsy of the synovial lining was performed in 38 cases. We normally anchor both ends of the LAD to obtain better stability and these anchors are removed after 6-12 months (release of the fixation points). Up to now control arthroscopy has been performed on 97 patients, who had their ACL reinserted and 114 patients, whose ACL were replaced by ligamentum patellae transplant, in both cases augmented with LAD. The control arthroscopy revealed 11 cases of tears of the LAD in case ACL were reinserted and 24 cases of LAD tears in case LAD were replaced by ligamentum patellae transplant. The findings of 38 biopsies of the synovial lining are as follows: In 18 cases LAD tears, in 15 cases foreign body reactions with wear particles and an instance of lymphocytic infiltration of the synovia was seen. In 20 cases arthroscopy was inconspicuous: In 2 cases wear particles were seen and lymphocytic infiltration in a single case. In all cases of LAD tears with foreign body reactions the LAD was removed.

[Control arthroscopy following alloplastically augmented anterior cruciate ligament reconstruction]. / Kontrollarthroskopie nach alloplastisch augmentierter vorderer Kreuzbandrekonstruktion.

97 patients who had their ACL replaced with ligamentum patellae transplant augmented with LAD were reviewed arthroscopically after an average period of 9.1 months (4-22 months). 52 patients whose metal implants have been removed are virtually symptom-free clinically (no swelling, stable knee joint, extension limitation of less than 5 degrees, less than 10 degrees limitation of flexion). Arthroscopy on these 52 patients revealed the following; no abnormalities in 37, 11 cases of cartilage lesions, 1 case of medial meniscal tear and 7 cases of LAD tears. 45 patients who have also had their metal implants removed have complaints, arthroscopy revealed the following; hypertrophy of Hoffa's fat pad in 5 cases, 3 cases of medial meniscal tears, 2 cases of lateral meniscal tears. Tears of the LAD were seen in 9 cases. In 2 cases the transplant was missing, in 5 cases the transplant was elongated and in 2 cases the transplant showed normal structure. There were cartilage lesions in 9 cases, 4 cases of synovitis and scar tissue adhesion in 3. In all there were 16 cases of LAD tears, in 9 out of these 16 cases the transplant ACL of good structure. All of this knees were stable. Control arthroscopy is routinely carried out when we remove the metal implants. This enables us to detect any early problems, such as limitation of extension or swelling, assess the success of the operation and commence the corresponding additional therapy.