Low avascular necrosis rates in femoral neck fractures: efficacy of cannulated screw fixation.

PURPOSE: Cannulated screw fixation for femoral neck fractures is often limited by concerns of avascular necrosis (AVN) occurring, historically seen in 5-40% of fixed intracapsular fractures. This study aims to assess the outcomes, particularly the AVN rate, associated with current surgical techniques within our unit. METHODS: We conducted a single-center cross-sectional study, manually searching operative records between July 14, 2014, and December 1, 2018, identifying patients with intracapsular fractured neck of femur fixed with cannulated screws, with a minimum of two years follow-up. Patient records and radiographs were reviewed for clinical and radiographic diagnoses of AVN, non-union, post-operative metalwork infection, and screw penetration of the head. Additionally, fracture pattern and displacement, screw configuration, reduction techniques, and adequacy of reduction were recorded, with radiographs independently analyzed by four orthopedic surgeons. RESULTS: Fifty-six patients were included; average age of 67 years (range 30-100). Forty-two patients (75%) sustained displaced fractures and 14 patients (25%) had undisplaced fractures. Two (4%) patients developed AVN, with no cases of non-union, post-operative metalwork infection or screw penetration of the head. Eight patients (14%) sustained a high-energy injury, though none of these patients developed AVN. All fractures required closed reduction; no open reductions performed. Twenty-seven (64%) of reductions were adequate. CONCLUSION: Our observed AVN rate is notably lower than the widely reported figures, even among a significant proportion of displaced fractures that were fixed. This study underscores that with adequate fixation, cannulated screws represent an excellent option for treating intracapsular neck of femur fractures, even in cases of displaced fracture patterns with imperfect reduction.

Rectal stump management in inflammatory bowel disease: a cohort study, systematic review and proportional analysis of perioperative complications.

BACKGROUND: The aim of this study was to analyse local single-institution data and perform a systematic review of the literature to calculate precise risk estimates of rectal stump-related morbidity and mortality following subtotal colectomy in patients with inflammatory bowel disease (IBD), including Crohn's colitis, ulcerative colitis and indeterminate colitis. METHODS: Institutional information systems were interrogated to obtain local patient data. A systematic review of MEDLINE and EMBASE was performed to identify relevant articles. Fixed-effects or random-effects meta-analysis of proportions was performed to calculate pooled incidence estimates, including local data. RESULTS: Sixty-one patients were included locally and all had their rectal stump closed intra-abdominally. Four patients (8.3%) had a rectal stump perforation and 30-day mortality was 0. Fourteen papers were included in our review alongside local data, with a total of 1330 patients included. Pooled mortality was 1.7% (95% confidence interval, CI 1.0-2.8), pooled incidence of pelvic abscess/sepsis, stump leak and wound infection was 5.7% (95% CI 4.4-7.3), 4.9% (95% CI 3.7-6.6) and 11.3% (95% CI 7.8-16), respectively. Subcutaneous placement of the stump was associated with the highest incidence of stump leak (12.6%, 95% CI 8.3-18.6), and closure of the stump with both staples and suture was associated with the highest incidence of pelvic abscess (11.1%, 95% CI 5.8-20.3). Mortality and the incidence of wound infection were similar across stump closure techniques. There was evidence suggesting considerable heterogeneity and publication bias among studies. CONCLUSIONS: This study provides estimates of morbidity associated with the rectal stump after subtotal colectomy for IBD. A closed intra-abdominal stump seems to be associated with the highest rate of pelvic abscess/sepsis. Further work in form of an international collaborative project would allow individual patient data analysis and identification of risk factors for complications.

MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up.

The MatOrtho proximal interphalangeal replacement is a cementless cobalt-chromium metal-on-polyethylene mobile-bearing surface replacement arthroplasty. The aim of this study is to report the outcome and complications of this implant at a minimum of 2 years follow-up from a single institution. A retrospective case review was performed on all MatOrtho proximal interphalangeal joint replacements performed with a minimum of 2 years follow-up. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated at latest follow-up, including pain scores, range of motion, function and radiographic assessment. A total of 109 implants were inserted in 56 patients. Nine implants (six patients) were lost to follow-up. Of the remaining 100 implants, 75 had been undertaken in females. The mean age at time of surgery was 64 years and the principal diagnosis was osteoarthritis in 74%. The mean follow-up was 47 months (range 24-77). Within the group there was a statistically significant diminution in pain. There was also an improvement in functional scores post-operatively. Improvement in range of motion was seen in those joints with a pre-operative range of motion greater than 20°. Radiologically there was no evidence of loosening or of implant subsidence at final follow-up. The revision rate was 13%. Nine joints were revised to the NeuFlex (silicone rubber) prosthesis, three were converted to an arthrodesis and one had exchange of the MatOrtho prosthesis. The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. Patients can be advised that the procedure achieves good pain relief, improvement in functional scores and may improve range of motion. We would, however, caution against this implant's use in joints that are either stiff or have significant deformity and/or instability pre-operatively.

The path of screw insertion for stabilization of the scapholunate joint: a cadaveric study.

The aim of this study was to determine the path of screw placement to avoid breaching the articular surface of both lunate and scaphoid bones at the radiocarpal and midcarpal joints. An Acutrak screw was inserted into the right scapholunate joint of ten cadavers starting immediately distal to the tip of the radial styloid and aiming for the tip of the ulnar styloid. The articular surfaces of the scaphoid and lunate bones in all ten cadavers were exposed and examined. A computed tomography (CT) scan of four wrists was performed. Eight of the ten cadavers had no perforation or destruction of the articular surfaces. Screw stabilization of the scapholunate joint can be performed without perforation or destruction of the lunate or scaphoid surfaces. We recommend that if this form of fixation is being used then the screw should be inserted commencing at the radial styloid tip and aiming for ulnar styloid tip, under radiological guidance.