Risk factors for postoperative urinary retention in fragility hip fracture patients: a prospective study.

BACKGROUND: Postoperative urinary retention (POUR) among older patients with hip fractures is common and may result in delayed ambulation, prolonged hospital stays, and urinary tract infections. Although preoperative urinary catheter indwelling and early postoperative removal can prevent perioperative urinary retention, this condition may occur in some patients after catheter removal, which requires urinary catheter re-indwelling or intermittent catheterization. Therefore, this study aims to identify risk factors and develop a screening tool for postoperative urinary retention in patients who have undergone operative treatment for fragility hip fractures subsequent to urinary catheter removal. METHODS: A prospective cohort study of 145 fragility hip fracture in older patients who were operatively treated between September 2020 and May 2022 was conducted. All patients were evaluated for urine retention after urinary catheter removal using a bladder scan. In addition, factors related to urinary retention were collected and utilized for screening tool development. RESULTS: Of the included patients, 22 (15.2%) were diagnosed with POUR. A multivariable logistic regression model using a stepwise backward elimination algorithm identified the current use of drugs with anticholinergic effect (OR = 11.9, p = 0.012), international prostate symptom score (IPSS) ≥ 8 (OR = 9.3, p < 0.001), and inability to independently get out of bed within 24 h postoperatively (OR = 6.5, p = 0.051) as risk factors of POUR. The screening tool that has been developed revealed an excellent performance (AuROC = 0.85, 95%CI 0.75 to 0.91) with good calibration and minimal optimism. CONCLUSIONS: Current use of drugs with anticholinergic effects, IPSS ≥ 8, and inability to independently get out of bed within 24 h postoperatively are significant variables of POUR. For additional external validation, a proposed scoring system for POUR screening was developed. TRIAL REGISTRATION: The study protocol was retrospectively registered in The Thai Clinical Trials Registry (TCTR20220502001: 2 May 2022).

Biomechanical performance of short and long cephalomedullary nail constructs for stabilizing different levels of subtrochanteric fracture.

INTRODUCTION: The aim of this study was to assess biomechanical performance of short and long Cephalomedullary nail constructs consisting of different number of distal screw for stabilizing different levels of subtrochanteric fracture. MATERIALS AND METHODS: The femur obtained from computed tomography scanner was used to create a transverse fracture at 15 mm (level A), 35 mm (level B), and 55 mm (level C) below the lesser trochanter. Short and long Cephalomedullary nails were virtually inserted to the fractured femur. Four-node tetrahedral element was used to build up finite element (FE) models for biomechanical analysis. The analysis focused on post-operative stage of partial weight-bearing. RESULTS: Stress on the implant localized at the surface between lag screw/nail and distal screw/nail. Short Cephalomedullary nail exhibited higher stress than long Cephalomedullary nail. The stress in short Cephalomedullary nail could be reduced by using two distal screws fixation and the fracture at level A produced less stress than that of level B and C. Either short or long nail with two distal screws is sufficient to withstand the stress magnitude produced from the physiologic load. When single dynamic distal screw was used, stress on implant, elastic strain at fracture gap, and bone stress reached the high values. Elastic strain of the fracture gap at level C were less than that of level A and B, but no statistically significant difference. There was no proximal cancellous bone damage observed from the FE analysis. CONCLUSIONS: Long Cephalomedullary nail with at least two distal locking screws remains a proper implant for subtrochanteric fracture fixation in overall locations. However, short Cephalomedullary nail with two distal screws may be a candidate for a high subtrochanteric fracture. Single dynamic screw insertion is strongly not recommended with either short or long nail regarding implant failure.

Breakage of a Lag Screw of Cephalomedullary Nail: A Technique of Removal.

A broken lag screw of the cephalomedullary nail is a rare condition. Removal of the retained lag screw from the femoral head is also very challenging. This article describes a surgical technique and the modified instrument that was available in the operating room for removing the broken implant by closed technique.

Radiation exposure in fluoroscopy of the shoulder: a comparison between mini and conventional C-arm image intensifier.

OBJECTIVE: To compare the radiation exposure of the primary surgeon while using the conventional c-arm and mini c-arm fluoroscopy at the shoulder MATERIAL AND METHOD: Twelve shoulders of six fresh cadavers were used to simulate this experimental study. Radiation exposure of the primary surgeon was measured at the head and neck region. The average radiation dose was measured using both the conventional c-arm and mini c-arm, then the findings were compared. RESULTS: Mean radiation energy of the conventional c-arm was significantly lower than the mini c-arm at 59.39 ± 1.43 kV and 70.58 ± 4.01 kV respectively (p < 0.001). Dose rates to which the primary surgeon was exposed from the conventional c-arm and the mini c-arm were 81.46 ± 30.37 µSv/hour and 87.54 ± 43.69 µSv/hour, respectively. However, the difference was not statistically significant (p = 0.875). CONCLUSION: There is no difference in the level of radiation safety for the primary surgeon when using the conventional c-arm vs. the mini c-arm for a fluoroscopic-assisted shoulder procedure. Therefore, selection of the methodology should be based on equipment availability and clinical considerations.

Risk of vascular injury at the proximal tibia for medial narrow locking plate fixation: an anatomical study using CT angiogram.

OBJECTIVE: To evaluate possibility of screw-related vascular injury at proximal tibia while using medial narrow tibial locking plate. MATERIAL AND METHOD: Cross-sectional images of CTangiographs (33 samples) at levels corresponding with the screw holes of a narrow locking plate were used to evaluate the risk of vascular injury relating to screw insertion. This was performed by measuring the distance and angle between the screw trajectory in each hole and the columns of arteries at the proximal tibia. RESULTS: There is a higher risk of injury to the anterior tibial artery than to the posterior tibial artery in cases of perfect placement of a medial locking plate for osteosynthesis of the tibial shaft fracture. In instance of plate tilting, thus causing a deviation ofscrew trajectory of up to 20 degrees from the perpendicular axis of the middle 1/3 of medial tibial surface, the posterior tibial artery is also at risk of being injured. CONCLUSION: Vascular injury relating to locking screw insertion from the medial aspect of the tibia is still a risk. To prevent vascular injury, the plate should be positioned in the middle 1/3 and parallel to the medial tibial surface. Attachment of the instrument beyond the far cortex of the tibia stillpresents a risk of injuring the tibial artery.

Prevention of excessive medialisation of trochanteric fracture by a buttress screw: a novel method and finite element analysis.

This paper proposes a novel method of using an antero-posterior buttress screw at the distal fragment just below the fracture site in conjunction with the sliding hip screw (SHS) to resist excessive femoral medialisation. A virtual assessment of the effectiveness of this new method was performed using the finite element analysis. The results indicate that the use ofa sliding hip screw (SHS) combined with a buttress screw can help resistfemoral medialisation better than using an SHS with no buttress screw. The von Mises equivalent stress (EQ ) was found to be in a safe range, which indicates increased integrity of the lateral wall with the addition of the buttress screw.

Removal of a broken cannulated femoral nail: a novel retrograde impaction technique.

This report presents a surgical technique to remove a broken cannulated nail from the femur. A Harrington rod was modified for retrograde impaction of the retained fragment. The broken implant was finally removed without complication. This particular procedure was safe, simple, and promising.

Posterior acetabular arc angle of unstable posterior hip fracture-dislocation.

PURPOSE: Posterior hip fracture-dislocation needs stability evaluation. A previous study in the normal acetabulum has shown that the coronal posterior acetabular arc angle (PAAA) could be used to assess an unstable posterior hip fracture. Our study was designed to assess PAAA of unstable posterior hip fracture-dislocation and whether posterior acetabular wall fracture involves the superior acetabular dome. METHODS: Using coronal computed tomography (CT) of the acetabulum and 3D reconstruction of the lateral pelvis, we measured coronal, vertical PAAA and posterior acetabular wall depth of 21 unstable posterior hip fracture-dislocations and of 50% normal contralateral acetabula. Posterior acetabular wall fracture was assessed to determine whether the fracture involved the superior acetabular dome and then defined as a high or low wall fracture using vertical PAAA in reference to the centroacetabulo-greater sciatic notch line. RESULTS: The coronal PAAA of unstable posterior hip fracture-dislocations and of 50% of the posterior acetabular wall of normal the contralateral acetabulum were 54.48° (9.09°) and 57.43° (5.88°) and corresponded to 15.06 (4.39) and 15.61 (2.01) mm of the posterior acetabular wall without significant difference (p > 0.05). The vertical PAAA of unstable posterior hip fracture-dislocation was 101.67° (20.44°). There were 16 high posterior acetabular wall fractures with 35.00 (16.18) vertical PAAA involving the acetabular dome and 5 low wall fractures. High posterior wall fractures resulted in four avascular necroses of the femoral head, three sciatic nerve injuries and one osteoarthritic hip. CONCLUSION: Coronal and vertical PAAA of unstable posterior hip fracture-dislocations were 54.48° and 101.67°. Vertical PAAA assesses high or low posterior acetabular wall fracture by referring to the centroacetabulo-greater sciatic notch line. High posterior wall fracture seems to be the most frequent and is involved with many complications.

Patients with osteoporotic hip fractures: factors affecting length of hospital stay (LOS) and outcome.

OBJECTIVE: Identify risk factors associated with prolonged hospital stay (LOS more than 14 days) in patients with osteoporotic hip fracture. MATERIAL AND METHOD: One hundred and fifty out of 356 patients with fractured femur were selected between April 2008 and August 2009. Analysis of patient's LOS (group I equal or less than 14 days, group II more than 14 days) is performed by backward binary multiple logistic regression. RESULTS: LOS in group I (n=46) was 12.5 (+/- 4) days compared to 21 (+/- 11) days in group II (n=104). Patients were mainly female (74%) and about 50% were aged over 80 years. The 30-days mortality in group I and II was zero and two patients respectively. Time-to-surgery was three days (+/- 2) in group I and seven (+/- 5) days in group II. Significant predicting risk factors were waiting for investigation (odds ratio (OR) 3.77, confidence interval (CI) 1.12-12.69) and receiving systemic opioids (OR 3.44; CI 1.54-7.66). CONCLUSION: Unnecessary surgery delay after hip fracture should be avoided. Higher need for opioids in those patients might be the result of prolonged waiting for surgical treatment.

Comparison of the effectiveness in bacterial decontamination between chlorhexidine gluconate and povidone-iodine solution in foot and ankle: a pilot study.

BACKGROUND: The decontamination for foot and ankle surgery should be considered as a special preparation due to higher rate of bacterial contamination. The footwear and humidity is also the issue of interest especially in tropical country. The contamination before surgery should be reduced to avoid the infection. The effectiveness of antiseptics and special condition for the foot and ankle surgery should be elucidated for better medical care. MATERIAL AND METHOD: The twenty volunteers were included in the present study. In group 1, the foot was scrubbed with 7.5% Povidone-lodine and painted with 10% Povidone-lodine solution. In group II, the foot was scrubbed with Chlorhexidine gluconate scrub and painted with 2% Chlorhexidine gluconate in 70% alcohol. At the beginning and end of the preparation, specimens were taking from all toes, nailfold, interdigital web spaces. These samples were sent for aerobic bacterial cultures. The results were interpreted as positive or negative cultivation and the number of bacterial colonies. RESULTS: All of the samples from 40 feet were collected; In Group I, positive culture was 5 samples (25%). In Group II, positive culture was 2 samples (10%) (p = 0.2). CONCLUSION: The Chlorhexidine gluconate and Povidone-lodine are effective in reduction the number of bacterial colonization. The steps of preparation before surgery also play an important role in eliminating the pathogenic bacteria. Both antiseptics were found no significant different in efficacy of pathogenic bacteria reduction.

Innervation of the elbow joint and surgical perspectives of denervation: a cadaveric anatomic study.

PURPOSE: Peripheral articular denervation has been proposed as an alternative treatment for degenerative arthritis. It shows particular promise in the elbow because the joint is non-weight bearing and easily exposed. Accurate knowledge of peripheral neuroanatomy is required for future denervation surgeries, yet very few studies focus on the articular branches of the ulnar, median, and radial nerves that provide elbow capsule innervation. METHODS: Twenty-three upper limbs from skeletally mature fresh-frozen cadavers were used for dissection of the ulnar, median, and radial nerves. The presence, number, location, and diameter of articular branches to the elbow capsule were recorded. RESULTS: The ulnar nerve typically supplied 1 to 2 large branches to the elbow capsule (range, 0-4). In the 3 specimens with a greater number, a thinner diameter was noted (<1 mm compared with 1.2 mm). The median nerve contributed an average of 1.3 branches (range, 0-4) and showed an inverse ratio with the ulnar nerve contribution. The posterior interosseous nerve contributed a range of 0 to 4 branches, arising at 5 mm to 2 mm after bifurcation of the radial nerve. CONCLUSIONS: Most previous upper-extremity nerve studies have failed to fully characterize the contributions of all 3 major nerves to capsular innervation. We have thoroughly documented the articular branching patterns of all 3 major nerves and show that all 3 may contribute branches to the capsule.

Removal of broken long gamma nail: a modified guide wires technique.

We report a simple alternative procedure, modified ball-tipped guide wires technique, to remove a broken long gamma nail at the level of lag screw hole which is detected during a removal procedure. The fragment retained in the medullary canal was successfully removed without complication.

Technique of closed unlocked femoral nailing using ultrasound guidance.

We report a method of closed femoral nailing, without locking, using only ultrasound guidance from the beginning to end of the operation. The method was evaluated as a prospective study in 150 cases of unilateral femoral mid-shaft fracture that underwent surgery within 1 week. There were 132 males and 18 females aged from 16 to 70 years (mean 26). The interval from injury to operation averaged 2.3 days (range 1-7). Twenty-seven cases had Winquist I comminution and 123 cases had no comminution. In 145 cases (97%), we were successful using this method, with an average operation time of 35.8 min (range 30-50). In five cases, we had to change to using fluoroscopic control. Of these, in one case the fracture could not be reduced under ultrasound monitoring, one had nail incarceration, in one there was breakage of the flexible reamer and in two cases we were unable to pass the guide-wire across the fracture within 10 min. Ultrasound is readily available in most hospitals and can be used as an alternative method for monitoring the fracture alignment in closed unlocked femoral nailing.

Radiation scattering to the primary surgeon during closed locked femoral nailing.

A prospective study of the radiation exposure to the primary surgeon during closed static locked femoral nailing was performed in 50 cases. There were 44 males and 6 females whose ages ranged from 15 to 70 years (average, 32). The degree of fracture comminution was classified by Winquist. The cases included 1 Winquist (WQ)1, 9 WQ2, 27 WQ3 and 13 WQ4. The Grosse-Kempf femoral nail was used in 40 cases and the AO interlocking femoral nail was used in 10 cases. The C-arm image intensifier model Phillip BV212 and BV 300 were used during the present study. The average operation time was 52 minutes (range, 30 to 120). The fluoroscopic time for the entire procedure average 132 seconds (range, 23 to 366). The radiation exposure to the primary surgeon ranged from 2 to 231 micro-Sv with an average of 30 micro-Sv per procedure. From the present study, it was found that radiation scattered to the primary surgeon during current practice for closed static femoral nailing using the recent model of C-arm image intensifier was minimal and far below the permissible dose. It was also found that the group using the C-arm model BV 300 (n = 16) had significant lesser fluoroscopic time and less radiation scattering to the primary surgeon than the group with model BV 212 (n = 34).

A protector for retrograde femoral nailing using proctoscope.

An improvised method of using a proctoscope as a protector during the reaming procedure for closed retrograde femoral nailing is described. This protector is easy to handle and can be effectively used to protect the intra-articular structures, patellar cartilage and patellar tendon during the reaming process. The protector can also help minimise the reaming bone dust spilling out into the joint cavity.

Capture of the screw during percutaneous screw insertion.

The simple technique to maintain the engagement of the screw and the screw driver during percutaneous locking screw insertion is presented. The method can capture the screw when the screw becomes disengaged. This will be helpful when percutaneous screw insertion is performed in the narrow and deep location of the bone such as a locking screw at the upper part of the femur during retrograde femoral nailing.