Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

INTRODUCTION: The British Orthopaedic Association published 2019 guidelines 'The Older or Frail Orthopaedic Trauma Patient'. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population. MATERIALS AND METHODS: We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality. RESULTS: We identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14). CONCLUSION: Patients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.

Anatomic ACL reconstruction: the normal central tibial footprint position and a standardised technique for measuring tibial tunnel location on 3D CT.

PURPOSE: The aim of this study was to define the normal ACL central tibial footprint position and describe a standardised technique of measuring tibial tunnel location on 3D CT for anatomic single-bundle ACL reconstruction. METHODS: The central position of the ACL tibial attachment site was determined on 76 MRI scans of young individuals. The central footprint position was referenced in the anterior-posterior (A-P) and medial-lateral (M-L) planes on a grid system over the widest portion of the proximal tibia. 3D CT images of 26 young individuals had a simulated tibial tunnel centred within the bony landmarks of the ACL footprint, and the same grid system was applied over the widest portion of the proximal tibia. The MRI central footprint position was compared to the 3D CT central footprint position to validate the technique and results. RESULTS: The median age of the 76 MRI subjects was 24 years, with 32 females and 44 males. The ACL central footprint position was at 39 (±3 %) and 48 (±2 %), in the A-P and M-L planes, respectively. There was no significant difference in this position between sexes. The median age of the 26 CT subjects was 25.5 years, with 10 females and 16 males. The central position of the bony ACL footprint was at 38 (±2 %) and 48 (±2 %), in the A-P and M-L planes, respectively. The MRI and CT central footprint positions were not significantly different in relation to the medial position, but were different in relation to the anterior position (A-P 39 % vs. 38 %, p = 0.01). The absolute difference between the central MRI and CT reference positions was 0.45 mm. CONCLUSIONS: The ACL's normal central tibial footprint reference position has been defined, and the technique of measuring tibial tunnel location with a standardised grid system is described. This study will assist surgeons in evaluating tibial tunnel position in anatomic single-bundle ACL reconstruction. LEVEL OF EVIDENCE: III.

Anesthetic management of a parturient with varicella presenting for cesarean delivery.

Varicella (chicken pox) infection is associated with a significant risk of maternal and fetal morbidity and mortality. The choice of anesthetic technique, either neuraxial or general anesthesia, in such patients remains controversial. Anesthetic management depends not only on the extent of disease involvement and associated complications, but also on the indication for cesarean delivery. We present the anesthetic management of a 25-year-old parturient with acute varicella infection who underwent emergency cesarean delivery under spinal anesthesia. The risks and benefits of neuraxial anesthesia in the setting of varicella are discussed.

TIGAR induces p53-mediated cell-cycle arrest by regulation of RB-E2F1 complex.

BACKGROUND: p53 induces cell-cycle arrest and apoptosis in cancer cells and negatively regulates glycolysis via TIGAR. Glycolysis is crucial for cancer progression although TIGAR provides protection from reactive oxygen species and apoptosis. The relation between TIGAR-mediated inhibition of glycolysis and p53 tumour-suppressor activity is unknown. METHODS: RT-PCR, western blot, luciferase and chromatin immunoprecipitation assays were used to study TIGAR gene regulation. Co-IPP was used to determine the role of TIGAR protein in regulating the protein-protein interaction between retinoblastoma (RB) and E2F1. MCF-7 tumour xenografts were utilised to study the role of TIGAR in tumour regression. RESULTS: Our study shows that TIGAR promotes p21-independent, p53-mediated G1-phase arrest in cancer cells. p53 activates the TIGAR promoter only in cells exposed to repairable doses of stress. TIGAR regulates the expression of genes involved in cell-cycle progression; suppresses synthesis of CDK-2, CDK-4, CDK-6, Cyclin D, Cyclin E and promotes de-phosphorylation of RB protein. RB de-phosphorylation stabilises the complex between RB and E2F1 thus inhibiting the entry of cell cycle from G1 phase to S phase. CONCLUSION: TIGAR mediates de-phosphorylation of RB and stabilisation of RB-E2F1 complex thus delaying the entry of cells in S phase of the cell cycle. Thus, TIGAR inhibits proliferation of cancer cells and increases drug-mediated tumour regression by promoting p53-mediated cell-cycle arrest.

Re-oxygenation causes hypoxic tumor regression through restoration of p53 wild-type conformation and post-translational modifications.

Hypoxic tumors are resistant to conventional therapies through indirect mechanisms such as the selection of resistant phenotype under chronic hypoxia. Hyperbaric oxygen (HBO) therapy has been shown to increase oxygen level and induce apoptosis in hypoxic tumor. However, it could produce significant adverse effects including oxygen toxic seizures and severe radiation tissue injury due to high pressure. We have shown that repeated oxygenation at 30% O(2) (1 atmospheres absolute) results in significant regression of MCF-7 tumor xenografts without any adverse effect. In MCF-7 cells, re-oxygenation showed an eightfold increase in cellular apoptosis. Both in hypoxic tumor and in hypoxic cells, that exclusively favor p53 to exist in mutant conformation, re-oxygenation restores p53 wild-type conformation. The oxygen-mediated rescue of mutant p53 followed by its trans-activation is responsible for the induction of p53-downstream apoptotic, cell-cycle arrest and DNA-repair genes. Further, p53 trans-activation may thus be due to its post-translational modifications as a result of re-oxygenation. We have thus concluded that oxygen therapy without pressure, as opposed to HBO therapy, may be ideal for hypoxic tumor regression, which functions through oxygen-mediated rescue of mutant p53 followed by induction of apoptosis.

The surgical management of intercostal lung herniation using bioprosthesis.

Lung hernia is a rare occurrence. Consequently there is little literature providing guidance to effective management. Classified as congenital or acquired, there are fewer than 300 cases described in current literature (1). We describe a unique method for the management of spontaneous rib fractures and, resulting posterior lung herniation in a 65 year old man following a bout of coughing.

Study of colour blindness in school children.

Of the 1553 male and 519 female students in schools of Patiala, between the age group of 10 and 15 years, 3.85% males and 0.38% females were found colour-blind. The students were tested by Ishihara Charts, Edridge Green Lantern and then assayed by Pickford Nicolson Anomaloscope and the results were presented in detail. In addition, the affected students were also tested for their acuity of vision and were found normal.