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.

Light and electron microscopic study of stress-shielding effects on rat patellar tendon.

In this second part of our study, the histomorphologic changes occurring in the patellar tendon (PT) of rats after sole stress-shielding were evaluated. In seven adult albino rats, both PTs were exposed by straight skin incision and then stress-shielded on one side by a cerclage, while the contralateral PT served as the sham-operated control. One animal died after the operation and was used as a negative control. After 10 weeks of otherwise unrestricted motion, the rats were killed, and the histomorphology of all PT specimen pairs compared by light and transmission electron microscopy. Light microscopy showed mid-portion thickening and irregularity of collagen bundles in the stress-shielded tendons. Intense remodelling was demonstrated by increased cellularity and vascularity, as well as by enrichment in acidic proteoglycans. Ultrastructural evaluation and morphometry revealed a predominance of large diameter (peak between 180 and 260 nm) collagen fibrils in the sham-operated controls, while in the stress-shielded tendons the number of apparently new, small-diameter (peak between 40 and 60 nm) collagen fibrils increased (up to 77% per cross-sectional field of view). The difference in peak diameters was statistically significant (p < 0.0005). This rat model demonstrated that sole stress-shielding not only causes biomechanical alterations, but also intense tissue remodelling and significant morphological changes in the collagen fibrils in the patellar tendon, comparable to so-called 'ligamentization' in experimental and clinical patellar tendon grafts for anterior cruciate ligament reconstruction.

Risk of injury through snowboarding.

OBJECTIVE: Survey of a group of snowboarders and study of their injuries, as well as analysis of the risk of injury considering the time spent on the snowboard. MATERIALS AND METHODS: Of 7,221 students participating in winter sport programs organized by Austrian schools, 2,745 of those riding snowboards were asked to fill out questionnaires pertaining to demographics, their experience level, equipment, snowboard riding habits, and associated injuries. RESULTS: A total of 2,579 snowboarders (94%), who spent a total of 10,119 days snowboarding, filled out a questionnaire which could be evaluated. A total of 152 snowboarders had suffered a mean of 10.6 injuries per 1,000 days of snowboarding, which required medical care; 5.4/1,000 injuries were moderate or severe. The most common injuries were to the wrist (32%), the hand (20%), and the head (11%). The rate of injury was especially high during the first half-day (roughly 3 hours). Use of wrist protection devices reduced injuries to the wrist from 2 to 0.5% (p = 0.048). CONCLUSION: Risk of snowboard related injury was highest in beginners. Through the use of wrist protection devices, the incidence of the most common injuries was dramatically reduced.

Mechanical properties of a rat patellar tendon stress-shielded in situ.

The effects of stress deprivation on the mechanical properties of the patellar tendon (PT) were studied using 14 albino rats. The PT was stress-shielded with cerclages on one side, while the contralateral patellar tendon served as a sham-operated control. After 10 weeks, paired load-strain as well as load-relaxation experiments were performed (11 and 3 specimen pairs, respectively). Mechanical tests showed, irrespective of the cerclage material used, that strain was increased significantly after stress-shielding (P < 0.02). The time constant significantly decreased in the stress-shielded specimens under 5 N loads, which may be considered 'physiological'. Tissue remodeling might explain the observed changes in the viscoelastic behaviour of the stress-shielded tendons. Loading, even in the physiological range of normal daily activity, may lead to an elongation of previously stress-shielded tendons or ligaments and consequently alter the behaviour of a joint.

Cyclops and cyclopoid formation after anterior cruciate ligament reconstruction: clinical and histomorphological differences.

Prospectively, 119 patients were pursued clinically and by follow-up-arthroscopy for the occurrence of a "cyclops syndrome" after ACL reconstruction with a patellar tendon autograft, augmented by LAD. Twenty-one patients showed nodular formations. Ten of these (group 1) developed early clinical evidence of a "cyclops syndrome" with a mean extension deficit of 19 degrees before follow-up-arthroscopy, on average 5.9 months after the index operation. The nodular formations found and excised during débridement had a hard consistency. Histomorphological undecalcified microtome section evaluation of six specimens revealed fibrocartilagineous tissue with active bone formation in the center. The other 11 patients showed no clinical symptoms (group 2). A similar but soft nodulous scar formation was detected at follow-up-arthroscopy, on average 9.5 months after the index operation. Histomorphologically these so-called "cyclopoid" formations were only built-up fibrocartilagineous islands surrounded by granulation tissue. Neither remnants of tendon graft fibers nor old bone particles were found in specimens of either group. It can be concluded that both the hard cyclops and the soft "cyclopoid" are de novo scar formations.

[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.

Rotational instability and integrity of the interosseous membrane in cadaveric ulnar shaft fractures.

The stability of isolated ulnar shaft fractures required further investigation because no data were available for fractures in the middle third or on the effect on rotational stability. Ten intact cadaveric arms were used to study the pathomechanics of fractures of the middle ulna. In all of them a transverse osteotomy was performed (A), then in five of them, an additional osteotomy was done in order to create a third fragment (B). The interosseous membrane was subsequently divided for 2 cm on either side of the osteotomy (A-->C, C-->D). On radiographs the displacement was recorded in pronation and supination, and the rotational displacement was calculated. Rotational instability occurred in all fractures studied, even in the so-called stable ones. Also, dissection of the interosseous membrane was not followed by a displacement of more than 50%, and shortening of the ulna should also be considered in fractures with less than 50% displacement as a sign of instability.

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.

Epidermoid cyst after arthroscopic knee surgery.

Eleven years after an arthroscopic procedure, a benign tumor of the knee located beneath the scar where the outflow canula was placed was excised. Histomorphological evaluation determined the diagnosis of an epidermoid cyst. This is the first case reported in the literature of an epidermoid cyst occurring after an arthroscopic operation. The previous epidermoid cysts reported were found after trauma or after dermal grafting for epithelium implantation.

Patients with increased intracranial pressure cannot be monitored using near infrared spectroscopy.

The hypothesis of this study was that with near infrared spectroscopy a decrease of the regional cerebral saturation would be detectable in patients with increased intracranial pressure. For this purpose, two study groups were compared: (A) eight healthy volunteers and (B) eight heart beating organ donors with brain stem herniation. The regional cerebral saturation was measured according to the developer's suggestions. Mean arterial pressure and peripheral pulse oximetry were recorded. The statistical comparison, using the unpaired t-test, revealed no significant differences for the regional cerebral saturation (p = 0.97) or for the mean arterial pressure or peripheral pulse oximetry between the groups. In both of the studied situations, no differences in the regional cerebral situation were detectable, even though the patient situations were completely antagonistic. Therefore, it is reasonable to discourage the use of the INVOS 3100 Cerebral Oxymeter to monitor patients with increased intracranial pressure indirectly.

The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique.

A prospective clinical trial from January 1994 to February 1996 evaluated the efficacy of a vacuum sealing technique in dealing with sacral pressure ulcers, acute traumatic soft tissue defects and infected soft tissue defects following rigid stabilization of lower extremity fractures in 45 patients. Polyvinyl foam under negative pressure generates an area of high contact forces at the wound/foam interface. This situation appears to facilitate granulation tissue production while maintaining a relatively clean wound bed. In 84% (38/45) of the patients the use of the vacuum sealing technique following irrigation and debridement decreased the dimensions of the initial wound, thus facilitating healing time and the eradication of any pre-existing infection. Wound closure by granulation, secondary closure, or split thickness skin grafting was achieved in 35 wounds. The vacuum sealing technique is an effective option in the management of infected wounds.

[Vienna Shoulder Score (VSS) and Vienna Shoulder Formula (VSF) for follow-up and assessment of shoulder and shoulder girdle injuries]. / Vienna Schulter Score (VSS) und Vienna Schulter Formel (VSF) für die Nachkontrolle und Begutachtung von Schulter- und Schultergürtelverletzungen.

The Vienna Shoulder Score (VSS) was screened by two groups of patients for use in medical expertises and follow-up examinations. One group (n = 157) consisted of patients with healed clavicular bone fractures, the other group (n = 130) consisted of healthy individuals. The study proved that the VSS is a useful, exact and fast method of shoulder evaluation after injuries to the shoulder and shoulder girdle. The side dominance is of no influence to the outcome of the VSS. The Vienna Shoulder Formula (VSF) helps to equalize the age factor in shoulder examinations.

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.

Opening wedge osteotomy for malunion of the distal radius with neuropathy. 13 cases followed for 6 (1-11) years.

13 patients with malunion of the distal radius after Colles' fractures and electroneurographically verified median nerve compression underwent an opening wedge osteotomy without a simultaneous release of the transverse carpal ligament. 12 patients had reduction of the typical night pain with normal or almost normal sensibility within the first 2 months. In 1 patient a release of the carpal ligament was necessary after 6 months. 6 years postoperatively all patients had acceptable wrist function with normal function of the median nerve in all but one.

Synthetic augmented repair of proximal ruptures of the anterior cruciate ligament. Long-term results of 66 patients.

The long-term results (five-to eight-year follow-up evaluation) of 66 patients with high proximal ruptures of the anterior cruciate ligament (ACL) who were treated operatively are presented in a retrospective and uncontrolled study. Technique of surgery was the reinsertion of the ACL in a multiple suture loop technique, augmented with Kennedy-LAD (ligament augmentation device) on over the top route in temporary double-end fixation. This technique was used in patients with proximal rupture of the anterior cruciate ligament found at arthroscopy. In the follow-up as well as in instrumented measurement, 97% of the knee joints have normal joint laxity. According to the evaluation sheet designed by the Orthopädische Arbeitsgemeinschaft Knie (OAK), excellent or good results were found in 86% of the patients. Nine percent had limited range of motion. The ACL reconstruction technique allowed 75% of the patients to regain their preinjury sports activity level. The potential advantages of synthetic augmented reinsertion of the ACL are anatomic reconstruction without destruction of other anatomic structures as grafts; securing early rehabilitation with weight bearing of the operated limb depending on individual pain tolerance; and presenting excellent long-term results of normal joint laxity.

Complications of interlocking nailing for lower leg fractures: a 3-year follow up of 102 cases.

Of the 109 patients treated by interlocking nailing for lower leg fractures between 1985 and 1990 at the A.ö.KH Schwaz and the LKH Bad Ischl, Austria, 92 underwent follow-up examination. Data were analyzed using a personal computer. Special attention was paid to fracture pattern, level, complications, and length of sick leave. Compared with a previous study, an increasing number of compound fracture patterns were evaluated. Except for 14 misalignments and two late infections after new injuries, no other serious complications were detected. Interlocking nailing can be highly recommended even for open fractures up to the second degree at any level from the second fifth to the fourth fifth of the tibia.

[Treatment procedure in humeral shaft fractures with primary or secondary radial nerve damage]. / Vorgehen bei Oberarmschaftfrakturen mit primärem oder sekundärem Radialisschaden.

We give an account of 28 patients with fractured humerus diaphysis, suffering from primary and seven patients suffering from secondary lesion of the radialis nerve, all treated by operation. In each case the radialis nerve was exposed and the fracture was treated by fixation with compression plates. In case of primary lesions of the radialis nerve, we found intraoperative damages by traction (six times), contusions (seven times), intraneural hämatomas (six times) and for one time perforation of the nerve by bones. The rest of this group (eight times) did not show any pathological finding. Those patients with secondary lesion of the radialis nerve showed damages by traction (three times) and in two cases the nerve was walled up by callus or connective tissue. Two times we could not find any pathological alteration of the nerve. 23 (six) out of 28 (seven) patients with primary (secondary) lesion of the radialis nerve could be followed up. On this occasion we stated complete neurological restitution 20 times (four times) and incomplete restitution three times (two times). The great number of pathological findings, which necessitate operative treatment, the short duration of remission and the high rate of restitution confirm us to leave the way of conservative treatment in cases of primary or secondary lesion of the radialis nerve and the indication of acute operation is given.