Surgical fixation of ipsilateral femoral neck and shaft fractures: a matter of debate?

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

Risk of Mortality for Proximal Femoral Fracture in Patients With and Without COVID-19. A Retrospective Cohort Study.

Background: SARS-CoV-2 (COVID-19) has resulted in a widespread loss of lives, morbidity, and major disruptions to the healthcare system. Hip fractures are an emergent condition which require early intervention to reduce increased risk of mortality and morbidity. Infection of SARS-CoV-2 may contribute to increased mortality due to the role of infection and immune response. This study investigated the impact of COVID-19 infection (defined by clinical symptoms) on mortality following proximal femoral fracture (PFF) repair procedures. Methods: This study was a retrospective cohort study. Data from the Premier Healthcare Database® was extracted for patients presenting for PFF during 2019 for control, and February 2020-September 2020 to represent a COVID time-period. Results: A total of N = 73 953 subjects were enrolled for the 2019 period, and a total of N = 34 842 subjects were enrolled for the COVID period. For the 2019 period, subjects who had a PFF procedure and who had flu/COVID-like illness had 2.47 (CI:2.11, 2.88) times the odds of mortality compared to those who did not have flu/COVID-like illness. Subjects who had a PFF procedure and who had flu/COVID-like illness during the COVID period had 2.85 times (CI:2.36, 3.42) the odds of mortality compared to those who did not have flu/COVID-like illness. For the COVID period, within subjects who did not have a PFF procedure, those with flu/COVID-like illness had increased odds of mortality compared to those who did not have flu/COVID-like illness (OR:2.26, CI:1.57, 3.21). Conclusions: Hip fractures present high risk for mortality and morbidity, where timely intervention is critical to improved outcomes. Presence of infection such as flu/COVID-like illness may influence mortality in patients undergoing hip fracture repair procedures. Consideration of infection status as a comorbidity is important to proper management and achieving optimal outcomes.

Long term results of lower limb posttraumatic acute bone defects treated with masquelet technique.

INTRODUCTION: Several alternatives are now available when treating posttraumatic acute bone defects. Masquelet's technique represents a safe procedure to treat lower limb open fractures associated with significant bone defects and allows surgeons to try to reduce complications incidence. MATERIAL AND METHODS: Retrospective study based on patients´ record files and images (2015-2017). Twelve patients suffering acute bone defect, treated using Masquelet technique, were evaluated. A total of ten patients were finally included after exclusion criteria were applied. RESULTS: Average time from injury to first stage surgery was 11 days. Free flaps were required in three cases (two latissimus dorsi and one anterolateral thigh flap). Time to second stage surgery was 115 days on average. As bone graft, reaming irrigation-aspiration system was associated to this technique. Consolidation was achieved in all patients but one after an average time of 8.4 months. There was only one case of limb shortening of 20 mm. There was no case of nonunion or infection, and patients could perform daily basic activities independently. VAS mean score was one point one year after final surgery. CONCLUSIONS: Masquelet's technique achieves encouraging results when treating lower limb acute bone defects. Using this technique, surgeons could decrease infection incidence in open fractures with severe bone loss. On the other hand, it is a two-stage surgery process, which makes the process longer.

Analysis of complications after a floating elbow injury.

BACKGROUND: The aim of the present study is to analyse complications after a floating elbow injury, attempting to establish which of them act as a poor prognosis factor regarding clinical and functional results. MATERIALS AND METHODS: Twenty-three patients who suffered a floating elbow injury, treated at our institution from 2004 to 2013, were retrospectively reviewed. Patients were divided into four groups depending on the type of injury. An analysis of demographic data, associated injuries, treatment options and complications was carried out. Clinical evaluation was made by a conventional goniometer, testing flexo-extension and prono-supination ranges. For functional evaluation, the Mayo Elbow Performance Score was employed. Association between radioulnar synostosis, articular surface disruption, nerve injury and clinical and functional results was analysed. RESULTS: Patients with radioulnar synostosis had worse results in functional evaluation than patients without it (56.6 vs. 75); this difference was statistically significant (p = 0.05). Regarding intra-articular extension, we found statistical association with worse results in functional evaluation (p = 0.018); however, nerve palsy does not seem to influence functional results. CONCLUSIONS: Radioulnar synostosis and intra-articular extension of the injury are poor prognosis factor in floating elbow.

Management of atypical femoral fracture: a scoping review and comprehensive algorithm.

BACKGROUND: Atypical femoral fractures (AFF) are a rare type of femoral stress fracture recently described, potentially associated with prolonged bisphosphonate therapy. Evidence-based recommendations regarding diagnosis and management of these fractures are scarce. The purpose of this study is to propose an algorithm for the diagnosis and management of AFF. METHODS: We performed a PubMed search of the last ten years using the keywords "atypical femoral fractures" and identified further articles through an evaluation of the publications cited in these articles. Relevant studies were included by agreement between researchers, depending on their specialization. Pertinent points of debate were discussed based on the available literature, allowing for consensus regarding the proposed management algorithm. RESULTS: Using a systematic approach we performed a scoping review that included a total of 137 articles. CONCLUSIONS: A practical guide for diagnosis and management of AFF based on the current concepts is proposed. In spite of the impressive large volume of published literature available since AFF were initially identified, the level of evidence is mostly poor, in particular regarding treatment choice. Therefore, further studies are required.

Análisis del coste del tratamiento del paciente politraumatizado en un hospital de referencia en España / Cost-analysis of treating patients with multiple injuries in a reference hospital in Spain

Introducción: El objetivo del estudio es analizar el coste que supone el tratamiento de un conjunto de pacientes con traumatismo grave. Adicionalmente investigamos la distribución del gasto entre los diferentes servicios implicados en el manejo de estos pacientes. Material y método Utilizamos para el estudio los datos registrados en la base de datos Traumasur donde se recogen de modo prospectivo los datos de los pacientes que sufren traumatismos graves. Se analizan de modo retrospectivo los datos clínicos de los pacientes recogidos en el año 2008, un total de 131 pacientes. Utilizamos los datos obtenidos por el servicio de control financiero de nuestro centro, con datos del coste global y la división del gasto entre los departamentos implicados en el tratamiento. Resultados El valor medio de ISS y NISS fue respectivamente 31,8 y 39,4. La tasa de mortalidad fue del 17,5%. El coste global de los pacientes fue 3.791.879,3 €. El coste medio por paciente fue 28.945 €. El porcentaje medio del gasto global que supusieron el ingreso en UCI y planta fue respectivamente de 62 y 12,7%. El coste del ingreso en UCI ascendió hasta 68,4% en pacientes con ISS>40. A pesar de que los pacientes fallecidos presentaron lesiones más graves, presentaron menor coste en todos los capítulos. Conclusión Los pacientes con traumatismos graves suponen un importante gasto sanitario; el mayor porcentaje se debe a la estancia hospitalaria sobre todo a la estancia en UCI. Otros capítulos de gasto suponen un porcentaje menor del gasto (AU)

Introduction: The aim of this study is to analyse the costs of the treatment of a group of patients with severe injuries. The distribution of the costs between the different departments involved in the management of these patients is also investigated. Material and method: The data from patients who suffered severe injuries, and recorded in the Traumasur data base, were prospectively gathered to be used in the study. The data from a total of 131 patients treated in the year 2008 were collected. Data obtained from the hospital (..) (AU)

[Cost-analysis of treating patients with multiple injuries in a reference hospital in Spain]. / Análisis del coste del tratamiento del paciente politraumatizado en un hospital de referencia en España.

INTRODUCTION: The aim of this study is to analyse the costs of the treatment of a group of patients with severe injuries. The distribution of the costs between the different departments involved in the management of these patients is also investigated. MATERIAL AND METHOD: The data from patients who suffered severe injuries, and recorded in the Traumasur data base, were prospectively gathered to be used in the study. The data from a total of 131 patients treated in the year 2008 were collected. Data obtained from the hospital finance office were also used, providing the overall cost as well as the separate costs of each of the departments involved in the treatment. RESULTS: The injury severity score (ISS) and the new injury severity score (NISS) mean values were 31.8 and 39.4, respectively. The mortality rate was 17.5%. The overall costs of the patients was 3,791,879.3 €, with a mean cost per patient of 28,945 €. The mean percentage of the overall costs of the treatment incurred by the ICU and the ward was 62% and 12.7%, respectively. The cost of the ICU admission increased up to 68.4% in patients with an ISS>40. Although the patients who died had more serious injuries, they had a lower cost in all areas. CONCLUSION: Patients with multiple injuries represent a significant health cost, with the greater percentage being due to the hospital stay, particularly that in ICU. Other cost areas involve a lower percentage of the cost.

Damage control orthopaedics in severe polytrauma with femur fracture.

OBJECTIVE: To evaluate the rate of systemic complications and mortality in severe polytrauma patients with associated femur fracture treated by early external fixation of femur. PATIENTS AND METHODOLOGY: We made a retrospective cohort study with forty-one adult multitrauma patients (New Injury Severity Score ≥ 19) with femur fracture treated by external fixation following Damage Control Orthopaedic surgery. The mortality rates, TRISS analysis, incidence of ARDS and MOF were analysed. RESULTS: The mean NISS was 41.2 and the mean age 32.7. 50% of patients were in shock on admission. All patients were treated in the first 12 hours with external fixation. 30% of patients developed ARDS and six patients had MOF. Five patients treated by external fixation died. Difference between predicted mortality by TRISS and actual mortality showed a reduction of 15.9% (0.71 predicted survival versus 0.88 real survival). CONCLUSIONS: An aggressive and early Damage Control approach to treat femur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality by TRISS.