Diagnostic impacts on management of soft tissue injuries associated with tibial plateau fractures: A narrative review.

INTRODUCTION: Currently there is no consensus on the need for investigating knee ligamentous and meniscal injuries in a patient with a tibial plateau fracture. Consequently, many soft tissue injuries are likely undiagnosed and therefore untreated. The impact this has on long term knee outcomes is not well defined. We aimed to identify the impacts of various diagnostic methods on the management of meniscal injuries associated with tibial plateau fractures and evaluate the clinical outcomes. MATERIALS AND METHODS: We performed a systematic review using Pubmed, Medline, Embase, CINAHL and Cochrane following Cochrane guidelines. We included studies that operatively managed tibial plateau fractures and soft tissue injuries, which were diagnosed with either preoperative MRI, intra-operative arthroscopy or arthrotomy. RESULTS: 18 articles with 884 people, with a mean age of 46.4 years were included. Soft tissue injuries were detected on MRI (32-73%) and arthroscopy (12-70%), of which the most common were lateral meniscal injuries (7-64% of tibial plateau fractures). When identified by arthroscopy and arthrotomy, these injuries were almost always treated, either by repair or debridement. The clinical outcomes of these patients were poorly reported, with a heterogenous use of patient reported outcome measures, and follow up time points. There were no randomised trials or control groups for comparative analysis, however operative treatment yielded good to excellent outcomes. CONCLUSION: There is a high incidence of concomitant soft tissue injuries with tibial plateau fractures, particularly lateral meniscal injuries. There are 2 main approaches to meniscal injuries: surgeons who don't investigate, don't treat, whilst surgeons who do investigate often do surgically treat. Although studies that treated these injuries achieved good to excellent results, the currently available evidence doesn't confirm treatment superiority. As there is plausibility for better outcomes, randomised studies are needed to further investigate this clinical question.

The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Use of Virtual Reality in the Education of Orthopaedic Procedures: A Randomised Control Study in Early Validation of a Novel Virtual Reality Simulator.

Background Virtual reality (VR) simulation is a potential solution to the barriers surgical trainees are facing. There needs to be validation for its implementation within current training. We aimed to compare VR simulation to traditional methods in acquiring surgical skills for a TFN-ADVANCED™ Proximal Femoral Nailing System (TFNA; DePuy Synthes, Auckland, New Zealand) femoral nailing system. Methods Thirty-one surgical trainees were randomised to two groups: traditional-training group (control group) and a VR-training group (intervention group) for insertion of a short cephalomedullary TFNA nail. Both groups then inserted the same TFNA system into saw-bone femurs. Surveys evaluated validity of the relevant activities, perception of simulation, confidence, stress and anxiety. The primary outcomes were tip-apex distance (TAD) and user anxiety/confidence levels. Secondary outcomes included number of screw- and nail-guidewire insertion attempts, the time taken to complete and user validity of the VR system. Results There was no statistical difference in TAD between the intervention and control groups (9mm vs 15mm, p=0.0734). The only TAD at risk of cut-out was in the control group (25mm). There was no statistical difference in time taken (2547.5ss vs 2395ss, p=0.668), nail guide-wire attempts (two for both groups, p=0.355) and screw guide-wire attempts (one for both groups, p=0.702). The control group versus intervention had higher anxiety levels (50% vs 33%) and had lower confidence (61% vs 84%). Interpretation There was no objective difference in performance on a saw-bone model between groups. However, this VR simulator resulted in more confidence and lower anxiety levels whilst performing a simulated TFNA. Whilst further studies with larger sample sizes and exploration of transfer validity to the operating theatre are required, this study does indicate potential benefits of VR within surgical training.

Compliance With the Royal College of Radiologists Guideline for Actionable Reporting and Its Impact on Patient Care: A Retrospective Analysis of Reporting Practices From a Major Trauma Center.

Introduction Prompt diagnosis forms the mainstay of management of any patient arriving at the hospital. In developed settings, apart from clinical assessment, imaging in the form of computed tomography (CT) scan plays a vital role in arriving at the patient diagnosis. The reporting should follow pre-defined Royal College of Radiologists (RCR) standards to improve the quality of the diagnostic process. Objectives To identify the compliance of reporting as per the RCR standards for the communication of radiological reports and fail-safe alert notification. Materials and methods A retrospective review of body CT scans was done in two cycles within a span of three months. A total of 100 randomized scans were assessed in each cycle, both from the A&E (accident and emergency) and inpatients. Normal scans and outpatient scans were excluded from the study. Data were collected using the online portal (CRIS) and statistical analysis was performed. Results After the first cycle of the audit, 95 reports out of 100 met the standard RCR criteria. After the second cycle, 97 reports met the criteria of the audit. One inpatient scan and two A&E reports did not meet the specified criteria in the second cycle. Conclusion After the two cycles of the audit carried out over three months, we were able to achieve almost 97% of reporting standards as compared to 95% obtained previously through a quality improvement project and create awareness.

Prevalence of High-Risk Pregnancy Among Pregnant Women Attending Antenatal Care Camps in Primary Health Centres in Kinaye and Vantamuri and Their Sub-Centres.

Introduction Identifying pregnancy-related complications and high-risk pregnancies early on and effectively managing care for these pregnant women through a holistic approach guided by the main objectives of antenatal care (ANC) and efficient, good-quality health care through ANC services can reduce the risk of pregnancy-related complications, being favourable for both mother and child. This study was intended to identify the percentage of pregnant women in high-risk groups attending ANC clinics. Objective This study's aim was to understand the prevalence of high-risk pregnancies in women attending ANC camps in Kinaye and Vantamuri villages in Belagavi, India. Methods A community-based cross-sectional study was carried out in a primary healthcare (PHC) setting that included all pregnant women attending antenatal camps and residing in the same areas. With a total study sample size of 200, consisting of pregnant women attending ANC camps in Kinaye and Vantamuri PHC, the data were collected using a pre-tested, pre-designed questionnaire after obtaining written informed consent from the participating pregnant women. Results The data were analysed using a chi-square test to uncover the relationship between socio-demographics, obstetric history, medical variables, and high-risk pregnancy. The results demonstrated that 48.5% of women attending ANC clinics were in the high-risk pregnancy group. Conclusion Pregnancy outcomes are greatly affected by a woman's socio-demographic, obstetric, and medical variables. The WHO recommends a minimum of four ANC visits to safely identify and mitigate the risks and complications of high-risk pregnancy to ensure positive outcomes for both mothers and children.

Fracture of pubic rami during hip fracture fixation: a rare case of traction table-related injury.

We present a case of an elderly and comorbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intraoperatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Closed-reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed-fixation should be accounted for when managing this complex and often frail group of patients.

Muscle Quantity at C3 and/or L3 on Routine Trauma Series Computed Tomography Correlate With Brain Frailty and Clinical Frailty Scale: A Cross-Sectional Study.

Background Sarcopenia (low muscle mass and function) is increasingly recognised to impact the quality of life and patient outcomes. The relationship with brain frailty is unknown. Objectives Assess if muscle mass at C3 correlates with muscle mass at L3 on routine trauma imaging. Assess for associations between muscle mass, brain frailty, and Clinical Frailty Scale (CFS) on routine trauma imaging. Methods Routine trauma-series computed tomography (CT) scans were retrospectively analysed for patients aged ≥16-years-old admitted to Queen Elizabeth Hospital in January 2020. Paravertebral, sternocleidomastoid, and total muscle cross-sectional area (CSA) at C3 (C3-SMM), and total psoas muscle CSA (TPA), total muscle CSA (L3-SMM), and total adipose CSA at L3 were calculated. Brain frailty scores were calculated assessing for leukoaraiosis, cerebral atrophy, and old vascular lesions/infarcts. CFS was calculated retrospectively from clinical notes. We assessed for correlation against age, CFS, muscle mass, and brain frailty using Pearson's correlations. Results We included 111 patients in this study (mean age 49, SD 25.6; 65.8% female). C3-SMM strongly correlated with L3-SMM (r=0.746, p<0.001). Paravertebral and sternocleidomastoid CSA correlated with C3-SMM (paravertebral: r=0.814, p<0.001; sternocleidomastoid: r=0.814, p<0.001). TPA strongly correlated with L3-SMM (r=0.800, p<0.001). Sternocleidomastoid CSA and TPA both negatively correlated moderately with age (sternocleidomastoid: r=-0.460, p<0.001; TPA: r=-0.468, p<0.001), CFS (sternocleidomastoid: r=-0.414, p<0.001; TPA: r=-0.431, p<0.001), and brain frailty (sternocleidomastoid: r=-0.395, p<0.001; TPA: r=-0.436, p<0.001). Adipose CSA at L3 did not correlate with age, CFS, brain frailty, or muscle mass. Conclusion Muscle mass at C3 relates to muscle mass at L3. Muscle mass on routine trauma imaging is negatively associated with age, CFS, and brain frailty.