Mapping recovery in simple and complex tibial plateau fracture fixation.

AIMS: The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures. PATIENTS AND METHODS: Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86). RESULTS: Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals. CONCLUSION: Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009-1014.

The construction and implementation of a clinical decision-making algorithm reduces the cost of adult fracture clinic visits by up to £104,800 per year: a quality improvement study.

INTRODUCTION Inappropriate referrals to the new patient fracture clinic unnecessarily consume hospital resources and many hospitals lack clear guidelines as to what should be referred. Many of these injuries can be definitively managed by the emergency department. Our aim was to construct and disseminate a clinical decision-making algorithm to reduce the frequency of inappropriate referrals to fracture clinics at our institution, to improve the management of patients with minor injuries and save the hospital and the patient the cost of unnecessary visits. MATERIALS AND METHODS Data were prospectively collected for all new fracture clinic referrals over two separate 1-week cycles with cohorts of 94 and 74 patients, respectively. After the first cycle, the referral algorithm was disseminated both electronically (intranet) and orally (presentations to emergency department staff). The results of this intervention were examined in the second cycle, which took place 6 months after the first cycle. RESULTS The introduction of this algorithm significantly reduced inappropriate referrals by almost 20% (P = 0.0445). DISCUSSION This simple intervention highlighted a potential annual cost saving of up to £104,000. We advocate the use of this concise algorithm in improving the efficiency of the referral system to fracture clinics.

The epidemiology and functional outcomes of operative fixation of extracapsular proximal femoral fractures (AO 31-A) in young adults.

Proximal femoral fractures in adults under 50 years are not as common as in the elderly, but may have just as significant an impact. There is little in the literature describing the functional outcomes of fixation in this age group. Our aim was to assess the clinical and functional outcomes of operative management of extracapsular proximal femoral fractures (AO 31-A) in the young adult (<50 years). Consecutive skeletally mature patients <50 years undergoing operative fixation of these fractures were obtained from a prospective database over a 12-year period. Complications and mortality data were obtained from this database and case note review. Outcome scores were obtained via postal questionnaires. Eighty-eight patients were included in the study of which 74 (84%) had fixation with the dynamic hip screw. The mean age was 39 years (range 17-50) with a male preponderance (73.8%). Mean hospital stay was 14 days (range 2-94). Seventeen (19.3%) patients had died at a mean of 40 months from their operation date. The 1-year mortality was 4.5%. There were five complications (5.7%). SF-36 and EuroQol 5D scores showed that 5-10% had severe problems with a 20% decrease in quality of life compared to population norms. The biggest differences were in the physical function modalities. One-third had fair to poor hip function as assessed by the Oxford Hip Score. Though these injuries are relatively rare in this age group, they do have significant mortality and functional impairment reflecting a higher energy of injury rather than the frailty seen in the elderly.

The outcomes of displaced paediatric distal radius fractures treated with percutaneous Kirschner wire fixation: a review of 248 cases.

This study aimed to evaluate the effect of manipulation under anaesthesia (MUA) and Kirschner wire (K-wire) fixation of displaced, paediatric distal radius fractures on residual radiological angulation, displacement, and shortening, as well as functional outcomes, including complication rates. A retrospective review was conducted of all paediatric patients undergoing MUA and K-wire fixation for an extra-articular distal radius fracture over a period of 5 years. A total of 248 patients were included in the study with a mean age of 9.9 years (3-15). Mean follow-up was 6.6 weeks (4-156). There was a statistically significant increase in median dorsal angulation (p<0.0001) between initial post-operative and follow-up radiographs at the time of K-wire removal. The number of K-wires used did not have a significant effect on dorsal angulation (p=0.9015) at time of K-wire removal, nor did the use of an above or below elbow cast (p=0.3883). Seventeen patients required a further general anaesthetic (5 revision operations, 12 removal of migrated K-wires). Eighty-seven percentage of (215 patients) of patients had normal function at follow-up post-K-wire removal. Angulation at time of K-wire removal of more than 15° was significantly associated with reduced functional outcome (p=0.0377). A total of 41 patients (17%) had complications associated with K-wire use. We conclude that though K-wire fixation is an effective technique, it does not prevent re-angulation of the fracture and is associated with a significant complication rate. Given the remodelling potential and tolerance to deformity in children, surgeons should give careful thought before utilising this technique for all displaced or angulated paediatric distal radius fractures. If used, 1 K-wire with immobilisation in a below elbow cast is sufficient in most cases.

Cardiovascular disease (CVD) risk factors: a patient’s perspective

OBJECTIVES: To identify CVD risk factors present in patients presenting with stroke; to assess knowledge of patients on risk factors for CVD; and to identify management methods employed (prior to admission) by patients to deal with these risk factors. DESIGN AND METHODS: This study used a cross-sectional, incident case design. All patients admitted to the hospital, within a 6 week period, given an initial diagnosis of stroke by the attending physician, were eligible for the study. Patients were recruited using consecutive sampling. Data on patient risk awareness and management methods were gathered using a survey. Data on risk factors present in patients were collected using patient records. RESULTS: A total of 102 patients were interviewed. The two major risk factors present in patients were hypertension (80.2%) and diabetes (57.8%). 83.3% of patients identified hypertension as a risk factor and 78.8% identified diabetes. However, 32.2% of hypertensive patients and 40.5% of diabetics reported not taking medication despite being awareness of their risk. Similarly 81.3% of patients knew lack of exercise was a risk factor, but only half were exercising frequently in the past 2 years. CONCLUSION: In this study, hypertension and diabetes were found to be the two major risk factors present in stroke patients. While patient knowledge about risk factors was high, their management of their risk factors as well as general knowledge about stroke prevention were lacking. This could be helpful in formulating public health strategy, if supported by larger population based studies.

Metastatic spinal cord compression as a result of the unknown primary tumour.

PURPOSE: Patients presenting with metastatic spinal cord compression (MSCC) due to an unknown primary tumour (UPT) present an interesting problem with limited literature available to provide guidance on management. Our aim was twofold-first, to analyse all our patients with MSCC due to a UPT pre-operatively, to review their treatment and outcome; second, make comparisons with those patients who presented with MSCC due to a known primary tumour (KPT) during the same period. METHODS: All data was collected retrospectively from October 2004 to October 2009, then prospectively from October 2009 to October 2012 (8 years). We reviewed all patient records held on the database, including patient demographics, primary tumour, neurological outcome (Frankel grade), complications and survival. RESULTS: During the 8-year study period, out of the 382 patients who underwent emergency surgery for MSCC, 285 patients were included in whom complete information was available. Of these, 17 patients presented with MSCC due to a UPT (6 %; mean age 61 years, 5 M, 12 F). When compared to those with a known primary, the UPT group trended to a longer duration of symptoms prior to surgery (200 vs. 156 days, p = 0.86). They had a similar neurological outcome (88 % remained the same or improved post-operatively vs. 90 % in KPT group; p = 0.42), similar complication rate (23.5 vs. 33.6 %; p = 0.32) and survival (222 vs. 251 days, p = 0.42). The primary site in the UPT group was confirmed in 10/17 (58.8 %)-all 10 were adenocarcinoma [lung (6) and GI (4)]. DISCUSSION: In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.

Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?

Non-union occurs in 5-10% of all fractures and is caused by a variety of mechanical and biological factors. Stable fixation is essential and many authors recommend the addition of bone graft. Our aim was to evaluate the results of internal fixation using Judet decortication and compression plating for long bone fractures and assess the impact of bone grafting on union rates. Our study group comprised all the patients undergoing compression plate fixation under a single surgeon over a fourteen year period (n=96). AO principles were used and the standard technique involved Judet decortication, compression plating and lag screws. Autologous bone graft was harvested from the iliac crest. The mean age was 45 years and 62% were male. The fracture site was the clavicle (n=20); humerus (n=23); radius and ulna (n=5); femur (n=31) and tibia (n=17). The primary fracture treatment was non-operative (n=41); IM nail (n=22); plate fixation (n=28) and external fixation (n=5). Deep infection was present in 6 cases. Bone graft was used in 40 cases. 91/96 non-unions treated with compression plating healed (95%). Bone grafting was used in all cases for the initial part of the series but its use declined as the surgeon became more confident that the non-unions would heal without the use of bone graft. The case mix and complexity remained constant throughout the study period and the union rate also remained constant. The mean time to radiological union was 6.4 months. In those treated with a compression plate without bone graft the union rate was 94.6% whilst the addition of bone graft resulted in a union rate of 95% (p=0.67). From our study we concluded that the routine use of autologous bone graft may not be necessary and, based upon the union rates observed in this study, a prospective randomised study to evaluate the use of bone graft in non-union surgery would need a sample size of 194,000 to detect a significant increase in union with 80% power. In terms of Numbers Needed Treat (NNT), we would need to give 1179 patients a bone graft to prevent one additional failure of healing.

Synergism between demethylation inhibitor fungicides or gibberellin inhibitor plant growth regulators and bifenthrin in a pyrethroid-resistant population of Listronotus maculicollis (Coleoptera: Curculionidae).

In 2007-2008, the "annual bluegrass weevil," Listronotus maculicollis Kirby (Coleoptera: Curculionidae), a serious pest of Poa annua L. (Poales: Poaceae) on U.S. golf courses, was shown to be resistant to two pyrethroids, bifenthrin and lambda-cyhalothrin. In 2008, we showed that bifenthrin resistance was principally mediated by oxidase detoxification (cytochrome P450 [P450]). P450s can be inhibited by demethylation inhibitor fungicides and gibberellin inhibitor plant growth regulators, both of which are commonly used on golf courses. We tested these compounds for synergistic activity with bifenthin against a pyrethroid-resistant population of L. maculicollis. The LD50 value for bifenthrin was significantly reduced from 87 ng per insect (without synergists) to 9.6-40 ng per insect after exposure to the fungicides fenarimol, fenpropimorph, prochloraz, propiconazole, and pyrifenox and the plant growth regulators flurprimidol, paclobutrazol, and trinexapac-ethyl. Simulated field exposure with formulated products registered for use on turf revealed enhanced mortality when adult weevils were exposed to bifenthrin (25% mortality, presented alone) combined with field dosages of propiconizole, fenarimol, flurprimidol, or trinexapac-ethyl (range, 49-70% mortality).

Salmeterol decreases eosinophilic cationic protein and rescue medication in patients inhaling beclomethasone dipropionate: preliminary study in mild and moderate asthma in Trinidad, West Indies.

Activated eosinophils play a critical role in asthma pathogenesis, and eosinophil cationic protein (ECP) is a useful indicator of inflammation. Inhaled corticosteroids and long-acting beta2-agonists (LABA) effectively control asthma symptoms and improve airway function. Salmeterol's anti-inflammatory efficacy as add-on therapy to inhaled corticosteroids has not been evaluated in Caribbean populations. We investigated nine non-smoking subjects (three men and six women; mean age: +/- SE, 50.7 +/- 3.82 years) with stable mild and moderate persistent asthma who were inhaling > or = 500 microg beclomethasone dipropionate (BDP) daily. This was a with-in-patient controlled laboratory blind study performed over 8 weeks. Patients received BDP for 2 weeks, add-on salmeterol 100 microg in weeks 3-6 and BDP alone in weeks 7-8. Patients recorded daily morning and night symptoms. Morning peak expiratory flow rate was measured on entry to the study and with sputum ECP at the end of weeks 2, 4, 6 and 8. Salmeterol together with BDP decreased sputum ECP from a pretreatment median value of 897.84 microg/l to 628.38 microg/l after 4 weeks, and ECP continued to decrease even after salmeterol withdrawal. Both drugs decreased the frequency of rescue medication use by approximately 50% and increased the median number of days per week without rescue salbutamol from 0 to 3 days. Salmeterol's bronchoprotective effect was maximal after 4 weeks and was sustained after its withdrawal. In conclusion, this study, performed in Trinidadian asthmatics, used ECP as a surrogate marker of bronchial inflammation and supports the recent Salmeterol Multi-center Asthma Research Trial (SMART) data recommending add-on salmeterol therapy to adequate anti-inflammatory medication such as inhaled corticosteroids for optimal asthma management. Further studies are required to evaluate the anti-inflammatory efficacy and possible tolerance to salmeterol in Caribbean patients.

"Inert" formulation ingredients with activity: toxicity of trisiloxane surfactant solutions to twospotted spider mites (Acari: Tetranychidae).

Organosilicone molecules are important surfactant ingredients used in formulating pesticides. These methylated silicones are considered inert ingredients, but their superior surfactant properties allow them to wet, and either suffocate or disrupt important physiological processes in mites and insects. Aqueous solutions of the tri-siloxane surfactants Silwet L-77, Silwet 408, and Silwet 806 were bioassayed against adult female two-spotted spider mites, Tetranychus urticae Koch, with leaf dip methods to compare their toxicity with organosilicone molecules containing bulkier hydrophobic components. All three tri-siloxanes in aqueous solutions were equivalently toxic (LC50 = 5.5-8.9 ppm), whereas Silwet L-7607 solutions were less toxic (LC50 = 4,800 ppm) and Silwet L-7200 was nontoxic to mites. In another experiment, the toxicity of Silwet L-77 was affected by the wettability of leaf surfaces. The LC50 shifted from 22 to 84 ppm when mites were tested on bean and strawberry leaf disks, respectively. Droplet spreading on paraffin and surface tension were both related to the toxicity of surfactant solutions. Surface tensions of solutions below 23 mN/m caused > 90% mite mortality in leaf dip bioassays. A field test of Conserve SC and its formulation blank, with and without Dyne-Amic adjuvant (a vegetable oil-organosilicone surfactant mixture) revealed that Dyne-Amic had the greatest miticidal contribution, reducing mite populations by 70%, followed by formulation inactive ingredients. Spinosad, the listed active ingredient in Conserve, only contributed miticidal activity when synergized by Dyne-Amic. Researchers should include appropriate surfactant or formulation blank controls when testing insecticides or miticides, especially when using high spray volumes.