Hemiarthroplasty for Femoral Neck Fracture.

Hemiarthroplasty is a common treatment for femoral neck fractures in the elderly population. The main complications are periprosthetic dislocation and infection, which potentially impact morbidity and quality of life and may contribute to mortality. This procedure can be technically demanding, and adequate closure of the capsule and soft tissue cannot be emphasized enough. One advantage of a bipolar prosthesis is that it can be easily converted to a total hip arthroplasty without replacing the femoral component and with approximately the same complication rates as a revision total hip arthroplasty. Cement should be used when the patient is osteoporotic or has a Dorr type-C canal because there is a significant reduction in risk of fracture. The addition of a collared stem is helpful if there is a crack in the calcar extending from the fracture. The procedure is as follows. (1) The patient is placed in the lateral decubitus position. (2) The surgical site is prepared and draped to above the iliac crest and mid-sacrum. (3) A posterior approach is utilized. (4) The hip is dislocated. (5) A cut is made at the femoral neck. (6) The implant is templated with the femoral head. (7) The femur is broached. (8) The trial implant is placed. (9) The femur is cemented. (10) Trial implants are removed and cement is placed. (11) The final stem implant is placed in 5° to 10° of anteversion. (12) The final head and neck implants are trialed and then placed. (13) Implant position and range of motion are tested. (14) The surgical wound is irrigated. (15) Short external rotators are repaired. The posterior approach, which is often used, is known for increased rates of dislocation. The rate of dislocation can be minimized with repair of the posterior capsule and posterior soft tissue. Proper placement of the implants is of the utmost importance to minimize complications. Other contributing factors that lead to dislocation are implant malpositioning and patient factors.

Conducting a Randomized Controlled Trial in Tanzania: Institute for Global Orthopaedics and Traumatology and the Muhimbili Orthopaedic Institute.

INTRODUCTION: Low- and middle-income countries (LMICs) experience a large volume of orthopaedic trauma, but limited research exists to evaluate effective treatments using locally available means. Academic partners can help design and implement research studies through collaborative efforts with local investigators. We will describe the study design and lessons learned from a randomized controlled trial in Tanzania comparing outcomes of 2 operative treatments for open tibia fractures. STUDY DESIGN: The Institute for Global Orthopaedics and Traumatology at the University of California, San Francisco, and the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania, partnered to design a prospective, randomized controlled trial. Adult patients with open tibia fractures were randomized to receive either intramedullary nailing or external fixation as definitive fixation. Our primary outcome was the rate of reoperation, and secondary outcomes included EQ-5D, pain, function, radiographic union, and return to work. RESULTS: We enrolled 40 patients in a pilot study that informed improvements in the study design and standard operating procedures. These modifications included development of a specific outline of the technical standards for each surgical intervention and held training workshops to disseminate this knowledge among operative surgeons. This resulted in the successful enrollment and standardized treatment of our target sample of 240 patients. DISCUSSION: There are several challenges in conducting high-quality, international research. Keys for success include maintaining a strong relationship between partners, having local research coordinators, simplifying data collection and storage, and incentivizing patients to attend follow-up visits.

Open Reduction and Internal Fixation with a Locking Plate Via Deltopectoral Approach for the Treatment of Three and Four-Part and Proximal Humeral Fractures.

Open reduction and internal fixation (ORIF) via the deltopectoral approach is the gold standard for operatively treated proximal humeral fractures when joint preservation is desired. Indications include an unacceptable deformity, need for stability and early mobilization, and osteoporotic bone. (1) A 12 to 14-cm incision is made in the deltopectoral groove. The fracture is reduced. (2) Pins and tension sutures are placed for provisional fixation. (3) The locking plate is placed with unicortical screws in the metaphysis of the proximal part of the humerus and bicortical screws in the shaft. (4) The rotator cuff tendon is sutured into the open suture holes of the plate. (5) The surgical wound is then closed in a layered fashion. Hertel et al. reported that calcar length <8 mm, disruption of the medial hinge, and complex fracture patterns are more predictive of future osteonecrosis. In a series of 34 patients managed with ORIF, Neviaser et al. showed that the length of the posteromedial hinge was not predictive of osteonecrosis. Additionally, with use of tetracycline labeling, Crosby et al. demonstrated that perfusion to the humeral head is maintained in more complex 3 and 4-part fractures following anatomic reduction. Although they are useful for surgical planning, the criteria proposed by Hertel et al. cannot accurately predict osteonecrosis. The most important predictor of ischemia is the length of the dorsomedial metaphyseal extension and the integrity of the medial hinge. Including medial support in the fixation greatly decreases the incidence of screw cutout and migration into the articular surface and increases functional outcomes. Proper and complete reduction is of the utmost importance because varus malreduction contributes to the loss of fixation and to technical complications, such as improper plate positioning, improper screw length, and screw cutout, that influence outcomes.

Descriptive study of an emergency centre in western Kenya: challenges and opportunities

Introduction:With the highest global burden of disease and injury; there is an urgent need for Emergency Centres (EC) and physicians in Africa. Essential to this is the need for information on demographics; complaints; and acuity of patients presenting for acute care in Sub-Saharan Africa. The goal of this study was to determine the characteristics of EC patients in Eldoret; Kenya. Methods : Between January 1; 2011 and December 31; 2011; patient demographics; chief complaints; diagnoses; and dispositions were recorded for all patients presenting to an EC in Eldoret; Kenya. Patient volumes were averaged by month; week; and time of day. EC provider diagnoses were categorized according to the World Health Organization (WHO) ICD-10 Classifications. Dispositions were categorized into the following categories: admitted; observed; discharged; died; or unknown. Results:20;666 patients were seen with 17;336 (83.9) having complete visit information. The average age was 35.6 years and 52.6 of patients were female. The majority of patients (70) presented between the hours of 8 am and 5 pm.Deaths were highest in the early morning. The most common diagnoses were related to injury (20.2) followed by infectious diseases (11.7) and mental health disorders (11.3). Patient acuity was high as 58.6 of patients required observation or admission. Conclusions: The most common presentation for acute care in western Kenya was injury related. However; the severity of illness; lack of pre-hospital transportation; and lack of community mental health services provide significant challenges and opportunities for developing ECs in sub-Saharan Africa