Does a skin incision along Langer's lines reduce complications following fixation of displaced middle-third clavicle fractures?

INTRODUCTION: Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer's lines, as opposed to a traditional transverse incision, reduces complications. METHODS: We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer's lines or a transverse incision was used according to surgeon's preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher's exact tests. RESULTS: Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified. CONCLUSION: Based on our data, an incision following Langer's lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.

Complications associated with plate fixation of acute midshaft clavicle fractures versus non-unions.

An important consideration when counselling patients with midshaft clavicle fractures is whether operative treatment of non-union, if it develops after non-operative treatment, is associated with higher complication rate than acute fracture fixation. The aim of this study is to compare complications and re-operations after open reduction and plate fixation for acute midshaft clavicle fractures versus non-unions. The study was retrospective. There were 90 patients in the acute fixation group and 20 patients in the non-union group. The mean follow-up was 8 and 15 months, respectively, Logistic regression analysis was used to assess whether 'non-union surgery' was a predictor of complications and re-operations. Of 90 patients, 23 had complications in acute fixation group. Of 20, 7 developed 8 complications in the non-union group (p = 0.4). Of 90, 12 required re-operations in the acute fixation group compared to 5/20 requiring 7 re-operations in the non-union group (p = 0.19). When any complication or re-operation was considered, 'non-union surgery' was not significant predictor for complications (p = 0.78) or re-operations (p = 0.99). The complication and re-operation rates were not higher after non-union surgery compared to acute fracture fixation and were mostly related to persistent delayed or non-union, rather than operative complications. When counselling patients about treatment of midshaft clavicle fractures, a 'higher complication rate after surgery for non-union, should it happen' should not be an argument against non-operative treatment.

Tranexamic acid versus fibrin sealant in primary total hip replacement: a comparative study.

BACKGROUND: The effectiveness of intravenous tranexamic acid (TA) in reducing blood loss and transfusion requirements during total hip replacement (THR) is well recognised. The aim of this study was to assess the effectiveness of a fibrin sealant in comparison to intravenous TA and a control group. PATIENTS AND METHODS: We prospectively studied 273 patients with primary hip osteoarthritis who underwent a THR between February 2012 and September 2013. The first 73 patients acted as the control group. The next 100 consecutive patients received fibrin sealant spray, and the last 100 patients received 1 g TA on induction. RESULTS: The demographic characteristics, surgical time, surgeon grade, anaesthetic type and pre-operative haemoglobin of the three groups were comparable. Both fibrin sealant and intravenous TA were effective in reducing blood loss during THR (15%, p = 0.04 and 22.5%, p = 0.01, respectively), when compared to the control group. However, neither treatment was found to be superior to the other in preventing blood loss p = 0.39. Tranexamic acid was superior to fibrin sealant in decreasing allogeneic transfusion requirements (0 vs. 10%, p = 0.05). There was no significant difference between the groups with regard to proportion of patients with wound leaking problems. CONCLUSION: Both fibrin sealant and intravenous tranexamic acid were effective in reducing blood loss. However, tranexamic acid use reduced post-operative transfusion requirements.

The accuracy of "subacromial grind test" in diagnosis of supraspinatus rotator cuff tears.

PURPOSE: The aim of this study is to assess the accuracy of a simple clinical test (subacromial grind test) in diagnosing supraspinatus tendon tears. PATIENTS AND METHODS: The test is considered positive if palpable crepitus or grinding is detected on passive internal and external rotation of the shoulder while abducted in the scapular plane. Data were collected prospectively on 47 patients undergoing shoulder arthroscopy, and the results of the test and arthroscopy compared. RESULTS: During arthroscopy, 17 patients had full thickness (FT) tears of supraspinatus tendon and 10 had partial thickness tears. For any supraspinatus tear, the sensitivity of the test was 63%, specificity 95%, positive predictive value 94%, negative predictive value 66% and overall accuracy 79%. For FT tears, the sensitivity was 82%, specificity 87%, positive predictive value 78%, negative predictive value 90% and overall accuracy 85%. CONCLUSION: We found that this is a useful single test for diagnosing FT supraspinatus tears. LEVEL OF EVIDENCE: Level IV diagnostic study.

Retrograde nailing for distal femur fractures in the elderly.

INTRODUCTION: We report the results of treating a series of 56 fractures in 54 elderly patients with a distal femur fracture with a retrograde femoral nail. METHODS: Fifty-four of the nails were inserted percutaneously with a closed reduction. After surgery all patients were allowed to weight bear as tolerated. Four fractures were supported in a temporary external splint. RESULTS: The mean age of patients was 80.6 years (range 51-103 years), 52/54 (96%) were females. There were no cases of nail related complications and no re-operations were required. One patient was lost to follow up. The 30-day mortality was 5/54 (9.3%) and the one year mortality was 17/54 (31.5%). CONCLUSIONS: Distal femoral nail fixation provides a good method of fixation allowing immediate mobilisation for this group of patients.

The effect of obesity on theatre utilisation time during primary hip and knee replacements.

INTRODUCTION: The aim of this study is to assess the effect of body mass index (BMI) and body weight on theatre utilisation time during primary total hip (THR) and knee replacements (TKR). METHODS: A total of 1859 cases were included (820 THR and 1039 TKR). Patients were divided into groups based on BMI and body weight. The time interval from 'starting anaesthesia' to 'transfer back to recovery' was used as total theatre time. Hierarchal regression analysis was then used to study the effect of BMI and body weight while controlling the effect of any confounding variables. RESULTS: In THR cases, the median theatre time was significantly different between BMI and body weight subgroups (p=0.001). In TKR cases, the median theatre time was more significantly different between weight subgroups (p<0.001) than BMI subgroups (p=0.021). Regression analysis showed that only weight remained a significant predictor (p=0.018) of theatre time in THR cases after controlling for other variables. In TKR cases, body weight and BMI were not predictors of theatre time after controlling for other variables. CONCLUSION: Body weight is a significant predictor of theatre time during THR. Neither weight nor BMI predicted theatre time during TKR.

The effect of obesity on blood metal ion levels after hip resurfacing and metal-on-metal total hip replacement.

There has been concern regarding potentially higher failure rates of metal-on-metal (MoM) bearings in obese patients, and possible adverse reaction to metal debris (ARMD). Elevated chromium (Cr) and cobalt (Co) levels in the blood indicate excess wear, and may predict secondary soft-tissue damage. We investigated the effect of obesity on blood Cr and Co levels in patients with MoM bearings. We reviewed data on 75 patients with hip resurfacing and MoM total hip arthroplasty (THA) at an average of 4 years follow-up. We excluded patients with factors that can affect metal ion levels including other metal implants, bilateral MoM bearings or during the 'running-in' phase. The patients were classified into two groups; obese (n=27) and control (n=48) depending on a body mass index (BMI) >= 30 kg/m2. There was no significant difference between the groups with regards to age, gender, renal function, cup inclination, implant type, femoral head size, time interval between operation and metal ion levels or the number of symptomatic patients. ?There was a trend for lower Cr and Co levels in the obese group but this was not statistically significant (p= 0.17 & 0.07, respectively). There was no correlation between the BMI and Cr or Co levels (Spearman's correlation coefficient r = - 0.13/p = 0.26 & - 0. 2/p = 0.1, respectively). There was no evidence of higher metal ion levels, suggestive of increased wear, in obese patients with MoM bearings.