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Injury May 2024One of the great challenges in the management of open fractures is postoperative infection with a higher incidence in Gustilo-Anderson type III fractures. Definitive...
Use of antibiotic-cement coated plate in the treatment of Gustilo-Anderson type III long bone fractures in low- and middle-income countries vs external fixation: A multicentre randomized control trial study protocol.
BACKGROUND
One of the great challenges in the management of open fractures is postoperative infection with a higher incidence in Gustilo-Anderson type III fractures. Definitive management of such fractures in developing countries is usually with external fixators with its attendant complications such as deep fracture-related infection, non-union, and consequent increased re-operation rates. Recently, there has been a novel method of using antibiotic-cement coated implants such as intramedullary nails and locking plates in the treatment of infected non-unions with reported excellent outcomes. This protocol aims to describe the hypothesis, objectives, design and statistical analysis of a randomized control trial that compares the infection rate between the use of antibiotics-cement coated plate and external fixation in the management of Gustilo-Anderson type III long bone fractures.
METHODS
This is a multicentre, open-label, parallel group, superiority, randomized, control trial. All patients with type III long bone fractures who present at the emergency department will be screened for enrolment and only those patients that meet the inclusion criteria will be registered for the study. Patients will be randomized using a centralized 24-hr computerized randomization system into two groups: antibiotic-cement coated plate group and the external fixation group. The primary outcome will be occurrence of infection at any time during the course of one year follow-up which will be counted once for each of the patients. The secondary outcomes are union rate, re-operation rate and change in Health Related Quality of Life (HRQoL) from baseline to end of follow-up. Analysis will be done using R (R Core Team, 2023) and Rstudio (Rstudio Team, 2023).
DISCUSSION
Literature has shown that use of antibiotic-coated plate in the management of severe open long bone fractures is effective in reducing infection rate. A significant difference in infection rate with use of antibiotic-cement coated plate compared to use of external fixator for open fractures will be a welcome intervention in developing countries.
TRIAL REGISTRATION
The study protocol is registered with ClinicalTrials,gov (NCT06193330).
PubMed: 38824836
DOI: 10.1016/j.injury.2024.111637 -
Bone & Joint Open Jun 2024Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In...
AIMS
Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.
METHODS
A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value.
RESULTS
A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm.
CONCLUSION
Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.
PubMed: 38823797
DOI: 10.1302/2633-1462.56.BJO-2023-0163.R1 -
Injury May 2024Reconstruction nails are commonly used to treat proximal femur fractures, with cephalic screw placement for femoral neck "prophylaxis" becoming standard practice. These...
INTRODUCTION
Reconstruction nails are commonly used to treat proximal femur fractures, with cephalic screw placement for femoral neck "prophylaxis" becoming standard practice. These implants are traditionally introduced through piriformis fossa (PF) or greater trochanter (GT) entry portals. A third "central collinear" (CC) portal has been proposed that allows entry along the femoral anatomic axis and central placement of cephalic screws. The present study aimed to quantify and compare the CC portal femoral neck strength with the two traditional (PF and GT) entry portals.
MATERIALS AND METHODS
Eighteen cadaveric femur specimens (nine matched pairs) were divided into three groups using a balanced incomplete block design to control for variations in age and sex: (1) GT, (2) CC, and (3) PF entry points. Specimens and implants were cut to a standard length and instrumented with straight or valgus bend nails of appropriate laterality and two cephalic screws. Specimens were mounted on a custom jig replicating load distribution along the mechanical axis. A 100 N compressive preload was applied to the femoral head, followed by loading to failure at a rate of 10 mm/s until fracture, indicated by 30 % drop in axial force.
RESULTS
THE THREE ENTRY POINTS DID NOT DIFFER IN LOAD-TO-FAILURE: GT (6378.7 ± 1494.9 N), P (6912.4 ± 4924.1 N) and CC (7044.2 ± 2911.4 N) (P = 0.948) or maximum displacement, stiffness, and toughness. Most PF specimens failed at the basicervical neck, whereas most GT specimens failed at the subcapital neck; these differences were not significant. CC specimens failed evenly split between subcapital and basicervical.
CONCLUSION
There were no significant difference in femoral neck load-to-failure after placement of a reconstruction nail through a CC entry portal when compared to both GT and PF entry. Clinically, this suggests the CC entry portal is a viable option when clinical considerations warrant its use.
PubMed: 38823097
DOI: 10.1016/j.injury.2024.111640 -
Injury May 2024The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for...
INTRODUCTION
The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails.
MATERIALS AND METHODS
This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated.
RESULTS
Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each.
DISCUSSION
DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results.
CONCLUSIONS
DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.
PubMed: 38823095
DOI: 10.1016/j.injury.2024.111634 -
The Bone & Joint Journal Jun 2024This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary... (Comparative Study)
Comparative Study
Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020.
AIMS
This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.
METHODS
We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH).
RESULTS
In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192).
CONCLUSION
This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment.
Topics: Humans; Male; Female; Hip Fractures; Norway; Aged; Bone Screws; Fracture Fixation, Intramedullary; Bone Nails; Registries; Aged, 80 and over; Middle Aged
PubMed: 38821494
DOI: 10.1302/0301-620X.106B6.BJJ-2023-1219.R1 -
JBJS Case Connector Apr 2024A 34-year-old man was acutely treated with radial head arthroplasty and central band repair following Essex-Lopresti injury. A 38-year-old man presented with chronic...
CASE
A 34-year-old man was acutely treated with radial head arthroplasty and central band repair following Essex-Lopresti injury. A 38-year-old man presented with chronic longitudinal instability following failed radial head arthroplasty, which was performed for failed fixation. Treatment with revision radial head arthroplasty and central band reconstruction restored longitudinal stability.
CONCLUSION
We have a low threshold to repair the central band in acute Essex-Lopresti injury with sufficient evidence of disruption. Nearly all chronic cases require central band reconstruction to restore longitudinal stability. We do not temporarily pin the DRUJ, and distal ulnar shortening is rarely indicated.
Topics: Humans; Male; Adult; Joint Instability; Elbow Injuries; Radius Fractures; Wrist Injuries; Arthroplasty
PubMed: 38820195
DOI: 10.2106/JBJS.CC.24.00059 -
Acta Orthopaedica May 2024Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with...
BACKGROUND AND PURPOSE
Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency.
PATIENTS AND METHODS
The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration.
RESULTS
The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes).
CONCLUSION
Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.
Topics: Humans; Clinical Competence; Simulation Training; Bone Nails; Hip Fractures; Female; Male; Adult; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Orthopedics; Denmark
PubMed: 38819402
DOI: 10.2340/17453674.2024.40812 -
Clinical and Experimental Dental... Jun 2024This study aimed to compare the flexural strength of monolithic zirconia with different thicknesses and two sintering techniques. (Comparative Study)
Comparative Study
OBJECTIVES
This study aimed to compare the flexural strength of monolithic zirconia with different thicknesses and two sintering techniques.
MATERIALS AND METHODS
This in vitro, experimental study was conducted on 28 monolithic zirconia discs with 10 mm diameter and 0.5 (n = 14) and 1.2 mm (n = 14) thickness. Each group was divided into two subgroups (n = 7) for fast (60 min) and conventional (120 min) sintering at 1450°C. After sintering, the specimens were thermocycled and their flexural strength was measured by piston-on-3-balls technique in a universal testing machine (0.5 mm/min, 1.2 mm pin diameter). Data were analyzed by the Weibull test, one-way analysis of variance, and Tukey's test (α = .05).
RESULTS
The flexural strength of specimens with 1.2 mm thickness was significantly higher than that of specimens with 0.5 mm thickness (p < .05). The flexural strength of 1.2 mm/120-min group was slightly, but not significantly, higher than that of 1.2 mm/60-min group (p > .05). The flexural strength of 0.5 mm/120-min group was slightly, but not significantly, higher than that of 0.5 mm/60-min group (p > .05).
CONCLUSION
The increase in thickness of monolithic zirconia increases its flexural strength; however, increasing the sintering time appears to have no significant effect on the flexural strength of monolithic zirconia.
Topics: Zirconium; Flexural Strength; Materials Testing; Dental Materials; Dental Stress Analysis; Surface Properties; Hot Temperature; In Vitro Techniques
PubMed: 38818850
DOI: 10.1002/cre2.856 -
Health Security May 2024The purpose of this study was to investigate the feasibility and effectiveness of COVID-19 throat swab samples delivered by medical drones in epidemic prevention and...
The purpose of this study was to investigate the feasibility and effectiveness of COVID-19 throat swab samples delivered by medical drones in epidemic prevention and control. This study was carried out in both southern and northern hospital districts of the Affiliated Hospital of Jiangnan University from May to October 2022. The main participants were the Affiliated Hospital of Jiangnan University and Zhejiang Antwork Technology Co., Ltd. We first constructed an urban medical unmanned aerial vehicle (UAV) delivery system and developed a UAV-specific storage box for COVID-19 samples. The UAV system was used to transport COVID-19 throat swab samples from the northern hospital district to the southern hospital district, and the following indexes were obtained: (1) flight time of COVID-19 samples delivered by UAV, (2) real-time temperature of COVID-19 nucleic acid samples during transportation, and (3) the time of distribution of COVID-19 nucleic acid samples by road traffic as measured using the Baidu Maps application, compared with the flight time of UAV. The COVID-19 sample delivery system for urban medical UAV mainly consists of intelligent logistics UAV, low-temperature COVID-19 throat swab sample storage box, unmanned logistics hub, and cloud operation control platform. The flight distance between the northern and southern districts of the Affiliated Hospital of Jiangnan University was 10 km, and the ground distance was 24 km. From May 11 to October 28, 2022, a total of 1,190 UAV flights occurred. The average flight time was 13 minutes, which was 40 to 70 minutes faster than the average road travel time required for manual delivery of COVID-19 throat swab samples. At different time points in the day, UAV delivery efficiency increased by 67.5% to 82%. The use of 5G with the Internet of Things and UAV technology to deliver nucleic acid samples has the characteristics of fast speed, being unaffected by ground traffic conditions, and the ability to ensure the safety of nucleic acid samples in the transportation process, which is worthy of further study.
PubMed: 38815144
DOI: 10.1089/hs.2023.0090 -
Indian Journal of Orthopaedics Jun 2024Neurofibromatosis is an autosomal-dominant multi-system disease affecting the nervous, integumentary, ocular, and musculoskeletal systems. In the small number of...
Neurofibromatosis is an autosomal-dominant multi-system disease affecting the nervous, integumentary, ocular, and musculoskeletal systems. In the small number of reported cases, the cause was either atraumatic or an intra-articular neurofibroma. Only a couple of articles in medical literature have reported synovial and capsular hemangioma originating within the hip joint. In this article, we present a rare case of pathological hip dislocation in a neurofibromatosis patient secondary to capsular hemangioma that would be reported for the first time in medical literature. We present the case of a 20-year-old female, resident of Karachi, who presented to the outpatient clinic with pain in the left hip join and inability to bear weight on left leg for 1 week. Diagnosed as a case of posterior hip dislocation after physical examination and imaging, her dislocation was reduced by the Allis method. This maneuver, however, was unsuccessful. Ultimately, the joint was reduced with open reduction via Steinmann pin because post-reduction hip joint was unstable to be contained into the acetabulum; therefore, Steinmann pin was used. The biopsy specimen taken from joint capsule and femoral neck during the surgery revealed cavernous hemangioma within the capsule. Hence, the etiology of posterior hip dislocation was attributed to the presence of capsular hemangioma within the hip joint. The surgery proved successful. The patient had remarkable recovery. The Steinmann pin was removed at 6 weeks, full weight-bearing started at 3 months, and range of motion extended from 0 to 90 degrees at 1 year with imaging studies showing a normally placed hip joint. The presented case reports an unusual etiology of a rare pathology occurring in association with a common genetic disease. It focuses on the importance of thorough examination and extensive relevant investigations in patients presenting with rare pathologies. These practices not only expedite the diagnosis and treatment of such patients, but can also reveal unusual etiologies responsible for uncommon pathologies. This case would help widen the differential diagnosis and treatment strategies of the physicians while dealing with neurofibromatosis patients with pathological hip dislocation. This is a case report having Level of Evidence 4 in accordance with the levels developed by the Centre of Evidence Based Medicine (CEBM) for treatment.
PubMed: 38812877
DOI: 10.1007/s43465-024-01166-8