SICOT-J - Société Internationale de Chirurgie Orthopédique et de Traumatologie
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Pain is vital in resuscitation in trauma
No full textImplementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet
Influence of mobilization and weight bearing on in-hospital outcome in geriatric patients with hip fractures
No full textIntroduction: Early recovery of mobilization after a fracture of the hip is associated with improved long-term ability to walk, lower complication rates, and mortality. In this context, early mobilization and full weight bearing are favorable. The aim of this study was (1) to analyze the influence of time between operation and first mobilization on in-hospital outcome and (2) the influence of early mobilization, full weight bearing, and ASA on pain, mobility of the hip, and ability to walk during the in-hospital phase of recovery.
Methods: This is a retrospective in-hospital study of 219 patients aged 70 years or older who were treated with surgery after a hip fracture. Data were collected by a review of medical records. The outcomes were mortality, complications, length of stay, and the Merle d’Aubigné score which evaluates pain, mobility of the hip, and ability to walk. Factors were sought in bivariate and multivariate analyses.
Results: A shorter time between operation and first mobilization was significantly associated with lower in-hospital mortality and complications. Early mobilization (within 24 h after the operation) and full weight bearing had no influence on pain, mobility of the hip, and ability to walk as well as length of stay in our cohort. Fracture type and treatment influenced mobility of the hip, while age as well as physical health status affected the ability to walk.
Discussion: Patients with femoral neck fractures, respectively after total hip arthroplasty, had less pain and showed better mobility of the hip and ability to walk during hospitalization than patients with trochanteric fractures; these results were irrespective of early vs. late mobilization and full vs. partial weight bearing. Foremost, a shorter time between operation and first mobilization is associated with lower complication and mortality rates
Spinal fusion achieves similar two-year improvement in HRQoL as total hip and total knee replacement. A prospective, multicentric and observational study
No full textIntroduction: Total hip and knee arthroplasty (THA/TKA) are surgical procedures with proven benefits. Although the literature reports outcomes of fusion of the lumbar spine comparable to those of THA/TKA in general health-related quality-of-life (HRQoL) questionnaires, functional assessment is nevertheless needed for these results to be of use in clinical practice and management. Aim of our study was to prove that lumbar spinal fusion has similar if not better outcomes than THA/TKA using intervention-specific HRQoL questionnaires and functional assessment questionnaires.
Materials and methods: Observational, ambispective, multicentre study of three cohorts undergoing lumbar spinal fusion (n = 115), THA (n = 119) and TKA (n = 253). Patients were evaluated using the Short-Form-12 (SF-12), Harris–Hip-Score, Hospital for Special Surgery Scale (HSS) and Oswestry Low Back Pain Disability questionnaires. A minimum follow-up of two years was conducted.
Results: The SF-12 showed significant improvement in all groups. The SF-12 physical component summary score indicated a more severe pre-operative status (p = 0.031) in the THA cohort. The mental component summary score indicated a less severe pre-operative status in the TKA cohort (p = 0.008) and greater post-operative improvement in the TKA and THA cohorts across follow-up (six months p = 0.021; one year p = 0.012; two years p = 0.042). Functional assessment indicated greater pre-operative disability in the THA group. At two years of follow-up, functional improvement according to the Harris, HSS and Oswestry questionnaires were 152.01%, 50.07% and 41.14% respectively.
Conclusions: This study demonstrates that lumbar spinal fusion and total knee and hip arthroplasty are comparable in terms of functional improvement when thoroughly studied with health, quality-of-life and functional assessment questionnaires
Neurovascular anatomy around the knee: Relevance of the dangers of self-drilling external fixator pin tips
No full textIntroduction: With external fixation of the femur and tibia, iatrogenic injury to neurovasculature from self-drilling tips of fixation pins is an important consideration in pin placement. Precise knowledge of the neurovascular anatomy in the distal femur and proximal tibia is important to limit potential pin misplacement.
Method: Six pin placement sites on six cadaveric legs were used in accordance with current placement techniques. After pin placement, the soft tissue around each pin was dissected and the distances between the pin tips and the surrounding neurovasculature were measured.
Results: The resultant data allow for a description of safe and unsafe corridors which can be used for external fixator pin placement. Safe sagittal insertion into the distal femur should consist of two pins: (1) 90 mm ± proximal from the proximal pole of the patella and 3 mm ± medially, (2) 55 mm ± proximal from the proximal pole of the patella and 2 mm ± laterally. Safe coronal insertion into the distal femur should consist of two pins: (1) 30 mm ± proximal to the lateral epicondyle, (2) 100 mm ± proximal to the lateral epicondyle. Safe proximal tibial pin placement should consist of two pins and be placed at an oblique angle: (1) 20 mm ± distal to the tibial tuberosity and 2 mm ± medially, (2) 55 mm ± distal to the tibial tuberosity and 2 mm ± medially.
Discussion: This study forms an investigation into the safe areas for placement of external fixator pins, within the distal femur and proximal tibia, specifically, detailing the best practice for pin placement in relation to the tips of the external fixation pins
Admission blood glucose as a predictor of shock and mortality in multiply injured patients
No full textIntroduction: Reliable diagnosis of shock in multiply injured patients is still challenging in emergency care. Point-of-care tests could have the potential to improve shock diagnosis. Therefore, this study aimed to analyze the impact of admission blood glucose on predicting shock in multiply injured patients.
Methods: A retrospective cohort analysis of patients with an injury severity score (ISS) ≥ 16 who were treated in a level I trauma center from 01/2005 to 12/2014 was performed. Shock was defined by systolic blood pressure ≤ 90 mmHg and/or shock index ≥ 0.9 at admission. Laboratory shock parameters including glucose were measured simultaneously. Receiver-operating-characteristic (ROC) analysis and multivariate logistic regression analysis was performed.
Results: Seven hundred and seventy-two patients were analyzed of whom 93 patients (12.0%) died. Two hundred and fifty-nine patients (33.5%) were in shock at admission. Mortality was increased if shock was present at admission (18.1% vs. 9.0%, p 11.5 mmol/L had a 2.2-fold risk of shock (95% CI [1.4–3.4], p = 0.001). Admission blood glucose of > 11.5 mmol/L positively correlated with mortality too (Spearman rho = 0.65, p < 0.001). Patients had a 2.5-fold risk of dying (95% CI [1.3–4.8], p = 0.004).
Discussion: Admission blood glucose was proven as an independent indicator of shock and mortality and, therefore, might help to identify multiply injured patients at particular risk
Percutaneous restoration of bone continuity with screws and PMMA cement in an extensive destruction of the pelvis
No full textWe report a case of combined percutaneous screw placement and cementoplasty guided by CT and fluoroscopy in a 66-year-old man with extensive osteolytic destruction of the right iliac bone and sacral wing due to metastasic infiltrative vesical carcinoma. The medical condition was responsible for very limited and painful walking. Two perpendicular screws were inserted into the iliac bone and sacroiliac joint, and bone cement injection was used to anchor the screws and restore the mechanical continuity of the pelvis ring. This minimally invasive procedure allowed for significant and rapid resumption of painless walking
Acetabular liner dissociation: A case report and review of the literature
No full textDissociation of the polyethylene liner from the acetabular shell is a rare but catastrophic complication of total hip arthroplasty (THA). There have been reports of polyethylene liner dissociation (PLD) as well as ceramic liner dissociation (CLD) in the literature. Amongst the commonly used implants, liner dissociation has been reported with the Pinnacle (DePuy), Harris–Galante (Zimmer) and Trident (Stryker) acetabular components.
To the best of our knowledge, this is the first case report of PLD in an R3 (Smith & Nephew) acetabular component. This case report highlights the implant choice for treatment of the liner dissociation and the role of constrained implants in such cases
Femoral malalignment after gamma nail insertion in the lateral decubitus position
No full textIntroduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position.
Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides.
Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019).
Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position
Surgical technique for biological fixation of closed segmental tibial fractures by the Less Invasive Stabilization System (LISS)
No full textIntroduction: This prospective case series study aimed to assess the value of the Less Invasive Stabilization System (LISS) to treat closed Segmental Tibial Fractures (STFs) using a proposed surgical technique.
Materials and methods: Between August 2010 and January 2014, 21 consecutive recently (within 1 week) closed STFs that matched the inclusion criteria were enrolled. Patients were treated with the 13-hole LISS plate. All patients were followed up every 2 weeks for the first 2 months, then every month for the rest of the first 6 months and then every 6 months thereafter. Patients were assessed radiologically during the follow-up appointments and clinically at the final visit by the Lower Extremity Functional Scale (LEFS) to evaluate the result.
Results: The mean time to union of the proximal fracture was 15.72 ± 2.78 (range: 12–20) weeks and for the distal fracture was 20 ± 2.22 (range: 16–24) weeks, excluding delayed union in three patients. All patients except the three showed radiological observable callus in a mean duration of 4.95 (range: 3–7) weeks. The mean final follow-up LEFS was 72.4 (range: 60–80).
Conclusion: The mean time to union of the proximal fracture was shorter than the distal fracture. The use of LISS to treat closed STFs using the proposed surgical technique has proved to give favorable results. Further studies using the described technique are needed to justify the achieved results.
Level of evidence: IV (Prospective case series)
Biomechanical evaluation of annulus fibrosus repair with scaffold and soft anchors in an ex vivo porcine model
No full textIntroduction: Altered biomechanical properties, due to intervertebral disc (IVD) degeneration and missing nucleus fibrosus, could be thought as one of the reasons for the back pain many herniation patients experience after surgery. It has been suggested to repair annulus fibrosus (AF) to restore stability and allow nucleus pulposus (NP) replacement and furthermore prevent reherniation. The aim of this study was to evaluate a new method for closing a defect in AF for use in herniation surgery.
Methods: Our repair method combines a polycaprolactone (PCL) scaffold plugging herniation and soft anchors to secure the plug. Ex vivo biomechanical testing was carried out in nine porcine lumbar motion segments. Flexion–extension, lateral bending and rotation were repeated three times: first in healthy specimens, second with a full thickness circular defect applied, and third time with the specimens repaired. Finally push out tests were performed to check whether the plug would remain in.
Results: Tests showed that applying a defect to the AF increases the range of motion (ROM), neutral zone (NZ) and neutral zone stiffness (NZS). In flexion/extension it was found significant for ROM, NZ, and NZS. For lateral bending and rotation a significant increase in ROM occurred. After AF repair ROM, NZ and NZS were normalized. All plugs remained in the AF during push out test up until 4000 N, but NP was squeezed out through the pores of the scaffold.
Discussion: A defect in the AF changes the biomechanical properties in the motion segment, changes that point to instability. Repairing the defect with a PCL plug and soft anchors brought the biomechanical behavior back to native state. This concept is promising and might be a viable way to repair the IVD after surgery