Syndesmosis screw: Leave it or remove it?

Background: Unstable ankle injuries with associated disruption of the distal-fibular syndesmosis are typically managed by adjunctive placement of temporary syndesmotic positioning screws. The widespread notion that positioning screws must be removed by default after healing of the syndesmosis remains a topic of debate which lacks scientific support. The present study was designed to test the hypothesis that syndesmotic positioning screws are safely retained per protocol in asymptomatic patients.  

Patients and Methods: A retrospective analysis of an institutional prospective database was performed during a 5-year time-window at an academic level 1 trauma centre in the United States. All ankle fractures requiring surgical fixation were included in the analysis. The primary outcome parameter consisted of the rate of elective hardware removal for syndesmotic positioning screws within 6 months after surgical fixation. 

Results: A total of 496 consecutive patients with 496 isolated ankle fractures managed by surgical fixation were included in this study. Of these, 140 injuries were managed by placement of syndesmotic positioning screws. Within 6 months follow-up, 17.1 % of all syndesmotic screws were found to be radiographically broken, and 13.6 % of syndesmotic screws revealed radiographic signs of loosening. Only 2 patients (1.4 %) required the elective removal of symptomatic positioning screws within 6 months of surgical fracture fixation. Conclusion: Despite the high rate of radiographic complications related to breaking or loosening of syndesmotic screws in almost one third of all cases, more than 98 % of all patients remain asymptomatic and do not require a scheduled hardware removal. The routine removal of syndesmotic positioning screws does not appear to be justified from a patient safety perspective.

Literature;

Weckbach S, Hahnhaussen J, Losacc o JT, Gebhard F, Stahel PF: Is the Standard Retention of Syndesmotic Positioning Screws after Ankle Fracture Fixation Safe and Feasible? A Retrospective Cohort Study in 140 Consecutive Patients at a North American Trauma Centre. Orthop Unfall 2014; 152(6): 554-557

Localisation and grade of soft tissue damage decide over risk of fracture infection

Objectives: To evaluate the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures.

Setting: Three Level 1 Canadian trauma centers.

Participants: A total of 736 (791 fractures) subjects were enrolled and 686 subjects (93%; 737 fractures) provided adequate follow-up data (1-year interview and/or clinical follow-up >90 days).

Intervention: Demographics, injury information, time to surgery, and antibiotics were recorded. Subjects were evaluated using standardized data forms until the fracture(s) healed. Phone interviews were undertaken 1 year after the fracture.

Main Outcome Measures: Infection requiring unplanned surgical debridement and/or sustained antibiotic therapy.

Results: Tibia/fibula fractures were most common (n = 413, 52%), followed by upper extremity (UE) (n = 285, 36%), and femoral (n = 93, 12%) fractures. Infection developed in 46 fractures (6%). The median time to surgery was 9 hours 4 minutes (interquartile range, 6 hours 39 minutes to 12 hours 33 minutes) and 7 hours 39 minutes (interquartile range, 6 hours 10 minutes to 9 hours 54 minutes) for those without and with infection, respectively (P = 0.04). Gustilo grade 3B/3C fractures accounted for 17 of 46 infections (37%) (P < 0.001). Four UE (1.5%), 7 femoral (8%), and 35 tibia/fibula (9%) fractures developed infections (P = 0.001). Multivariate regression found no association between infection and time to surgery [odds ratio (OR), 0.97; 95% confidence interval (95% CI), 0.90–1.06] or antibiotics (OR, 1.0; 95% CI, 0.90–1.05). Grades 3A (OR, 6.37; 95% CI, 1.37–29.56) and 3B/3C (OR, 12.87; 95% CI, 2.72–60.95) relative to grade 1 injuries and tibia/fibula (OR, 3.91; 95% CI, 1.33–11.53) relative to UE fractures were significantly associated with infection.

Conclusion: Infection after open fracture was associated with increasing Gustilo grade or tibia/fibula fractures but not time to surgery or antibiotics.

 Weber D et al. Time to Initial Operative Treatment Following Open Fracture Does Not Impact Development of Deep Infection: A Prospective Cohort Study of 736 Subjects. J Orthop Trauma 2014; 28: 613–619; doi: 10.1097/BOT.0000000000000197

Osteoarthritis 3 Times More Likely After ACL Surgery

People who have had reconstructive surgery for a knee ligament tear develop osteoarthritis in the injured knee three times more often than in the uninjured knee, according to a new study.

About 200,000 anterior cruciate ligament (ACL) injuries happen each year in the United States, and half of those injuries are surgically repaired, according to the American Academy of Orthopaedic Surgeons. Usually, surgeons replace the torn ligament with a grafted replacement.

Researchers have known that reconstructed knees get osteoarthritis more often than healthy knees, but how much the risk increases was hard to determine.

"The time interval between the ACL injury and osteoarthritis is long, usually more than five years," Dr. Bjorn Barenius from  the Karolinska Institutet in Stockholm, Sweden, said. "Ten to fifteen years after the injury is often quoted as a time when you can expect signs of osteoarthritis", he explained

But osteoarthritis can be influenced by many factors, like sustaining more injuries or gaining weight, which might make arthritis hit earlier, he said. 

For the new study, radiologists examined X-rays of both knees of people who'd had ACL surgery at least 14 years earlier. Based on the expert assessments, 57% of ACL-reconstructed knees had arthritis, compared to 18% of healthy knees, according to the results published in The American Journal of Sports Medicine.

How long people had waited between the knee injury and surgery didn't seem to change their likelihood of having arthritis.

Since there was no comparison group of people who had ACL injuries that were not repaired with surgery, it's impossible to say if the surgery or the injury itself increased arthritis risk, Barenius said.

Surgery may help keep the knee from giving way during sports but not restore all of its normal mechanics, he said.

Isolated ACL injuries are rare. The injury is usually complex and includes meniscal tear, which exposes more cartilage to higher wear and tear.For athletes who have ACL reconstruction, osteoarthritis may start to affect their performance many years down the line, but they will have more immediate issues to deal with first, the author claims.

"For most sports and most athletes the instability of the ACL injury will affect their sport more than the future prospect of osteoarthritis," he said.

As far as what patients can do to try to ward off arthritis, Barenius suggests maintaining a healthy weight. Rehabilitation and exercise can help too, Dhaher said. Without surgery, most badly injured knees do develop arthritis, he said.

SOURCE: http://bit.ly/1gWIWzD
Am J Sports Med 2014.

The "Reverse Startle Reflex": Can it avoid "Whiplash" Symptoms?

A Loud Tone Played Before Impact May Reduce Whiplash

NEW YORK (Reuters Health) - If a vehicle could emit a loud tone just before a crash, the sound might startle the occupants and induce muscle reactions that limit the extent of injury, a new study suggests.

A 105 decibel tone emitted just 205 ms before impact appears to reduce the reflexive responses of muscles in the head and neck that ordinarily activate during whiplash, according to research published online August 7 in The Spine Journal.

The results are too preliminary to suggest that a pre-impact tone emitter should become a standard safety device, but the findings merit research in the real world, according to Gunter Siegmund, Director of Research at MEA Forensic Engineers and Scientists in Richmond, BC, Canada, who led the study.

Siegmund told Reuters Health by email, "We know that startle forms part of the neuromuscular response during the kinds of vehicle impacts that can cause whiplash injury. We also know that a loud pre-impact sound can attenuate the startle portion of the response and reduce neck muscle activation levels and head/neck motion. While it seems reasonable to postulate that reduced forces and motion will reduce the likelihood of tissue injury in some individuals, we don't yet know whether this will decrease the rate of actual whiplash injuries in the field."

To study the effect of the tones, 12 volunteers sat in a test sled made up like the driver's seat of a Honda Accord. They each underwent three simulated rear-end crashes either with a tone or without. In each simulation the sled accelerated suddenly at a maximum speed of 19.5 m/s2.

The volunteers were fitted with electromyographic electrodes, both on the surface and inserted into their muscles. They were also fitted with accelerometers to record the motion of the head and torso.

The tone appears to have significantly reduced the amplitude of the C6 multifidus muscle by 42% and the C4 paraspinal muscles by 30%.

Changes in amplitudes in the C4 multifidus and sternocleidomastoid muscles were not statistically significant.

The accelerometers recorded decreased head retraction after the tone by 3.3mm, which was a 9% difference. Peak head angular acceleration in extension and head extension angle were also improved after the tone, while a difference in peak horizontal head acceleration was not found to be statistically significant.

Further testing may require the installation of devices into vehicles because standard crash-test dummies will not be adequate to evaluate muscle responses, Siegmund said.

"Should manufacturers consider including this as a safety feature? I think so," he said. "The technology to detect imminent collisions already exists in some vehicles, and virtually all modern vehicles have speakers that can play a loud tone. Therefore the incremental cost of including this safety system may be relatively low. Two companies have already approached us to commercialize the technology, but I don't know what if anything they are doing with it."

Loud preimpact tones reduce the cervical multifidus muscle response during rear-end collisions: a potential method for reducing whiplash injuries. Spine J 2014.  SOURCE: http://bit.ly/1oRwSd1

Plates not better than K-wires in distal radius fractures?

 Kirschner wire fixation is a longstanding technique in which smooth metal wires with a sharp point are passed across the fracture site through the skin. This technique is rapidly being superseded by locking plate fixation, in which a plate is attached to the bone with fixed angle screws. Locking plates are widely considered to provide stronger fixation, which facilitates earlier return to normal activities. This potential benefit is said to justify the greater cost of the plates.To date, studies comparing the two methods have indicated that locking plates provide improved radiological and/or functional outcomes, particularly in the early stages of rehabilitation; though these studies were smaller single centre trials.

In this multicentre randomised trial, the distal radius acute fracture fixation trial (DRAFFT), the authors examined Kirschner wire fixation compared with volar locking plate fixation for patients with a dorsally displaced fracture of the distal radius. The hypothesis was that locking plates would provide improvements in the patient rated wrist evaluation (PRWE) score in the 12 months after surgery.

Objectives To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.

Design A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.

Setting 18 trauma centres in the United Kingdom.

Participants 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.

Interventions Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.

Main outcome measures Primary outcome measure: validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient’s experience of pain and disability to give a score out of 100. Secondary outcomes: disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.

Results The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was −1.3, 95% confidence interval −4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.

Conclusions Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.

 Dr Pietsch, distal radius fractures, treatment of radius fractures, K-wires in radius fractures, theexpertwitnessreference.blogspot.com

 Literature:

 BMJ 2014;349:g4807

Smoking kills, but how quick?

Cigarette smoking, adiposity, unhealthy diet, heavy alcohol drinking and physical inactivity together are associated with about half of premature deaths in Western populations. The aim of this study was to estimate their individual and combined impacts on residual life expectancy (RLE).

Lifestyle and mortality data from the EPIC-Heidelberg cohort, comprising 22,469 German adults ≥40 years and free of diabetes, cardiovascular disease and cancer at recruitment (1994–1998), were analyzed with multivariable Gompertz proportional hazards models to predict lifetime survival probabilities given specific baseline status of lifestyle risk factors. The life table method was then used to estimate the RLEs.

For 40-year-old adults, the most significant loss of RLE was associated with smoking (9.4 [95% confidence interval: 8.3, 10.6] years for male and 7.3 [6.0, 8.9] years for female heavy smokers [>10 cigarettes/day]; 5.3 [3.6, 7.1] years for men and 5.0 [3.2, 6.6] years for women smoking ≤10 cigarettes/day). 

Other lifestyle risk factors associated with major losses of RLE were 

1. low body mass index (BMI <22.5 kg/m², 3.5 [1.8, 5.1] years for men; 2.1 [0.5, 3.6] years for women), obesity (BMI ≥30, 3.1 [1.9, 4.4] years for men; 3.2 [1.8, 5.1] years for women).The obesity-associated loss of RLE was stronger in male never smokers, while the loss of RLE associated with low BMI was stronger in current smokers.
2. heavy alcohol drinking (>4 drinks/day, 3.1 [1.9, 4.0] years for men), and 
3. high processed/red meat consumption (≥120 g/day, 2.4 [1.0, 3.9] years for women).  
4. The loss of RLE associated with low leisure time physical activity was moderate for women (1.1 [0.05, 2.1] years) and negligible for men (0.4 [−0.3, 1.2] years). 

And even worse:

The combined loss of RLE for heavy smoking, obesity, heavy alcohol drinking and high processed/red meat consumption, versus never smoking, optimal BMI (22.5 to 24.9), no/light alcohol drinking and low processed/red meat consumption, was 17.0 years for men and 13.9 years for women.

Conclusions

Promoting healthy lifestyles, particularly no cigarette smoking and maintaining healthy body weight, should be the core component of public health approaches to reducing premature deaths in Germany and similar affluent societies.

5 Minutes For A Longer Life

Although running is a popular leisure-time physical activity, little is known about the long-term effects of running on mortality. The dose-response relations between running, as well as the change in running behaviors over time, and mortality remain uncertain.

Objectives

We examined the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, 18 to 100 years of age (mean age 44 years).

Methods

Running was assessed on a medical history questionnaire by leisure-time activity.

Results

During a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately 24% of adults participated in running in this population. Compared with nonrunners, runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit. In dose-response analyses, the mortality benefits in runners were similar across quintiles of running time, distance, frequency, amount, and speed, compared with nonrunners. Weekly running even <51 min, <6 miles, 1 to 2 times, <506 metabolic equivalent-minutes, or <6 miles/h was sufficient to reduce risk of mortality, compared with not running. In the analyses of change in running behaviors and mortality, persistent runners had the most significant benefits, with 29% and 50% lower risks of all-cause and cardiovascular mortality, respectively, compared with never-runners.

Conclusions

Running, even 5 to 10 min/day and at slow speeds <6 miles/h, is associated with markedly reduced risks of death from all causes and cardiovascular disease. This study may motivate healthy but sedentary individuals to begin and continue running for substantial and attainable mortality benefits.

Comments:

If you transfer these results into the treatment of patients, it may well be questioned if the patient's contiuned and regular imput into physical work-outs can result in a quicker healing time.

Lee DC et al. Leisure-Time Running Reduces All-Cause and CV Mortality Risk. J Am Coll Cardiol 2014; 64: 472–81

Instability of the distal radioulnar joint: Have your say!

Dear Colleagues,

instability of the distal radioulnar joint can occur after trauma of the wrist. As Expert Witness, I have tie impression that the prevalence of this pathology is more common than we think. And it appearss to be easily missed. It presents with ongoing symptoms that occur with manual ADL, e.g. lifting and carrying. If it remains untreated, it can result in disability of the wrist.

Considering the severity of this pathology, I would like to ask for opinion. Please find the minute to complete a short survey. It is anonymous and does not ask for any personal details.

Thank you

Click here for the Survey

Degenerative Meniscus tears: You better leave it

Background: Arthroscopic surgery for degenerative meniscal tears is a commonly performed procedure, yet the role of conservative treatment for these patients is unclear. This systematic review and meta-analysis evaluates the efficacy of arthroscopic meniscal debridement in patients with knee pain in the setting of mild or no concurrent osteoarthritis of the knee in comparison with nonoperative or sham treatments.

                   

Methods: We searched MEDLINE, Embase and the Cochrane databases for randomized controlled trials (RCTs) published from 1946 to Jan. 20, 2014. Two reviewers independently screened all titles and abstracts for eligibility. We assessed risk of bias for all included studies and pooled outcomes using a random-effects model. Outcomes (i.e., function and pain relief) were dichotomized to short-term (< 6 mo) and long-term (< 2 yr) data.

                   

Results: Seven RCTs (n = 805 patients) were included in this review. The pooled treatment effect of arthroscopic surgery did not show a significant or minimally important difference (MID) between treatment arms for long-term functional outcomes (standardized mean difference [SMD] 0.07, 95% confidence interval [CI]–0.10 to 0.23). Short-term functional outcomes between groups were significant but did not exceed the threshold for MID (SMD 0.25, 95% CI 0.02 to 0.48). Arthroscopic surgery did not result in a significant improvement in pain scores in the short term (mean difference [MD] 0.20, 95% CI –0.67 to 0.26) or in the long term (MD –0.06, 95% CI –0.28 to 0.15). Statistical heterogeneity was low to moderate for the outcomes.

                   

Interpretation: There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the firstline treatment for such patients.

         

M Khan. N Evaniew, A Bedi, OR Ayeni, M Bhandari: Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ August 25, 2014 First published August 25, 2014, doi: 10.1503/cmaj.140433 

Meniscus tears, degenerative meniscus tears, outcome after meniscus debridement, Dr Pietsch, the-expert-witness.de

What is the best treatment for shoulder pain?

Both manual physical therapy (MPT) and corticosteroid injections (CSI) significantly improve symptoms in patients with shoulder impingement syndrome (SIS), but physical therapy may be less costly to the healthcare system, according to a new study.

Objective: To compare the effectiveness of 2 common nonsurgical treatments for SIS.

Design: Randomized, single-blind, comparative-effectiveness, parallel-group trial. (ClinicalTrials.gov: NCT01190891)

Setting: Military hospital–based outpatient clinic in the United States.

Patients: 104 patients aged 18 to 65 years with unilateral SIS between June 2010 and March 2012.

Intervention: Researchers randomly assigned consecutive patients aged 18 to 65 years with unilateral shoulder pain to receive CSI or MPT. Patients were referred from family practice and orthopedic clinics. None had had physical therapy or corticosteroid injections within the previous 3 months.

 The CSI group received up to 3 injections of 40 mg triamcinolone acetonide 1 month apart. The injections were administered by a family practice physician with sports medicine fellowship training.
Matched to individual impairment, the MPT intervention consisted of a combination of joint and soft-tissue mobilizations, manual stretches, contract-relax techniques, and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Patients were treated twice weekly over a 3-week period and prescribed home exercises.
 Ten CSI patients crossed over to receive physical therapy, and 9 in the MPT group crossed over to receive injections.

Measurements: The primary outcome was change in Shoulder Pain and Disability Index scores at 1 year. Secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores, and 1-year health care use.

Results: After 1 year, both the CSI group (n = 52) and the MPT group (n = 46) had a greater than 50% improvement in the Shoulder Pain and Disability Index (SPADI), with neither group being superior. The between-group difference in the SPADI, a 13-item, self-administered questionnaire that includes pain and disability subscales, was 1.55% (95% confidence interval [CI], –6.3% to 9.4%; P = .70). The minimal clinically important difference for the SPADI is a change between 8 and 13 points (6% to 10%).

Ratings on the Global Rating of Change (GRC) scale improved by 3 points (95% CI, 2 - 4) for each group. The GRC measures overall perceived changes in quality of life, with a score of 3 or more points being clinically meaningful.
Self-reported pain intensity as measured by the 11-point Numeric Pain Rating Scale significantly improved from baseline (P < .05) in both groups, but neither intervention was superior (between-group difference 0.4 (95% CI, –0.5 to 1.2; P = .42).

During the 1-year follow-up, patients receiving CSI had more SIS-related visits to their primary care provider (60% vs. 37%) and required additional steroid injections (38% vs. 20%), and 19% needed physical therapy. Transient pain from the CSI was the only adverse event reported.

Conclusion: Both groups experienced significant improvement. The manual physical therapy group used less 1-year SIS-related health care resources than the CSI group.

Rhon DI, Boyles RB, Cleland JA. One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. doi online 5.8.2014

Errors of level in spinal surgery

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. 

METHODS:We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. 

RESULTS:A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. 

CONCLUSION: The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery. 

Read:
Longo JG et al. Errors of level in spinal surgery. An evidence based systematic review. J Bone Joint Surg Br 2012; 94-B: 1546–1550

Sutured Achilles tendon benefits from early weight bearing

BACKGROUND:The choice of rehabilitation management after the surgical repair of acute Achilles tendon (AT) ruptures remains controversial because of insufficient clinical evidence. The current study analyzes the postoperative rehabilitation of AT ruptures based on the current clinical evidence. PURPOSE:To identify and analyze the high-level clinical evidence regarding postoperative rehabilitation after the surgical repair of AT ruptures. Subgroup analyses were also performed to obtain more reliable and specific results. 

STUDY DESIGN:Meta-analysis. 

METHODS:The studies were retrieved by searching the Medline, Embase, and Cochrane databases through the OVID retrieval engine from 1990 to August 14, 2013. Two independent reviewers critically reviewed the studies using preset inclusion and exclusion criteria. The quality of the eligible studies was assessed by the Cochrane 12-item scale. All included studies were summarized, and their data were extracted. Subgroup analyses were performed according to the different protocols of early functional rehabilitation. 

RESULTS:Nine studies, consisting of 6 randomized controlled trials and 3 quasi-randomized studies, were ultimately included. A total of 402 patients were identified. Six of the included studies utilized early weightbearing combined with early ankle motion exercises, while the other 3 only employed early ankle motion exercises. The subgroup analyses demonstrated that 11 of the 15 functional outcome measurements were significantly superior for patients who underwent both early weightbearing and ankle motion exercises than for those who underwent conventional cast immobilization. Similar rates of reruptures (odds ratio [OR], 1.36; 95% CI, 0.38-4.91; P = .64) and major complications (OR, 0.67; 95% CI, 0.24-1.87; P = .44) as well as a significantly lower rate of minor complications (OR, 0.51; 95% CI, 0.27-0.95; P = .03) were also observed in this early functional rehabilitation group. For the patients who solely performed early ankle motion exercises, only 2 of the 14 functional measurements were observed to be significantly superior to immobilization. There were also no significant differences in the rates of reruptures (OR, 0.47; 95% CI, 0.08-2.70; P = .40) and other complications (OR, 1.09; 95% CI, 0.41-2.92; P = .86) between the 2 groups. 

CONCLUSION:Postoperative early weightbearing combined with early ankle motion exercises is associated with a lower minor complication rate and achieves superior and more rapid functional recovery than conventional immobilization after surgical AT repair. In contrast, few advantages were identified when only early ankle motion exercises were applied.

Huang J et al. Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures. A Systematic Review With Meta-analysis. Am J Sports Med 2014; online 2. Mai; doi: 10.1177/0363546514531014

Age is no contraindication for surgery of fracture nonunion

Introduction: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. 

Materials and Methods: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients. 

Results: Despite demographic differences in the aged population, including a predominance of medical comorbidities (P < .01) and osteopenia (P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. 

Conclusions: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient’s age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.





Taormina DP et al. Older Age Does Not Affect Healing Time and Functional Outcomes After Fracture Nonunion Surgery. Ger Orthop Surg Res 2014; online 14. Mai; doi: 10.1177/2151458514532811

Younger Age Is Associated with a Higher Risk of Early Periprosthetic Joint Infection and Aseptic Mechanical Failure After Total Knee Arthroplasty

Although early aseptic mechanical failure after total knee arthroplasty has been reported in younger patients, it is unknown whether early revision due to periprosthetic joint infection is more or less frequent in this patient subgroup. The purpose of this study was to determine whether the incidence of early periprosthetic joint infection requiring revision knee surgery is significantly different in patients younger than fifty years of age compared with older patients following primary unilateral total knee arthroplasty.

Methods: 

A large population-based study was conducted with use of the California Patient Discharge Database, which allows serial linkage of all discharge data from nonfederal hospitals in the state over time. Patients undergoing primary unilateral total knee arthroplasty during 2005 to 2009 were identified. Principal outcomes were partial or complete revision arthroplasty due to periprosthetic joint infection or due to aseptic mechanical failure within one year. Multivariate analysis included risk adjustment for important demographic and clinical variables. The effect of hospital total knee arthroplasty volume on the outcomes of infection and mechanical failure was analyzed with use of hierarchical modeling.

Results: 

At one year, 983 (0.82%) of 120,538 primary total knee arthroplasties had undergone revision due to periprosthetic joint infection and 1385 (1.15%) had undergone revision due to aseptic mechanical failure. The cumulative incidence in patients younger than fifty years of age was 1.36% for revision due to periprosthetic joint infection and 3.49% for revision due to aseptic mechanical failure. In risk-adjusted models, the risk of periprosthetic joint infection was 1.8 times higher in patients younger than fifty years of age (odds ratio = 1.81, 95% confidence interval = 1.33 to 2.47) compared with patients sixty-five years of age or older, and the risk of aseptic mechanical failure was 4.7 times higher (odds ratio = 4.66, 95% confidence interval = 3.77 to 5.76). The rate of revision due to infection at hospitals in which a mean of more than 200 total knee arthroplasties were performed per year was lower than the expected (mean) value (p = 0.04).

Conclusions: 

Patients younger than fifty years of age had a significantly higher risk of undergoing revision due to periprosthetic joint infection or to aseptic mechanical failure at one year after primary total knee arthroplasty.

Fat with 20 - knee replacement with 60?

Previous studies could demonstrate the positive relationship between obesity and earlier hip replacement. This study focussed on the association between weight gain and the risk of knee replacement (KR) due to primary osteoarthritis (OA), and to evaluate whether the association differs by age.

225,908 individuals from national health screenings with repeated measurements of height and weight were followed prospectively with respect to KR identified by linkage to the Norwegian Arthroplasty Register. Cox proportional hazard regression was used to calculate sex-specific relative risks (RR) of KR according to change in Body Mass Index (BMI) and weight, corresponding analyses were done for age categories at first screening.

It was found that during 12 years of follow up, 1591 participants received a KR due to primary OA. Men in the highest quarter of yearly change in BMI had a RR of 1.5 (95% confidence interval (CI) 1.1-1.9) of having a KR compared to those in the lowest quarter. For women the corresponding RR was 2.4 (95% CI 2.1-2.7). Men under the age of 20 at the first screening had a 26% increased risk for KR per 5 kg weight gain, for women the corresponding increase was 43%. At older age the association became weaker, and in the oldest it was lost.

As a result, the authors concluded that weight gain increases the risk for later KR both in men and women. The impact of weight gain is strongest in the young, at older age the association is weak or absent. Our study suggests that future OA may be prevented by weight control and that preventive measures should start at an early age.

Weight gain and the risk of knee replacement due to primary Osteoarthritis. A population based, prospective cohort study of 225,908 individuals: Osteoarthr Cartil 2014

Dom't feel safe with double gloving!

INTRODUCTION

Surgical gloves provide a protective barrier against blood borne pathogens such as human immunodeficiency virus, hepatitis B and hepatitis C. Glove perforation occurs frequently – in some types of surgery at a rate of up to 45%, but is often unnoticed by the surgeon and nurse. One estimate suggested that a surgeon risks more than one hepatitis infection per lifetime and more than one in 1,500 surgeons is likely to be infected by HIV during the next 35 years because of

damaged gloves.

One study has concluded that the use of a double gloving system featuring a colored under-glove gives an accuracy of detection of 97%.This study therefore aimed to compare puncture rates between this double gloving indicator system and single-use gloves. It also aimed to determine the extent to which glove perforations remain undetected during surgery.

METHOD

The study analyzed all gloves used at the Satakunta Central Hospital, Pori, Finland in

September and October 1999. The study was open and prospective and randomization was

made according to the year of birth of the patient – patients born in even years were operated on

with double gloving and those born in odd years were operated on with single gloving. Gloves were tested using the approved standardized water-leak test method EN455-1 where the glove is filled with water and checked for two minutes to detect any holes.The gloves used in the study were either Biogel Indicator™ or Gammex and Nutex, which were the standard gloves used at the

hospital.

An analysis was made according to glove type, operating time, surgeon or assistant and type

of surgery. A comparison was also made to see whether or not glove perforation was noticed

during the operation.

RESULTS

In a total of 885 surgical procedures 2,462 gloves were tested – 1,020 single gloves, 1,148 double glove systems and 294 combination gloves were studied. The overall perforation rate was 192 out of 2,462 gloves (7.8%) or 162 out of 885 operations (18.3%). The inner glove of the double-gloving system was punctured in 6 out of 88 (6.8%) outer glove perforations. Detection of perforation during surgery was 28 out of 76 (36.8%) with single gloves, 77 out of 89 (86.5%) with the double gloving system and 9 out of 27 (33.3%) with combination gloves.

CONCLUSION & COMMENT

The authors conclude that in order to maintain a sterile barrier between surgeon and patient it is important to use a double gloving puncture indication system, particularly in operations where there is a high risk of glove perforation.

Laine T, Aarnio P: How often does glove perforation occur in surgery? Comparison between single gloves and a double gloving system.The American Journal of Surgery. 2001; 181: 564-6

Complications After Arthroscopic Knee Surgery

Background: Knee arthroscopies are among the most common procedures performed by orthopaedic surgeons, yet little is known about the associated complications and complication rates. 

Purpose: To examine the nature and frequency of complications after the most common arthroscopic knee procedures, with particular attention to fellowship training, geographic location of practice, and age and sex of the patient. 

Study Design: Cross-sectional study; Level of evidence, 3. 

Methods: Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2003 to 2009. The database was queried to determine the type and frequency of complications for patients who underwent knee arthroscopy and for those who underwent sports medicine knee arthroscopy, including arthroscopic partial meniscectomy, meniscal repair, chondroplasty, microfracture, anterior cruciate ligament reconstruction, or posterior cruciate ligament reconstruction. Factors affecting complication rates that were investigated included type of procedure, fellowship training status, geographic location of practice, and age and sex of the patient. 

Results: There were 4305 complications out of 92,565 knee arthroscopic procedures obtained from the American Board of Orthopaedic Surgery database for an overall candidate-reported complication rate of 4.7%. The complication rates were highest for posterior cruciate ligament reconstruction (20.1%) and anterior cruciate ligament reconstruction (9.0%); complication rates for meniscectomy, meniscal repair, and chondroplasty were 2.8%, 7.6%, and 3.6%, respectively. The complication rate for sports fellowship–trained candidates was higher than for non–sports trained candidates (5.1% sports, 4.1% no sports; P < .0001) and for male patients (4.9% male vs 4.3% female; P < .0001). Younger patients (<40 years; 6.2%) had a higher complication rate than older patients (≥40 years; 3.58%) (P < .0001). Procedure complexity is a likely confounding factor affecting sports-trained candidates and younger patients. There were no geographic differences (P = .125). The overall rate of pulmonary embolus was 0.11%. Surgical complications (3.68%) were more common than medical (0.77%) or anesthetic complications (0.22%), and infection was the most common complication overall (0.84%). 

Conclusion: The overall self-reported complication rate for arthroscopic knee procedures was 4.7%. Knee arthroscopy is thought not to be a benign procedure, and patients should be made aware of the risk of complications. 

Comment:
Please note that the article reflects the figures for fellowship trainees. They may be different in the group of a specialised surgeon. However, the range of complications and their proportions may be the same.

  

Salzler MJ et al. Complications After Arthroscopic Knee Surgery. Am J Sports Med 2013; online 27. November; doi: 10.1177/0363546513510677

"Red flags" under fire

Most clinical practice guidelines for back pain recommend the use of red flags to help identify those patients with a higher likelihood of spinal fracture or malignancy who then become candidates for more extensive diagnostic investigations. There is confusion, however, as the guidelines have produced different lists of red flags to screen for spinal fracture and malignancy. Eight of the guidelines investigated by Koes and colleagues in their review of back pain guidelines, endorsed 26 red flags for fracture and 27 for malignancy. 

None of the eight guidelines endorsed the same set of red flags, for either condition, so it is unclear what clinicians should use in clinical care. Additionally, guidelines generally provide no information on diagnostic accuracy of the endorsed red flags, which limits their value in clinical decision making. Adding to the uncertainty, the same agency can provide inconsistent information on red flags. For example, the National Institute for Health and Care Excellence clinical guideline on the early management of persistent non-specific low back pain does not endorse red flags, whereas the group’s clinical knowledge summary for the management of low back pain does

To resolve the uncertainty around application of red flags in clinical practice, the authors conducted two Cochrane diagnostic test accuracy reviews assessing the accuracy of red flags to screen for the most common forms of serious pathology—spinal fracture and malignancy—in patients with low back pain. They have provided a distilled summary of both reviews to help guide clinical decision making.

Objective To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

Design Systematic review.

Data sources Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

Inclusion criteria Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

Review methods Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

Results We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

Conclusions While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

Read the article:

BMJ 2013;347:f7095 BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7095 (Published 11 December 2013). 

Excise or save: Do we need a fat pad?

The infrapatellar fat pad is one of the structures that obscures exposure in minimally invasive total knee arthroplasty (MIS TKA). Most MIS TKA surgeons (and many surgeons who use other approaches as well) excise the fat pad for better exposure of the knee. There is still controversy about the result of fat pad excision on patella baja, pain, and function.

QUESTIONS/PURPOSES:

In the setting of a randomized controlled trial, we sought to determine whether infrapatellar fat pad excision during MIS TKA causes (1) patellar tendon shortening (as measured by patella baja); (2) increased anterior knee pain; (3) decreases in the Knee Society Score or functional subscore; or (4) more patella-related complications.

METHODS:

We randomized 90 patients undergoing MIS TKA at one institution into two groups. In one group, 45 patients underwent MIS TKA with complete infrapatellar fat pad excision and in the other group, 45 patients received MIS TKA without infrapatellar fat pad excision. The patella was selectively resurfaced in these patients; there was no difference between the groups in terms of the percentage of patients whose patellae were resurfaced. We measured patellar tendon shortening, knee flexion, anterior knee pain, Knee Society Score (KSS), functional subscore, and patellar complications at preoperative and postoperative periods of 6 weeks, 3 months, 6 months, and 1 year; complete followup data were available on 86% of patients (77 of 90) who were enrolled.

RESULTS:

At the final followup, no significant differences were observed in patellar tendon shortening, KSS, functional subscore, or knee flexion in either group. However, patients with their infrapatellar fat pad excised experienced more anterior knee pain (8.3% versus 0%; p = 0.03; 95% confidence interval, -0.007 to 0.174) at the end of the study. No patellar complications were found in either group.

CONCLUSIONS:

Infrapatellar fat pad excision in MIS TKA resulted in an increasing small percentage of patients with anterior knee pain after surgery. Surgeons should keep the fat pad if excellent exposure can be achieved but resect it if needed to improve exposure during TKA.

LEVEL I OF EVIDENCE:

 Pinsornsak P, Naratrikun K, Chumchuen S:The Effect of Infrapatellar Fat Pad Excision on Complications After Minimally Invasive TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2013 Oct 18.