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