Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established.Aims
Methods
The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection.
The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86).Aims
Patients and Methods
Fluoroscopic C-arms are operated by medical radiography technologists (RTs) in Canadian operating rooms (ORs). While they do receive formal, accredited training, most of it is theoretical, rather than hands-on. During their first encounters in the OR, new RTs can experience difficulty achieving the radiographic views required by surgeons, often needing several scout X-rays during C-arm positioning. Furthermore, ambiguous language by surgeons often inadequately conveys their request. The result is often frustration, unnecessary radiation exposure, and added OR time. The purpose of this study was to evaluate the value of artificial X-rays in improving C-arm positioning performance, with inexperienced C-arm users. We developed an Artificial X-ray Imaging System (AXIS) that generates Digitally Reconstructed Radiographs (DRRs), or artificial X-ray images, based on the relative position of a C-arm and manikin. 30 participants were enrolled in the user study and performed four activities: an introduction session, an AXIS-guided evaluation, a non-AXIS-guided evaluation, and a questionnaire. The main goal of the study was to assess C-arm positioning performance with and without AXIS guidance. For each evaluation, the participants had to replicate a set of target X-ray images by taking real radiographs of the manikin with the C-arm. During the AXIS evaluation, artificial X-rays were generated at 2 Hz for guidance, while in the non-AXIS evaluation, the participants had to acquire real scout X-rays to guide them toward the correct view. For each imaging task the number of real X-rays and time required per task was recorded, and the C-arm's pose was tracked and compared to the target pose to determine positioning accuracy; these were averaged for each participant and condition. Hypothesis testing on the means and paired t-tests were carried out using a significance level of α=0.05. On average, users took significantly fewer real scout X-ray images (53% fewer (2.8 vs 6.0), p<0.001) when guided by AXIS. Lateral distance accuracy was improved by 10% for final C- arm positions and by 26% for the most accurate intermediate C-arm positions when guided by AXIS (p<0.05). There was no significant difference in average task time or angular accuracies between the AXIS and non-AXIS evaluations. Overall, we are encouraged by these findings and plan to further develop this system with the goal of deploying it both for training and intraoperative uses.
Pedicle screw fixation is a technically demanding procedure with potential difficulties and reoperation rates are currently on the order of 11%. The most common intraoperative practice for position assessment of pedicle screws is biplanar fluoroscopic imaging that is limited to two- dimensions and is associated to low accuracies. We have previously introduced a full-dimensional position assessment framework based on registering intraoperative X-rays to preoperative volumetric images with sufficient accuracies. However, the framework requires a semi-manual process of pedicle screw segmentation and the intraoperative X-rays have to be taken from defined positions in space in order to avoid pedicle screws' head occlusion. This motivated us to develop advancements to the system to achieve higher levels of automation in the hope of higher clinical feasibility. In this study, we developed an automatic segmentation and X-ray adequacy assessment protocol. An artificial neural network was trained on a dataset that included a number of digitally reconstructed radiographs representing pedicle screw projections from different points of view. This model was able to segment the projection of any pedicle screw given an X-ray as its input with accuracy of 93% of the pixels. Once the pedicle screw was segmented, a number of descriptive geometric features were extracted from the isolated blob. These segmented images were manually labels as ‘adequate’ or ‘not adequate’ depending on the visibility of the screw axis. The extracted features along with their corresponding labels were used to train a decision tree model that could classify each X-ray based on its adequacy with accuracies on the order of 95%. In conclusion, we presented here a robust, fast and automated pedicle screw segmentation process, combined with an accurate and automatic algorithm for classifying views of pedicle screws as adequate or not. These tools represent a useful step towards full automation of our pedicle screw positioning assessment system.
Hospital type is an indicator for structures and processes of care. The effect of hospital type on hip fracture in-hospital mortality is unknown. We determine whether hip fracture in-hospital mortality differs according to hospital type. We retrieved records of hip fracture for 167,816 patients aged 65 years and older, who were admitted to a Canadian acute hospital between 2004 and 2012. For each hospital type we measured and compared the cumulative incidence of in-hospital death by in-patient day, accounting for discharge as a competing event. The cumulative incidence of in-hospital death at in-patient day 30 was lowest for teaching hospital admissions (7.3%) and highest for small community hospital admissions (11.5%). The adjusted odds of in-hospital death were 12% (95% CI 1.06–1.19), 25% (95% CI 1.17–1.34), and 64% (95% CI 1.50–1.79) higher for large, medium, and small community hospital versus teaching hospital admissions. The adjusted odds of nonoperative death were 1.6 times (95% CI 1.42–1.86), and 3.4 times (95% CI 2.96–3.94) higher for medium and small community hospital versus teaching hospital admissions. The adjusted odds of postoperative death were 14% (95% CI 1.07–1.22) and 20% (95% CI 1.10–1.31) higher at large and medium community hospitals versus teaching hospitals. The adjusted odds of postoperative death were largest at small community hospitals but the confidence interval crossed 1 (OR = 1.25, 95% CI 0.92–1.70). A higher proportion of hip fracture patients die at non-teaching compared to teaching hospitals accounting for length of stay. Higher mortality at small community hospitals may reflect disparities in access to resources and delay to treatment.
We performed a systematic review of the literature
pertaining to the functional outcomes of the surgical management
of acetabular fractures. A total of 69 articles met our inclusion
criteria, revealing that eight generic outcome instruments were
used, along with five specific instruments. The majority of studies
reported outcomes using a version of the d’Aubigne and Postel score,
which has not been validated for use in acetabular fracture. Few validated
outcome measures were reported. No psychometric testing of outcome
instruments was performed. The current assessment of outcomes in
surgery for acetabular fractures lacks scientific rigour, and does
not give reliable outcome data for either scientific comparison
or patient counselling. Take home message: The use of non-validated functional outcome
measures is a major limitation of the current literature pertaining
to surgical management of acetabular fractures; future studies should
use validated outcome measures to ensure the legitimacy of the reported
results. Cite this article:
The prevention of a subsequent, contralateral hip fracture is targeted as an avoidable event in the elderly. Fall prevention and bone strengthening measures have met with limited success and the urgency of their effect is undetermined. Our objective was to evaluate the time to second hip fracture (the time between a first and a subsequent, contralateral fracture) in elderly patients, using a population-based administrative health data set. The 58,286 records of persons older than 60 yrs and hospitalized for a hip fracture between 1985 and 2005 were obtained from a Provincial administrative health database. We excluded non-traumatic cases and identified the care episodes related to a subsequent hip fracture for each patient using unique identifiers. We used a 5 year “wash-out period” to avoid counting a second fracture as a first one. We calculated the proportion of first and second fractures and sex distribution over time (fiscal years) and quantified the time between first and second fracture, while correlating it to age, sex and fracture type.Purpose
Method
Radiographs are the most common imaging modality used to guide orthopaedic interventions. Ultrasound (US) imaging offers potential advantages for intraoperative imaging by its portability and ability to produce real-time 2D or 3D images without radiation to either the patient or surgical team. Our objective in this study was to determine in a live emergency room setting, if a newly-developed image processing method for 3D US would allow us to accurately extract (reproduce) the surfaces of fractured bones. We obtained both CT scans and US images from consenting patients admitted to our Level 1 Trauma Centre for radius or pelvic fractures clinically requiring a CT scan. All US examinations in this clinical study were performed with a GE Voluson 730 machine with a 3D RSP5-12 transducer (a mechanized probe in which a linear array transducer is swept through an arc range of 20). Dorsal, volar, and radial views were obtained in the case of radial fractures and iliac crest views in the case of pelvic fractures. The bone surfaces on CT were extracted using a thresholding algorithm [1]. Standard, clinical 3D reconstructions were also created using GE Voxtool 4.0.1 to serve as a qualitative comparison. The US images were processed using the phase-processing algorithm described in [2] then registered to the CT images using a manually-supervised anatomical landmark-based rigid registration algorithm. The quality of the resulting surface matching was evaluated by computing the root mean square distance between the two surface representations [2] and by inter-observer agreement of the registered images to the clinical renderings.Purpose
Method
To determine whether there have been changes in the age, sex and subtype specific first hip fracture rates in Canadian province of British Columbia (BC) between 1990 and 2004. Records of all persons aged 60 years and older hospitalized with hip fractures in BC between 1985 and 2004 were obtained from the Canadian Institute for Health Information Discharge Abstract Database. Only the first hip fracture records were included, and fractures likely due to causes other than trauma were excluded. Age- and sex-specific rates were calculated using population denominators from Statistics Canada and direct standardization was used. Age standardized rates allowed for comparison across years with adjustment for age distribution.Purpose
Method
The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. A cohort of 95 patients with AO type C tibial pilon fractures underwent primary ORIF. Of these patients, 21 had open fractures. Sixty-eight fractures were sustained in falls, 21 in motor vehicle collision, 5 in crushes and one in an aircraft crash. The principal outcome measure was wound dehiscence or infection requiring surgery. Radiological and functional outcomes were assessed at a mean of five years using the SF36 and the Foot and Ankle Outcome Score.Background
Methods
to define the articular injuries of PM fractures into clincially relevant groups, as complex articular injuries could require specific surgical steps; to identify clinical and radiographic parameters which would alert the surgeon to the presence of complex injuries.
an axial loading injury mechanism (.000), a radiographically captured dislocation (.006), posteromedial comminution [as defined Tor-netta] (.005) the size of the fragment (.000). For example, axial loading would result in a complex fracture in >
85% of cases. In contrast, there was a statistically significant association between a Weber C fracture and older age and the presence of a SIMPLE PM fracture. These factors being potentially “protective” from joint comminution.
prompt surgeons to order further imaging (CT) to better delineate the lesion, and draw his/her attention to potentially malaligned fragments at the time surgery.
ACL deficiency can have detrimental pathological effects on the menisci in the knee. A database review in Quebec over a three-year period was previously reported (Canadian Academy of Sport Medicine, Winnipeg, 2003), which examined the relationship between waiting times for ACL surgery and the requirement of a meniscal procedure. The purpose of this study is to determine if the length of time between an index injury and ACL reconstruction (ACLR) surgery correlates with the incidence of meniscal repair and meniscectomy in Alberta, and to compare the results to those of the Quebec study. Retrospective study, using procedure and billing codes to search the Alberta Health and Wellness databases for knees undergoing primary ACLR surgery between 2002–2005. Inclusion: Patients sixteen years or older at time of reconstruction. Exclusion: Revision ACLR, duplicate billing and coding, and insufficient database information. For each reconstructed knee, databases were searched for initial injury evaluation date with primary care physician, dates of meniscectomy or meniscal repair procedures, and date of ACLR. Over a three-year period, there were 3382 primary ACL reconstructions performed in Alberta, 3812 ACLR in Quebec. Of these patients, 2583 in Alberta (76%) and 1722 in Quebec (45%) required a meniscal procedure. On average, Albertans waited 1389 days from injury to ACLR compared to 422 days in Quebec. In Alberta, patients not requiring a meniscal procedure waited 1212 days, patients requiring meniscal repair waited 1143 days, and patients requiring meniscectomy waited 1519 days, compared to 251, 413 and 676 days in Quebec, respectively. Three percent of patients in Alberta had ACLR <
three months after injury (114 patients), with 45% requiring meniscectomy. Overall, 61% of patients in Alberta required a meniscectomy for significant meniscal injury, compared to 48% of patients in Quebec. The proportions for each province were statistically significant. Compared to Quebec, patients in Alberta are waiting longer for ACLR, with only a small proportion of cases being treated acutely. The proportion of patients requiring surgery for significant meniscal injury is also greater in Alberta. The higher proportion of patients in Alberta requiring meniscectomy may be due to the delay in ACLR.
To determine if intraoperative positioning in the supine or lateral position affects morbidity and mortality in orthopaedic trauma patients with femur fractures. Retrospective cohort study of 991 patients representing 1030 femoral shaft fractures admitted to our level one trauma center between the years of 1987 to 2006. Primary outcome measures included mortality and admission to ICU. Secondary outcome measures included length of stay in hospital, length of time admitted to the intensive care unit and discharge disposition. Logistic regression analysis was performed to compare to effect of intraoperative position in addition to other known dependent variables on primary and secondary outcome measures. Intraoperative position in the supine or lateral position had no effect on morbidity or mortality in orthopaedic trauma patients with femur fractures. There is no difference in immediate mortality or morbidity between patients with femur fractures treated with IM nails in either the lateral or supine position. We conclude that either position is safe for the surgical stabilization of femur fractures and intraoperative position should be determined by surgeon preference.
Evidence suggests that femoral neck fractures initiate in the superolateral cortex, where it is significantly thinner in older than younger individuals (Mayhew, et al. Lancet 2005). Thus, we sought to determine the relative time-course of crack initiation and propagation during a simulated hip fracture. Four unembalmed frozen, human cadaveric specimens (mean age = 78 yrs) were loaded to failure in sideways fall configuration at a rate of 100 mm/sec using a materials testing system. Images of the fracture were captured with two high-speed video cameras at a resolution of 384x384 pixels, and sample rate of 9,111 Hz (frames/second). Test A: The load-displacement (L-D) curve had three distinct peaks: at the first peak (4390 N), the head and neck rotated slightly. At the second peak (4607 N), a visible local compressive fracture appeared in the superior cortex of the proximal neck. At the third peak (3582 N), a neck-spanning tensile failure occurred in the inferior neck. Test B: At the first and second peak loads (1714 N and 3040 N) fluid was released from the posterior then superior and inferior surfaces. The third peak load (3361 N) corresponded to a local compressive failure in the lateral superior neck, followed by a neck-spanning tensile failure medially. Test C: The L-D curve was linear until ultimate load (3038 N). A compressive crack first appeared on the anterior-superior surface of the neck cortex, then fractured in the inferior neck. Test D: The L-D curve was linear until ultimate load. A small local crack appeared in the superior cortex of the proximal neck at ultimate load (3841 N). We found that during ex vivo simulations of hip fracture, the femur failed initially in the superior cortex of the neck, and then failed in the inferior cortex. This is the first study to demonstrate, with high speed video data, the location of crack initiation and its propagation. These preliminary data support the hypothesis of Mayhew et al. (Mayhew, et al. Lancet 2005) in terms of fracture development and could relate to clinically relevant fracture types.
In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone. Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing. The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding. In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing. No additional incision or soft tissue stripping is required for plating of the fractured fibula. The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant. Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site. The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant.
We reviewed the results of sixteen patients with three and four part proximal humerus fractures treated with the Locking Proximal Humerus Plate (LPHP) in two trauma centres. All fractures were radiographically healed by six weeks. We found a high rate of fixation failure 4/16 cases within two weeks of surgery and range of motion results similar to previously reported techniques. This device has not demonstrated its clear superiority when used in trauma centres which commonly treat proximal humerus fractures. A randomised control trial comparing it to classical techniques and using outcome-based measures would seem appropriate. Proximal humerus fractures with poor functional outcomes are expected to increase in frequency owing to an active ageing population. New angle stable devices have been developed to address the frequently associated osteoporosis and loss of fixation. This study reviews the early experience of fixation with an angle stable device, the LPHP (Synthes Canada). Three and four part fractures treated with the LPHP were identified from the database of two trauma centres. Demographics, patient activity level, mechanism of injury, fracture type were collected. Early complications, maintenance of reduction, and ROM were reviewed. Sixteen fractures treated with the LPHP. Male to female ratio was 1.3:1. Mean age was 51.5 (29–77) Activity: 12/16 sedentary, 4/16 manual labourers. Mechanism: four Low and twelve High-energy injuries. Fracture classification: Five three part, and Eleven four part fractures. Early complications: one wound haematoma,one re-operation for intra-articular hardware, and four of sixteen pts pulled off the greater tuberosity fixation within two weeks of surgery. Union was achieved in all sixteen by six weeks. The mean forward elevation was 60° at six weeks and 80° at three months. This review of the early experience with the LPHP shows a significant rate of fixation failure (4/16 cases) and functional ROM results similar to other previously described techniques. Although a “learning curve effect” is possible, this device has not demonstrated clear superiority with surgeons who commonly treat proximal humerus fractures. A randomised control trial comparing it to classical techniques would seem appropriate.
We examined the relationship between waiting times for ACL surgery and the need for meniscal surgery at time of reconstruction. Using the Provincial Billing Database we identified 3812 ACL reconstructions between 1999–2001. Patients waited on average four hundred and twenty-two days from initial medical visit to reconstruction. 1722 patients (45%) required meniscal surgery with the ACL procedure. The delay to surgery was: two hundred and fifty-one days (no meniscal surgery required), four hundred and thirteen days (meniscal repair) and six hundred and seventy-six days (meniscectomies). This difference was significant, p<
.01, ANOVA. The rate of meniscal surgery per time period was also significantly different: 17% if <
3months, 57% if >
6months. Our present Health Care policies place patients at risk of requiring avoidable meniscal surgery and developing osteoarthritis. The purpose of this study was to examine the relationship between waiting times for ACL surgery and outcome. The outcome measure was the need for meniscal surgery at the time of ACL reconstruction. The Provincial Data Base Billing information was reviewed for ACL reconstruction between 1999–2001. The simultaneous need for a meniscal procedure was noted. Tracking back in time, all demographic, diagnostic and interventional billing data (ICD &
Visit billing code) preceding their ACL surgery was recorded. Between 1999–2001, 3812 ACL reconstructions were identified. Of these, 1722 patients required a meniscal procedure (45%). On average, patients waited over four hundred and twenty-two days from injury to reconstruction. Patients who did not require any meniscal procedure waited on average two hundred and fifty-one days, meniscal repairs waited four hundred and thirteen days, while meniscectomies waited six hundred and seventy-six days. More importantly, the need for a meniscal procedure correlated with the timing of surgery: 17% of those reconstructed <
three months from injury had a significant meniscal injury, compared to 57% at >
six months. Almost half of which (48%) required a meniscectomy for significant meniscal injury. These differences all attained statistical significance (p<
0.01). Previous reports suggest that the ACL-deficient knee increases the risk of meniscal injury and meniscal incompetence hastens OA. Our data show a progressive increase in the rate to meniscal surgery, and meniscal injury complexity with time. These delays and rates are higher than the ones proposed in the literature. It appears that the experience in our Province simply reproduces (rather than improves upon) the natural history of the ACL injury. We postulate restricting access to specialists and to surgery place the patient at risk for requiring avoidable surgery and developing osteoarthritis
This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were assessed by PQCT at four, eight and ten percent site from distal and tested in compression at the twenty-five percent distal portion. Ultimate compressive loads were recorded with a mean of 8276 ± 2915 N. Spearson rank correlation and stepwise regression analysis revealed that CoA, total BMC, SSI and SSI4-TrA4-CoD4 combination had statistically significant correlations with the failure loads. Among all imaging parameters, SSI had the highest relevance due to its account for geometry, density and material distribution, important factors for structural properties. Musculoskeletal diseases, especially hip fractures, have huge and growing impact on Canadian society. To develop techniques for identification of high risk population, we needed a link between clinical evaluations and laboratory measures of bone health. This study identified imaging parameter(s) which best predict the mechanical properties of distal tibia. Seventeen human cadaver tibiae were considered in this study (mean age seventy-four, SD six years). PQCT was used to assess the four, eight and ten percent site. It measured the cross-sectional area, bone mineral content and bone mineral density of the cortical bone, trabecular bone and combined. Strength Strain Index (SSI) was calculated from these measurements. Each tibia was cut at twenty-five percent distal. Compressive force was applied uniaxially through a custom-made PMMA indentor onto the distal plateau along the longitudinal axis of the tibia at a rate of 10mm/s. Load and displacement data were recorded. Spearson rank correlation and stepwise regression analysis were used to identify individual and combination of imaging variables that were related to ultimate failure load. Ultimate failure loads were recorded with a mean of 8276 ± 2915 N. Cortical area (R_0.72), total BMC (R_0.72) and SSI (R_0.86) had statistically significant correlations with the failure load. Stepwise regression revealed that the combination of SSI, TrA, CoD at 4% site explained the greatest amount of variance (R2 = 0.868) and SSI was the major contributor. SSI takes the polar moment of inertia (geometry), density and distribution of material into account. This explains its relevance towards predicting the ultimate failure load. Please contact author for referenced images
Osteoporosis investigation following a low-trauma fracture is often missed. The aim of this study was to (i) measure the current rate of osteoporosis investigation and (ii) to test a simple intervention that seeks to increase patient awareness and physician alerting following these sentinel events. Our study showed that 92% of the intervention group was investigated compared to 18% of the control group. This study suggests that a simple inexpensive intervention can increase the rate of osteoporosis investigation in an at risk population. National guidelines (1–3) emphasize that low-trauma fractures should prompt to investigate for osteoporosis but more than 80% of “at risk” people are not investigated. To measure the rate of diagnosis of osteoporosis when patients with low-trauma wrist fractures obtain usual care compared to a patient education and physician alerting intervention. This is a prospective, controlled trial of patient education and physician alert following a distal radius fracture. Participants in the intervention group received four-parts: (i) an information sheet, (ii) a letter from the treating orthopedic surgeon to the patient’s family physician signaling the recent low-trauma fracture (iii) a follow-up reminder call to return to the family doctor for assessment and (iv) a fax to the family physician suggesting assessment and management of osteoporosis. The control group received usual care of the fracture and no specific information about osteoporosis. All participants were telephoned at 6 months to assess investigation status. Fifty-one participants >
50 yrs. with a fragility wrist fracture were enrolled: 92% of the Intervention participants were investigated for osteoporosis by the family physician compared to 18% of the Control group. This is a significant difference (p ≤ 0.01). This study suggests that a simple inexpensive intervention by the surgeon can increase the rate of osteoporosis investigation in an at risk population. Orthopedic surgeons can contribute to the care of osteoporosis by readily adopting simple clinical actions which will make patients more likely to be investigated for osteoporosis.
Non-unions of pilon fractures are difficult Orthopaedic problems. Significant bone loss and infection can lead to amputation. Joint stiffness in conjunction with disuse osteopenia make stabilization in this area challenging. We present the use of a custom blade plate design that offers sufficient stability for successful treatment in six successive cases. With a mean follow-up of thirty-three months, all fractures treated with this method healed. The five infected cases healed without recurrence of infection. With average scores of 70.7 on the Maryland Foot Score, and sixty-eight on the Foot and Ankle Society Ankle-Hindfoot Scale, the patients overall had satisfactory results. The purpose of this study was to describe a new technique of treating non-unions of distal tibia pilon fractures using a custom blade plate design. A report of successful outcomes in six consecutive cases. A retrospective analysis of fifty-six pilon fractures treated over a three- year period revealed six patients with significant complications related to their fractures. Of these, all had significant bone loss and five were infected. All six failures were revised using a custom blade plated design with oblique locking screws for triangular fixation of the distal pilon. The average follow-up period was thirty-three months. These patients were evaluated with the Maryland Foot Score (MFS) and the Foot and Ankle Society Ankle-Hindfoot Scale (AHS). All of the six patients treated with the proposed method went on to heal without recurrence of infection. Three patients required additional surgical interventions including bone grafting, debridement and hardware removal to achieve the final result. Their average MFS and AHS were 70.7 and sixty-eight respectively. Stable fixation is an absolute necessity for a successful outcome in the failed pilon fracture. A custom blade plate design with oblique interlocked screws offers sufficient long-term stability, despite infection and disuse osteopenia, for healing of the non-united fracture to occur. As shown by our series, satisfactory clinical results can be expected and amputation can be avoided in complicated cases using this surgical technique.
This study attempted to ascertain if patients with high superior pubic ramus fractures (HSPR) have worse clinical functional outcomes than patients with low superior pubic ramus fractures (LSPR). A retrospective cohort of patients was examined. A statistically significant difference was found with respect to Harris Hip Score, MFA score, Bother Index, and Functional Index. Patients with LSPR fractures consistently scored better on mobility and activity of daily living functional testing. Patients with HSPR fractures were limited in physical abilities and lifestyle adjustment. This study illustrates a need to re-examine our treatment of high pubic ramus fractures. The purpose of this study was to ascertain if patients with high superior pubic ramus fractures have worse clinical functional outcomes than patients with low superior pubic ramus fractures. Patients with Low Superior Pubic Ramus (LSPR) fractures consistently scored better on mobility and activity of daily living functional testing. Patients with High Superior Pubic Ramus (HSPR) fractures were more limited in physical abilities and lifestyle adjustment. No distinction of level of this common fracture is routinely distinguished with treatment usually independent of level. This study illustrates a need to re-examine our treatment of high pubic ramus fractures. A statistically significant difference was found when the HSPR fracture group was compared to the LSPR fracture group with respect to Harris Hip Score (P=0.0024), MFA score (P=0.0304), Bother Index (P=0.0338), and Functional Index (P=0.0385), and had hip pain which was a limiting factor (P=0.011). This is a retrospective cohort study of patients sustaining a superior pubic ramus fracture. The criterion for grouping was fracture proximity to the acetabulum. MFA (Short Form) and Harris Hip Score were performed. A physical exam was performed on all patients. The two groups were compared using the Wilcoxon test for continuous variables and the Chi-square test for contingency tables. These fractures are commonly felt to be of minimal significance. Common treatment regimes consist of pain control and early mobilization. The etiology of the increased pain and functional disability in patients with HSPR fractures is unclear. Our hypotheses include labral tear and missed true acetabular fractures.
Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim. The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach. Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks. Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum. Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p<
0.05) into two groups according to Femoral Head diameter: FH<
47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm. Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference <
1mm in >
90% of cases. Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points.